Developing Authenticity Through Values-Guided Behavioural Experiments

Daniel Mirea (16 September, 2026)
| The NeuroAffective-CBT® Journal | 

Companion article: This article develops the clinical illustration and conceptual pathway introduced in Beyond ‘Fake It Till You Make It’: The Pendulum-Effect, Embodied Rehearsal and the Development of the Integrated-Self. Whereas the earlier article examined how embodied rehearsal can make an inhibited response increasingly available, the present article explores how values-guided behavioural experiments may support the development of preferences, boundaries, authorship and authentic living.


Abstract

Authenticity is sometimes understood as the expression of a stable inner identity that must be discovered before it can be lived. Conversely, behavioural change may be presented as “acting as if”: imitating confidence or concealing distress until a preferred identity becomes convincing. Both positions are incomplete. The first risks treating familiar protective responses as evidence of an essential self; the second risks encouraging performance, masking and emotional invalidation. This conceptual article proposes that authenticity can be both discovered and developed through values-guided behavioural experiments. It argues that shame-organised protective responses are repeatedly enacted through attention, posture, voice, affect, behaviour and relationship. Within the NeuroAffective-CBT® (NA-CBT) Pendulum-Effect Formulation, overcompensation, avoidance and capitulation are understood as interconnected protective positions organised around a shared affective threat. In the form examined here, that threat is internalised shame. Repeated enactment can make a restricted protective repertoire feel natural, personal and true.

Building upon an earlier NA-CBT account of embodied rehearsal and the development of the Integrated-Self, the present article examines the implications of this process for authenticity. It draws upon Stanislavski’s pursuit of truthful action under imagined circumstances, Vygotsky’s socially situated account of the actor’s emotion, Moreno’s use of role and enactment in psychodrama, contextual accounts of values, and contemporary research on mental imagery. It describes how the therapeutic relationship and everyday life can become contexts in which clients recognise Pendulum movements and test alternatives to proving, hiding or surrendering. Through imagery, embodied rehearsal, graded action, reflection, recovery and repetition, unfamiliar responses may become increasingly available within the Integrated-Self. Repeated values-guided experiments may do more than make an inhibited response behaviourally available: they may help clients differentiate values, discover preferences and boundaries, and recognise authorship of unfamiliar but genuinely chosen actions. Authenticity is therefore conceptualised neither as an unchanging essence waiting to be uncovered nor as a persona installed through performance. It develops through an iterative relationship among felt experience, values, chosen action, relational feedback and autobiographical meaning.

Keywords: authenticity; values; behavioural experiments; embodied rehearsal; mental imagery; shame; Pendulum-Effect Formulation; Integrated-Self; NeuroAffective-CBT®

Introduction: Can Authenticity Develop Through Action?

“Anna” is a fictionalised composite constructed from several clinically similar cases. Identifying details, circumstances and sequences of events have been altered and combined to protect confidentiality. She had long experienced anxiety in social and interpersonal situations, although her difficulties did not fully meet the diagnostic criteria for social anxiety disorder.

When Anna entered therapy, she said that she wanted to become more confident. What she meant was that she wanted anxiety to disappear before she acted. She imagined that confident people spoke because they felt certain, while she remained silent because something essential was missing within her.

Her first behavioural experiment was deliberately modest. She was not asked to dominate a meeting, deliver a flawless presentation or behave as though she felt no anxiety. She prepared one genuine question and agreed to raise it within the first ten minutes.

When Anna imagined herself speaking, her shoulders lifted, her jaw tightened and she felt an urge to delay. She oriented towards the imagined room, felt the support of the chair and allowed a slower exhalation. She then rehearsed the question aloud. At first, her voice was quiet and apologetic, and she surrounded the question with explanations designed to protect her from being wrong. Gradually, she practised saying the same words more simply. She was not pretending to be another person. She was using her own voice to attempt a response that her established protective system rarely permitted.

At the meeting, Anna’s chest tightened and the familiar instruction returned: Wait until you are completely certain. This time, she asked the question. Nobody applauded, and she did not feel suddenly transformed. The question was answered and the meeting continued.

That ordinary continuation mattered. Anna had spoken while activated; her body mobilised and then began to recover. Her prediction of humiliation had not occurred, but neither had she proved that criticism would never happen. She learned something more credible: uncertainty did not make participation impossible. The anxiety was real, the bodily activation was real and the old prediction was still present. The action was also real.

Do not fake the feeling. Practise the action, remain connected to the body, observe what happens and allow the experience to revise what seems possible.

