Rethinking Mechanisms of Change in CBT: A Historical Review Through Predictive Processing and Embodied Cognition

Dr Kristina Ivings and Daniel Mirea (10 November 2026)
| The NeuroAffective-CBT® Journal |

Abstract

This historical review draws on predictive processing and 4E cognition to reconsider how change occurs in cognitive behavioural therapies. It proposes that bodily regulation, imagery and behavioural practice may help clients revise threat expectations and expand what they feel able to do. NeuroAffective-CBT® serves as an example of how these methods can be integrated with cognitive reflection. The review also briefly considers the use of imaginal rehearsal in Hypno-CBT®. Further research could test which components contribute to change and whether gains carry into everyday life.

Keywords | Cognitive behavioural therapy, mechanisms of change, predictive processing, 4E cognition, embodiment, integrative psychotherapy

Introduction

Cognitive Behavioural Therapy (CBT) is the most extensively researched form of psychotherapy (Hofmann et al., 2012), and Dialectical Behaviour Therapy (DBT) is among the best-supported treatments for borderline personality disorder (Storebø et al., 2020). The models used to explain how these therapies work, to therapists and to clients, have not kept pace with contemporary neuroscience.

Psychoeducation in CBT and DBT commonly draws on simplified neuroanatomical stories and evolutionary models of emotion and behaviour. Compassion-Focused Therapy teaches a distinction between an “old brain” of evolved emotions and motives and a “new brain” of thought and imagination (Gilbert, 2009, 2010), echoing MacLean’s (1990) triune model. Widely used CBT-informed self-help presents anxiety as the product of an amygdala pathway that the cortex must work around or retrain (Pittman & Karle, 2015). DBT’s skills materials teach that primary emotions such as fear, anger, disgust and shame are innate and evolved, each serving a survival function (Linehan, 2015). Dual-system models also appear in theoretical accounts of CT: Clark and Beck (2010) proposed that anxiety and depression involve heightened bottom-up, amygdala-driven processing combined with weakened top-down, prefrontal reflective control. The dual-process theorists themselves are more cautious. Kahneman (2011) describes System 1 and System 2 as useful fictional characters rather than brain systems, and Evans and Stanovich (2013) prefer to speak of Type 1 and Type 2 processes. The clinical version hardens these metaphors into anatomy and casts the amygdala as a fear centre, a view that LeDoux (2015), whose earlier research helped establish the amygdala’s role in threat detection, now argues against.

Contemporary affective neuroscience describes cortical and subcortical regions as densely interconnected and jointly involved in both emotion and cognition (Pessoa, 2013; Barrett, 2020). Predictive processing retains a hierarchy of top-down and bottom-up signalling, but it is a single integrated hierarchy, not a contest between separate emotional and rational systems.

Our concern is not with the efficacy of CBT and DBT but with the models offered to explain it. Therapists and clients are asked to accept inaccurate accounts of their own biology, and the mismatch may obscure which components of treatment are effective. We suggest it may also have slowed the development of approaches that work with, rather than in spite of, the brain’s predictive and embodied organisation.

This paper draws on predictive processing and 4E cognition to set out a contemporary account of mind and brain, then uses it to re-read the history of psychotherapy: its Stoic antecedents, early somatic and behavioural methods, Beckian Cognitive Therapy (CT), metacognitive therapy, the third-wave approaches and DBT.

This review considers whether some interventions may work through processes that their original theories gave less attention to. Early behavioural approaches, including Salter’s (1949) conditioned reflex therapy and Wolpe’s (1958) systematic desensitisation, made action and bodily experience central to therapeutic learning. Beckian cognitive therapy (CT) retained behavioural methods and used some of them to test and revise beliefs. Later approaches, including Meichenbaum’s (1985) Stress Inoculation Training (SIT), continued to emphasise rehearsal and the graded application of coping skills. We use predictive processing and 4E cognition to explore how bodily regulation, rehearsal and action may contribute to therapeutic change. We close by considering how these methods can be integrated with cognitive reflection and how future research might test the proposed mechanisms.