Anna’s first experiment was introduced in an earlier article examining how embodied rehearsal, graded action, reflection and repetition may allow a previously inhibited response to become increasingly available within the Integrated-Self (Mirea, 2026). That article focused principally on the movement from a shame-organised protective pattern towards embodied possibility. Anna discovered that she could participate while anxiety and self-doubt remained present.

Her question at the meeting, however, was not an isolated success or the conclusion of the therapeutic process. It became the beginning of a broader inquiry into how she related to her work, her therapy and herself. If she no longer allowed the need to prove her competence, avoid exposure or surrender to self-attack to organise every decision, what would she genuinely value? What preferences, boundaries and ways of relating might become visible? Could an action that initially felt unfamiliar nevertheless be recognised as authentically her own?

The present article continues Anna’s clinical illustration and develops the implications of this process for authenticity. Its central question is no longer only how a different response becomes possible, but what a person may discover and develop by repeatedly acting in relation to what matters. As Anna experimented with participation, honesty and self-respect across work and therapy, her values became more differentiated, previously obscured preferences and boundaries became increasingly available, and unfamiliar actions could gradually be recognised as her own.

The theoretical progression is therefore from embodied possibility towards values-guided authorship and authentic living. Imagery and rehearsal make a different response conceivable and enactable. Graded behavioural experiments test that response within the therapeutic relationship and everyday life. Reflection helps the person evaluate what the experience reveals about their values, preferences and capacities. Authorship connects the chosen action with a developing autobiographical understanding of self. Authenticity, from this perspective, is neither uncovered as a finished identity nor installed through repeated performance. It is discovered and developed through the continuing relationship among felt experience, values, chosen action, relational feedback and meaning.

People frequently postpone action until an internal state grants permission: When I feel confident, I will speak. When I stop feeling ashamed, I will allow myself to be visible. When I know who I really am, I will begin to live authentically. This expectation appears reasonable, yet it can maintain the very pattern the person hopes to escape. Confidence remains unavailable because participation is repeatedly postponed. Personal preferences remain unclear because approval is continually prioritised. Identity feels fixed because only a narrow protective repertoire is enacted.

The familiar instruction to “fake it till you make it” reverses this sequence by placing action before feeling. Its intuition is clinically useful, but its language is misleading. It suggests that change requires a counterfeit performance: the person should conceal anxiety, imitate a socially valued identity and continue until the performance becomes subjectively convincing. For clients whose difficulties already involve masking, compliance, perfectionistic performance or disconnection from their needs, such an instruction may reproduce the problem rather than resolve it.

A more useful starting point is that the person is already repeatedly enacting a way of being. Internalised shame is not maintained by belief alone. It is enacted through where attention is directed, how the body mobilises or withdraws, which words are spoken or withheld, how relationships are approached, and how the person interprets and treats themselves afterwards. Over time, these responses may become sufficiently familiar to be mistaken for identity.

The distinction between familiarity and authenticity is therefore crucial. A response does not necessarily express an authentic self simply because it feels natural or longstanding. Someone who has spent years accommodating other people may experience a reasonable boundary as artificial. A person organised around perfectionism may experience ordinary participation as careless. Someone accustomed to silence may describe speaking clearly as “not me”. These reactions do not prove that the unfamiliar response is fraudulent. They may show that the existing protective response has been rehearsed for longer.

The Pendulum-Effect Formulation identifies protective movement around a shared affective threat. The present article focuses specifically on movements organised around internalised shame, although other affective threats may organise comparable protective patterns. Within a shame-organised pattern, a person may move among three broad protective positions: Overcompensation, through which the shame-based account is disproved by achievement, control, perfectionism or approval; Avoidance, through which anticipated exposure is prevented; and Capitulation, through which the shame-based account is accepted as though it were established fact.

These positions may appear contradictory, but they can belong to the same protective system. The person may overperform until certainty or approval can no longer be secured, withdraw to escape anticipated exposure, and then attack or abandon the self for having withdrawn. Each response protects against or regulates the same affective threat while also restricting the person’s available ways of acting and relating.

If protective Pendulum movements are already being repeatedly enacted, psychotherapy can redirect rather than invent the human capacity for rehearsal. The person can begin to imagine and embody responses organised around emerging values rather than shame. These responses are tested within the therapeutic relationship and everyday life, reflected upon, adapted and repeated. New emotions, preferences, boundaries and forms of relationship may emerge through this process.