Neuroscientific Foundations

Predictive Processing and Allostasis

A useful starting question is what a brain is for. Barrett (2017) argues that its core task is regulating the body rather than thinking: anticipating the needs of the organism and meeting them before they arise, a process she describes as running a budget for the body. The view draws on Sterling’s (2012) account of allostasis, the predictive regulation of physiological variables such as glucose, oxygen, water and salt. It is not universally accepted as the brain’s primary function, but it supplies the framing adopted here.

Predictive processing describes how this regulation might be achieved. The brain is modelled as a generative system that continually predicts its inputs and revises those predictions in light of prediction error, the mismatch between what was expected and what arrives (Friston, 2010; Clark, 2013). Predictions prepare the cardiovascular, metabolic and muscular systems in advance of anticipated demand, so prediction serves allostasis rather than operating separately from it.

Peters et al. (2017) argue that sustained uncertainty is metabolically costly, because a system that cannot resolve its predictions must remain mobilised. We propose that some of what clients describe as chronic worry, ambient threat and the urge to ruminate reflects this state of unresolved prediction error and sustained autonomic arousal. On this view, deliberate, linguistic thought is one form of the brain’s predictive activity, serving the regulation of the body and the guidance of action, rather than the brain’s defining function.

Precision weighting determines how much influence a signal has. The brain estimates the reliability of its predictions and of incoming sensory evidence and weights each accordingly (Friston, 2010; Clark, 2013). Precision weighting operates throughout the hierarchy, across exteroceptive, proprioceptive and interoceptive signals. Applied to interoception, the brain’s inference about the internal state of the body, it shapes how bodily states are felt and interpreted (Seth, 2013).

Where a prediction carries high precision, conflicting evidence can be discounted. In the rubber hand illusion, synchronous stroking of a visible rubber hand and the participant’s hidden hand leads participants to feel the touch as located on the rubber hand and to experience it as their own (Botvinick & Cohen, 1998). The sense of ownership is associated with activity in premotor cortex (Ehrsson et al., 2004), and threatening the rubber hand produces skin conductance responses (Armel & Ramachandran, 2003). Visual evidence given high precision reshapes the felt location of the body. Clinically, the analogy suggests that a high-precision prediction of threat could lead the brain to discount interoceptive and environmental evidence of safety, which would help explain why reassurance and contrary evidence often fail to reduce distress.

4E Cognition

4E cognition holds that the mind is not a program running inside an isolated skull. Mind is:

• Embodied: shaped by visceral, gut–brain and autonomic states.
• Embedded: functioning within a physical, socioeconomic and cultural niche.
• Enacted: brought forth through sensorimotor activity and engagement with the environment.
• Extended: offloading cognitive work onto external tools, technologies and spaces.

The 4E paradigm emerged as a philosophical and phenomenological critique of computer-metaphor cognitive science, with roots in the work of Varela, Thompson and Rosch (1991). Predictive processing grew out of computational neuroscience, formalised through models of Bayesian inference and the free-energy principle (Friston, 2010).

Clark (2016) argues that the two frameworks are compatible: predictive processing offers a candidate mechanism for embodied and enacted cognition, because the brain minimises prediction error partly by acting on the body and the world. The compatibility is debated, and radical enactivists reject the representational reading of predictive processing (Hutto & Myin, 2013). The argument here requires only the weaker claim that the brain’s predictions serve an organism that is embodied, embedded and acting in the world.

Affordances and Self-Efficacy

Gibson (1979) introduced the concept of affordances: the possibilities for action an environment offers an organism, given the fit between the organism’s capacities and the properties of its surroundings. Rietveld and Kiverstein (2014) extend this into a landscape of affordances, the field of possibilities open to an organism within a given practice and situation. A chair affords sitting; a phone affords contact with others.

We propose that the state of the body budget shapes which affordances are salient. When resources are ample, the landscape is rich with invitations to approach, connect and explore. When the budget is depleted, or the system is held in high-precision threat prediction, invitations to reward recede while obstacles and threats gain salience. A flight of stairs becomes a barrier and a social encounter becomes a threat.

This proposal offers a mechanistic reading of two earlier ideas. Salter (1949) argued that psychological health depends on excitation predominating over inhibition, illustrated by the image of a dog bounding into a room to see what it offers. Bandura (1977) argued that efficacy expectations, a person’s belief that they can carry out the behaviour an outcome requires, govern whether they initiate and persist in coping. In predictive processing terms, self-efficacy can be modelled as the precision the brain assigns to predictions of its own capacity to act and cope. High self-efficacy would make approach-related affordances salient before any action is taken, whereas low self-efficacy would act as a confident prediction of failure that narrows the perceived field in advance.

Emotions as Constructed

The view that emotions are discrete, biologically fixed responses is often traced to Darwin (1872), who argued that emotional expressions are innate and shared across cultures and species. Darwin did not present most expressions as adaptations; he explained many as “serviceable associated habits”, vestiges of actions that had once been useful. The later basic-emotion tradition recast emotions as evolved programmes, each with a characteristic expression and physiology (Ekman, 1992).

The idea acquired an anatomical home in MacLean’s limbic system, which he developed from 1949 and later incorporated into the triune brain model, summarised in his 1990 book (MacLean, 1990). The triune model presents the limbic system as an older emotional brain lying beneath a rational neocortex.

DBT’s skills curriculum draws on the basic-emotion tradition. It teaches that emotions have evolutionary functions and unfold through a sequence of prompting events, interpretations, biological changes, action urges and expressions (Linehan, 2015). Because the sequence includes interpretation, the model is not purely reflexive, but it presents a set of primary emotions as universal, biologically prepared responses, and this is the model taught to DBT therapists and clients.

Barrett’s (2017) theory of constructed emotion offers an alternative. On this account, emotions are categories the brain constructs in the moment by applying learned concepts to core affect, rather than circuits waiting to be triggered. Core affect is a continuous blend of valence (pleasant or unpleasant) and arousal, often represented as a circumplex (Russell, 2003; Barrett, 2006). An emotion such as fear or anger arises when the brain categorises a change in core affect, in context, using culturally learned concepts. Basic-emotion theorists dispute this account (Ekman, 1992), but it is consistent with the predictive framework above and carries different clinical implications: if emotions are constructed predictions, they can be changed through the body, the situation and the concepts available to the client.

A Historical Re-Reading of the Clinical Lineage

This section does not claim that earlier clinicians held predictive processing views. It asks how far each approach’s effective components can be explained by the framework above, and how closely its stated theory matches those components.

Stoic Antecedents

Epictetus held that people are disturbed not by events but by their judgements about them (Enchiridion 5) and advised wanting events to happen as they do rather than as one wishes (Enchiridion 8) (Epictetus, 2014). In predictive processing terms, a rigid judgement about how events should unfold resembles a high-precision prediction that reality repeatedly violates. Beck and Ellis both acknowledged Stoicism as an antecedent of their approaches, but they adopted its emphasis on judgement more readily than its emphasis on acceptance.

Somatic and First-Wave Behavioural Approaches

Early somatic approaches targeted the body directly. Jacobson’s (1938) progressive relaxation and Benson’s (1975) relaxation response aimed to lower muscular tension and sympathetic arousal. These methods change the interoceptive evidence available to the brain, and we hypothesise that they reduce the precision assigned to threat predictions without requiring verbal engagement.

First-wave behaviour therapy focused on environmental contingencies, conditioning and overt behaviour (Skinner, 1953; Salter, 1949; Wolpe, 1958). It did not exclude internal experience. Wolpe’s systematic desensitisation paired deep muscle relaxation with imagined scenes from a graded hierarchy, and Wolpe used hypnosis to deepen relaxation (Wolpe, 1958). Systematic desensitisation is an early demonstration that embodied imagery, practised in a regulated bodily state, can change fear responses.

Salter (1949) argued that anxiety reflects an excess of inhibition and prescribed excitatory exercises: spontaneous, expressive action, including voicing feelings and acting on impulse. His approach was clinically influential but was never tested in controlled trials. Salter had earlier written on hypnosis (Salter, 1944), and his emphasis on action, expression and expanded behavioural capacity anticipates the enactive view later developed in 4E cognition. Read through this lens, uninhibited action exposes the person to real-world prediction errors whose evidence is likely to update the generative model more effectively than abstract verbal reflection.