The person does not simply behave differently because they have discovered a finished authentic self. Nor do they manufacture an identity by repeatedly performing a preferred character. Instead, they participate in developing a more authentic way of living through what they choose, enact, experience and make meaning of. Authenticity remains responsive to context: a chosen boundary may be authentic, but so may proportionate openness; participation may express a value, but so may deliberate withdrawal from an unsafe situation. Function and authorship matter more than appearance alone.

A behavioural experiment commonly tests a belief or prediction through planned experience rather than discussion alone (Greenberger and Padesky, 2016). A values-guided behavioural experiment is not designed merely to determine whether a feared prediction is accurate. It also explores what becomes possible when a value is permitted to influence action alongside fear, shame or self-doubt.

The person identifies the protective prediction, attempts a specific values-consistent response, observes its bodily, emotional and relational consequences, and reflects upon what the experience reveals about their capacities, preferences and ways of relating. The action may be retained, modified or rejected. The purpose is not to confirm a predetermined ideal but to generate information that could not become fully available while the person remained organised around proving, hiding or surrendering.

In this sense, the experiment tests not only what will happen in the situation, but what the person may become able to recognise, tolerate and choose. Through repetition across different contexts, a response that initially feels unfamiliar may become increasingly available. Through reflection and authorship, the person may also begin to recognise: This was not merely a role I performed. It was something I chose and was capable of doing.

The central proposition of this article is therefore:

Overcompensation, Avoidance and Capitulation repeatedly enact the predictions of internalised shame and can make those predictions feel personal and true.

Values-guided behavioural experiments use imagery, embodied rehearsal, relational testing and everyday action to explore alternative responses without requiring fear, shame or uncertainty to disappear first.

Through reflection, adaptation and repetition, these responses may become increasingly available within the Integrated-Self, while helping the person differentiate values, discover preferences and boundaries, recognise authorship and develop what an authentic life means for them.

Acting Truthfully Under Imagined Circumstances

The apparent contradiction between rehearsal and authenticity has a long history in the theatre. Acting can be treated as imitation: the performer reproduces recognisable external signs of emotion while remaining experientially separate from the role. Yet the tradition associated with Konstantin Stanislavski sought something more demanding than the reproduction of emotional appearance. His system was concerned with truthful, purposeful action within the given circumstances of the drama. The actor knows that the setting is constructed, but does not therefore approach every response as false. Through attention, imagination, objectives, physical action and repeated rehearsal, the performer develops conditions under which the role can be experienced and enacted with psychological credibility (Stanislavski, 2008, 2009).

Stanislavski’s “magic if” is especially relevant. The question is not simply, How would this character look? It is closer to, What would I do if I were living within these circumstances? The “if” creates an imaginative bridge without requiring the actor to confuse theatre with ordinary life. It connects possibility with action. The actor works neither by waiting passively for spontaneous inspiration nor by mechanically displaying an emotional stereotype. Rehearsal creates a structured route through which attention, intention, movement and feeling may become organised around the dramatic situation.

This does not mean that psychotherapy is theatre or that clients should perform invented characters. The parallel is more precise. Both fields challenge the assumption that authenticity must arrive fully formed before disciplined action begins. An actor may approach truthful performance through rehearsal; a client may approach a more authentic life by rehearsing actions that express values and inhibited capacities before those actions feel familiar. Indeed, their initial unfamiliarity does not make them fraudulent; it may simply reflect how much longer the existing protective response has been rehearsed.

At the same time, Stanislavski’s work warns against a shallow understanding of acting as if. The aim is not to paste the outward signs of confidence over an unchanged relationship with shame. In therapeutic rehearsal, the action requires an internal and relational purpose. The client is not instructed to appear assertive, warm or independent. They are invited to explore what they would do if a chosen value—self-respect, honesty, connection, curiosity or courage—were allowed to influence the situation alongside fear.

Emotion, Role and Social Meaning

Lev Vygotsky’s discussion of the psychology of the actor complicates any simple division between genuine and performed emotion. Engaging with Stanislavski’s system and Diderot’s paradox of the actor, Vygotsky asked whether an actor must personally experience the feelings represented on stage or whether those feelings are produced through the organisation of performance. He rejected an account of the actor’s emotion as a purely private or biological event. The experience is shaped by role, dramatic action, historical tradition, social meaning and the relationship with an audience (Vygotsky, 1999; original work published 1932).

Vygotsky did not provide a modern psychotherapy protocol for values or embodied rehearsal. His relevance lies elsewhere. He placed emotion within a culturally and socially organised activity. The actor’s feeling cannot be understood simply by isolating an internal state from the role being enacted and the meanings surrounding it. This position helps resist two opposite errors in psychotherapy. The first is to treat an emotion as an unmediated revelation of identity: I feel inadequate, therefore inadequacy is who I am. The second is to treat emotion as irrelevant so long as an acceptable behaviour can be performed. In both acting and therapy, the relationship among feeling, action, meaning and context matters.