Self-Efficacy and Stress Inoculation Training

Two later developments kept action and rehearsal central. Bandura’s (1977) self-efficacy theory identified performance accomplishments as the most powerful source of efficacy expectations, ahead of vicarious experience, verbal persuasion and physiological states, and proposed that desensitisation and exposure work partly by raising self-efficacy. SIT combined conceptual preparation with skills acquisition and rehearsal, including imaginal and in vivo rehearsal of coping, followed by graded application (Meichenbaum, 1985). SIT includes cognitive restructuring and self-instruction, but its rehearsal and application phases embody the principle that coping is learned through practice.

Neither was rejected by CBT. Self-efficacy is widely used within CBT, and SIT remains in use, particularly for stress and trauma. Our claim is narrower: in Beckian theory, efficacy and rehearsal are not the mechanism of change; belief change is.

The Cognitive Revolution

Beck (1976) and Ellis (1962) placed thought content at the centre of the clinical model. Beck’s CT identified negative automatic thoughts, underlying assumptions and core beliefs, organised in schemas, as the primary targets of treatment. Ellis targeted irrational beliefs, worked through his ABC (later ABCDE) framework in Rational Emotive Behaviour Therapy.

Beck’s later work broadened the model. His theory of modes integrates cognitive, affective, motivational, behavioural and physiological systems (Beck, 1996), the generic cognitive model extends this account across disorders (Beck & Haigh, 2014), and Clark and Beck (2010) linked the model to neurobiological findings. In clinical practice, however, CT remains centred on content: identifying “thinking errors”, examining the evidence for and against thoughts, and constructing more rational alternatives through thought records and Socratic questioning.

CT retained behavioural methods, including activity scheduling, graded tasks, exposure and behavioural experiments, but changed their rationale. Behavioural experiments are framed as tests of explicit predictions, with success measured by the degree of belief change, so that action serves as evidence in a cognitive argument. The approach rests on an implicitly Cartesian assumption that the problem lies in the accuracy of mental representations and that the remedy is better representations.

Metacognitive Therapy

Wells’ Self-Regulatory Executive Function (S-REF) model (Wells & Matthews, 1994) is the clearest precedent for the process-over-content position taken here. It locates the maintenance of disorder in the Cognitive Attentional Syndrome (CAS), the pattern of perseverative worry and rumination, threat monitoring and counterproductive coping driven by positive and negative beliefs about thinking, rather than in thought content. Metacognitive Therapy (MCT) accordingly does not dispute content. It modifies these beliefs and trains non-engagement with thoughts through detached mindfulness and the Attention Training Technique (ATT; Wells, 2009). ATT involves focusing on and switching attention between multiple external sounds; Wells stresses that it is not distraction but training in flexible, executive control of attention, which also disconfirms beliefs that attention and worry are uncontrollable.

Predictive processing allows this account to be restated. Metacognitive beliefs can be read as high-level priors governing the precision assigned to internally generated content, so that believing worry to be necessary or uncontrollable keeps precision on threat simulations. ATT can be read as practice in reallocating precision away from such content. The frameworks differ in what they treat as the substrate of change. S-REF is framed in information-processing terms of levels, stored plans and executive control, whereas a predictive and 4E account treats the same phenomena as properties of a single embodied hierarchy regulating the body budget.

MCT therefore converges with the present argument at the clinical level while offering a different account of how change occurs. Hypno-CBT® uses hypnosis to rehearse coping responses in imagination (Davis, 2016). Whether using hypnosis to help clients disengage from thoughts, followed by imaginal rehearsal, offers benefits beyond detached mindfulness remains an open question.

Third-Wave Approaches and DBT

Mindfulness-Based Cognitive Therapy (MBCT) and Acceptance and Commitment Therapy (ACT) also moved from content to process. MBCT trains clients to relate to thoughts as passing mental events rather than facts (Segal et al., 2002). ACT targets the function of thoughts through defusion, acceptance and contact with the present moment, and is grounded in functional contextualism and relational frame theory (Hayes et al., 2006). ACT explicitly rejects mechanistic information-processing models, and its contextual, action-oriented stance is arguably closer to the enactive view taken here than any other variant of CBT. Its limitation, from the present perspective, is that it deliberately works at the level of functional analysis rather than mechanism, so it does not offer an account of how these processes relate to prediction and the regulation of the body.

DBT combines behavioural science with Zen-informed acceptance and mindfulness practice (Linehan, 1993). Its distress tolerance skills include TIPP: changing body Temperature (for example, cold water on the face to trigger the dive reflex), Intense exercise, Paced breathing and Paired muscle relaxation (Linehan, 2015). These skills act directly on autonomic arousal. We hypothesise that a strong, immediate change in bodily input forces rapid updating of interoceptive predictions and draws precision away from internally generated threat content. DBT’s mindfulness skills ask clients to observe and describe internal experience without judgement, echoing contemplative traditions that aim to quieten the mind rather than argue with it. DBT thus restored much of what CT had marginalised, but its explanatory framework remains the basic-emotion model described above, together with the states-of-mind metaphor of emotion mind, reasonable mind and wise mind.

Recent Integrative Models

Daniel Mirea’s NeuroAffective-CBT® (NA-CBT), developed for difficulties involving shame, self-disgust and low self-esteem, combines cognitive-behavioural methods with affective neuroscience and embodied regulation (Mirea, 2018). Its six-module structure places physiological stabilisation early in treatment. The Tiredness, Exercise and Diet (TED) framework addresses sleep and fatigue, physical activity and nutrition as foundations for emotional regulation (Mirea, 2025). The Pendulum Effect formulation describes how clients may oscillate between overcompensation, avoidance and capitulation in response to a shared affective threat. More recent work uses embodied rehearsal, mental imagery and values-guided behavioural experiments to develop what Mirea calls the Integrated-Self (Mirea, 2026).

This emphasis on embodied and experiential learning is evident in NeuroAffective Narrative Reconsolidation (NNR), the fourth of the six NA-CBT modules. The method can be interpreted through the lens of 4E cognition, as illustrated by its use in clinical supervision (Mirea & People, 2026). It brings bodily sensations and emotional responses into the retelling of a significant experience (embodied) and situates that experience within the person’s relationships and circumstances (embedded). First-person role-play, imagery and rehearsal allow alternative responses to be explored through action (enacted). The supervisor’s prompts and the structure of the exercise can also serve as external supports for organising and revisiting the account (extended).

Mirea reports learning directly from Donald Meichenbaum and identifies Stress Inoculation Training as an influence on NA-CBT’s use of coping-skills rehearsal and graded practice. The NeuroAffective-CBT® Journal publishes Mirea’s conceptual and clinical papers alongside case studies and reviews by other clinicians. The case studies illustrate how clinicians have applied the framework in practice. Mirea presents NA-CBT as a clinical formulation framework, and its effectiveness as a treatment protocol remains to be established.

Clinical Implications

If the brain is a predictive system whose core task is allostasis, distress is better understood as a problem of prediction and precision than as a problem of inaccurate belief. When rigid top-down expectations repeatedly meet contrary evidence, the system remains mobilised, and the client experiences worry, ambient threat and the drive to ruminate.

Predictive processing also suggests why CT’s focus on content may be limited. Thoughts are simulations generated by a predictive system, and their influence depends on the precision (the confidence or salience) the system assigns to them. Sustained analytical engagement with distressing content is itself a precision-raising act: attending to a thought, interrogating it and treating it as a problem to be solved signals that it matters. The client may exchange irrational rumination for rational rumination without leaving the loop. A related difficulty is familiar to cognitive therapists: clients often report knowing an alternative thought to be true without feeling it to be true, a pattern described as rational-emotional dissociation (Stott, 2007). Where behavioural experiments succeed, predictive processing would locate the change in the precision updating produced by acting, not in the verbal re-rating that follows, which suggests they may work despite their stated rationale rather than because of it.

This does not mean that only overt action can produce change. Imagined action engages much of the neural machinery used to plan and perform it (Jeannerod, 2001), so vivid, embodied rehearsal is closer to offline action than to verbal reflection, and Wolpe’s imaginal hierarchies show its clinical value. The relevant distinction is between abstract, evaluative thinking about experience and embodied simulation of it. Bandura (1977) nonetheless ranks performance accomplishments above other sources of efficacy, so simulation is best treated as preparation for enactive mastery rather than a replacement for it.