Values also acquire substance within social and practical life. They are shaped and negotiated within family, cultural, relational and material contexts rather than chosen by an isolated individual. Honesty, care, creativity or self-respect are not merely words selected from a list. They become meaningful through situated choices: what the person says when disagreement risks rejection; whether care includes boundaries; whether belonging requires self-erasure; and whether fear is permitted to coexist with participation. A value is not demonstrated by verbal endorsement alone. It becomes visible in patterns of action and relationship.

From this perspective, acting as if does not ask the client to experience a prescribed emotion. It asks whether a different action can be organised within the current emotional and relational conditions. The client may still feel fear, shame or doubt. The question is whether those experiences must control the entire response.

Role, Enactment and Surplus Reality

J. L. Moreno carried action and role directly into psychotherapy. In psychodrama, clients do not only describe conflicts, memories and relationships. They enter a structured dramatic space in which these experiences and possible responses can be enacted. Role reversal, doubling, mirroring and role training allow different perspectives and behavioural positions to be attempted, witnessed and reflected upon (Moreno, 1946; Cruz et al., 2018).

Moreno’s role theory is particularly relevant to authenticity. He proposed that the self emerges through the roles a person develops and performs, describing role as a bridge between psychiatry, psychology and sociology (Moreno, 1946, 1961). Development, from this perspective, need not mean excavating one fixed identity concealed beneath behaviour. It may involve expanding the role repertoire and increasing spontaneity: the capacity to produce a sufficiently new response to an old situation, or an adequate response to a new one (Moreno, 1947, 1955).

This expansion does not require a person to become somebody else. A new role may offer temporary access to an inhibited capacity. Someone organised around compliance may rehearse disagreement. Someone governed by shame may practise being visible without performing perfection. Someone who anticipates helplessness may speak from a position of agency. Initially, the words can feel borrowed or artificial. Nevertheless, it is the client’s body producing the voice, tolerating the visibility and remaining in relationship.

Moreno’s concept of surplus reality extends this possibility. The psychodramatic space permits enactment of what did not happen, has not yet happened or could not safely be expressed in everyday life (Moreno, 1965). A boundary may finally be spoken; an unacknowledged need may be voiced; a future encounter may be rehearsed. The enactment is not equivalent to lived reality, but it can provide an experiential bridge between what the person currently predicts and what they may gradually become able to tolerate and perform.

The fictional or protected frame may also reduce immediate self-surveillance. A client can first try a sentence “in role”, or speak from a chair representing a possible future position. Yet therapeutic consolidation eventually asks: What did you do—not merely what did the role do? The purpose is not to credit a temporary character with the action, but to help the person recognise authorship of a capacity that was previously excluded from their self-understanding.

Contemporary drama-based interventions employ related processes, including role, narrative, enactment, distancing and witnessed performance. Reviews report promising findings while also identifying substantial variation in populations, interventions, methods and study quality (Berghs et al., 2022; Jiang et al., 2023). These findings justify careful clinical exploration; they do not establish that enactment reliably installs safety, authenticity or a new identity.

Mental Imagery in Values-Guided Experiments

Imagery adds an important psychological bridge between verbal intention and lived enactment. Mental imagery can evoke emotion more strongly than purely verbal representation and can simulate perceptual and experiential aspects of events (Holmes and Mathews, 2010; Ji et al., 2016). Prospective imagery can also influence anticipation, motivation and behavioural engagement, although effects depend upon the task, population and way imagery is used (Ji, Geiles and Saulsman, 2021; Cole et al., 2021).

This makes imagery clinically powerful but not inherently therapeutic. A shame-organised future image may function as a rehearsal of failure: the person sees faces turning towards them, hears their own voice falter, anticipates contempt and experiences bodily mobilisation before entering the room. Repetition may increase the subjective availability of the feared sequence. The image is treated as foresight rather than as a prediction shaped by prior learning.

Therapeutic imagery does not merely replace this scene with effortless success. An idealised image in which anxiety disappears and everyone responds warmly may be emotionally appealing but provide little preparation for the actual task. A more useful exercise activates the anticipated situation within tolerable limits and introduces a values-consistent response while preserving uncertainty.