Through the lens of affordances, anxiety and depression can be understood partly as the perception of an impoverished, threatening field of possibilities, not only as misinterpretation. The aim of therapy then shifts from changing what a client thinks about the world toward expanding what they perceive themselves able to do in it, by raising self-efficacy and the salience of approach-related affordances.

The same framework explains why contemplative traditions aim to quieten the mind rather than dispute its content. Laukkonen and Slagter (2021) propose that meditation progressively reduces the precision and influence of high-level predictions. Epictetus’s advice to want events to happen as they do points in the same direction, since relaxing demands on reality reduces the prediction error those demands generate. We hypothesise that resting in non-evaluative awareness lowers the precision of top-down expectations about how things should be, reducing prediction error, autonomic arousal and metabolic cost.

A clinical model built on this account would be enactive and embodied. It would use somatic regulation to restore the body budget, embodied simulation to raise self-efficacy, and real-world action to confirm it, opening the client’s landscape to possibilities for safety, agency and action not previously perceived.

The Efficacy Question

Johnsen and Friborg (2015) reported that the effects of CBT for depression declined across trials published since 1977. The finding is contested: a re-analysis by Ljótsson et al. (2017) argued that the decline was not robust. The data cover depression only, and because they begin after CT was established, they cannot show that the shift from behaviour therapy to CT reduced efficacy. We cite the finding as a reason for concern rather than as evidence for the present thesis.

More direct evidence comes from studies separating CT’s components. In a component analysis, behavioural activation alone produced outcomes comparable to full CT for depression (Jacobson et al., 1996), and in a later trial behavioural activation performed comparably to antidepressant medication and better than CT among more severely depressed clients (Dimidjian et al., 2006). Longmore and Worrell (2007) reviewed the evidence and questioned whether challenging thoughts is necessary for CBT’s effects. The evidence is not uniform, and Lorenzo-Luaces et al. (2015) review findings that cognitive change can mediate symptom change in CT. Taken together, these findings are consistent with the view that much of CBT’s effectiveness derives from its behavioural and experiential components, and that CT may be effective despite, rather than because of, its stated rationale.

Conclusion

Across its history, psychotherapy has developed somatic, behavioural, experiential and process-focused interventions whose effects can be understood in more than one way. Predictive processing and 4E cognition offer complementary perspectives on how bodily regulation, expectations, action and context may shape therapeutic learning. From this perspective, some of the benefits of CBT and DBT may arise from changes in what people feel able to do as well as from changes in how they interpret their experiences.

Cognitive reflection can help people identify what they expect to happen, while bodily regulation, imagery and rehearsal can help them prepare to try a different response. Acting in everyday settings gives them an opportunity to learn from what happens. NeuroAffective-CBT® offers one example of how embodied narrative work and values-guided behavioural experiments might connect new understandings with action in daily life (Mirea, 2026; Mirea & People, 2026).

Further research could examine what these components contribute, for whom and under what conditions. Comparing an established intervention with and without imaginal rehearsal could test whether rehearsal improves coping in situations clients previously avoided. Tracking bodily arousal, threat expectations and perceived coping ability during therapy could help clarify whether changes in these processes precede improvements in everyday functioning. Follow-up could show whether those improvements persist.

Taken together, these ideas make the case for a new wave of integrative cognitive behavioural therapies rooted in embodied learning, informed by contemporary neuroscience and guided by research into how change occurs in therapy and carries into everyday life.

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Declaration of interests

Dr Kristina Ivings (HCPC, BPS) is Head of the Hypno-CBT® Research Unit. Daniel Mirea is the founder of NeuroAffective-CBT® and has authored and co-authored publications on the model that are cited in this review. These professional interests are relevant to the selection and interpretation of material on Hypno-CBT® and NeuroAffective-CBT®. The review discusses both approaches as examples of recent integrative developments. The proposed mechanisms of change are presented as hypotheses for empirical investigation.

Authorship and attribution

This selective historical review and conceptual analysis draws on published research and publicly available clinical and training resources. The authors distinguish the claims made in the cited sources from their own interpretation of earlier therapies through predictive processing and 4E cognition.

Data availability

No original participant data were collected or analysed for this review. The sources are listed in the references.

Ethics and confidentiality

The article draws on publicly available sources and contains no original participant data or identifiable clinical material.