The client might imagine entering a meeting and noticing the first signs of bodily bracing. They identify the urge to overexplain, remain silent or agree automatically. The image is slowed sufficiently to make choice possible. They then rehearse a concise contribution, feel their feet on the floor, direct attention towards the conversation and imagine remaining present while uncertainty continues. The sequence includes not only the desired action but recovery: how the person breathes after speaking, tolerates an ambiguous expression, responds to disagreement and prevents the event from becoming fuel for later self-attack.

Imagery therefore contributes at least four functions:

  1. It makes the shame-based prediction observable rather than unquestioned.
  2. It evokes sufficient affective and bodily involvement for rehearsal to be meaningful
  3. It permits alternative actions and responses to difficulty to be explored before real-world testing.
  4. It helps translate an abstract value into a situated pattern of attention, voice, movement and relationship.

The aim is not to imagine a completed ideal identity and perform it into existence. It is to create a provisional model of possible action, embody it sufficiently to increase the likelihood that it cn be accessed, test it, and revise it in response to experience.

The Pendulum-Effect Formulation: How Shame Narrows What Feels Possible

The Pendulum-Effect Formulation identifies a recurring movement among overcompensation, avoidance and capitulation around a shared affective threat. Shame is especially important because it readily becomes an account of the whole self. The person moves from:

 ‘I feel exposed’ to ‘I am inadequate’

I made a mistake’ to ‘I am a failure’

This relationship feels uncertain’ to ‘I am unlovable’

Overcompensation attempts to disprove that conclusion. The person works excessively, controls detail, becomes indispensable, seeks reassurance, performs confidence or monitors other people for evidence of approval. Avoidance prevents the anticipated exposure by withholding opinions, declining contact, delaying action, concealing need or leaving situations. Capitulation accepts the shame-based conclusion through helplessness, self-attack, submissiveness or withdrawal from valued activity.

These positions are repeatedly embodied. Overcompensation may appear as urgency, muscular tension, restricted breathing, relentless speech and vigilant attention to other people’s reactions. Avoidance may involve constricted movement, reduced voice, averted gaze and narrowed participation. Capitulation may be accompanied by heaviness, reduced agency and repetitive self-condemning language. The body does not merely display a belief that has already been formed elsewhere. Bodily state, attention, prediction, affect, behaviour and relationship participate in the experience from which the shame-based identity feels true (Barsalou, 2008; Niedenthal, 2007).

The Pendulum is also relationally self-reinforcing. A person who overfunctions may attract dependence while remaining unknown. Someone who conceals disagreement may experience relationships as superficially peaceful but internally unsafe. A person who withdraws before others can respond receives little information about whether contact, difference or repair were possible. Capitulation then interprets the resulting loneliness, exhaustion or resentment as evidence of defectiveness.

The issue is therefore not simply that the person possesses an inaccurate core belief. They repeatedly encounter themselves while proving, hiding or surrendering. These enacted experiences become autobiographical evidence for the identity they were originally designed to protect against.

The Pendulum positions can be summarised through three shame-organised instructions:

  • Overcompensation: I must prove my worth.
  • Avoidance: My presence, needs or imperfection must remain hidden.
  • Capitulation: The shame-based account of me is true, and I have no effective choice.

Therapeutic change does not add a fourth Pendulum position. It develops a more flexible alternative to automatic Pendulum control:

I can remain present, relate honestly and act according to what matters without having to prove, hide or abandon myself.

The Therapeutic Relationship as the First Site of Experimentation

The therapy room is not merely a protected place in which the client prepares for relationships elsewhere. It is itself a real relationship in which the Pendulum may become visible.

A client moving towards overcompensation may try to become the ideal client: completing every task perfectly, intellectualising their experience, presenting sophisticated explanations or assuring the therapist that treatment is working. Another may monitor the therapist’s face and rapidly revise what they say. Avoidance may appear through silence, changing the subject, minimising need, withholding disagreement, arriving late or becoming emotionally absent. Capitulation may involve automatic agreement, treating the therapist as unquestionably right, relinquishing agency or interpreting therapeutic difficulty as proof of being beyond help.

These responses should not be confronted as resistance or dishonesty. They can be recognised as relationally intelligent adaptations with histories and protective purposes. The therapeutic question becomes: What does this movement anticipate, prevent, disprove or make certain between us?

Once recognised, the relationship offers an immediate opportunity for a different response. The client may rehearse telling the therapist that a formulation does not fit, that an intervention felt unhelpful, that they are disappointed, or that they need more time. They may allow a silence without filling it through performance. They may receive care without becoming compliant, or express a boundary without withdrawing from the relationship.

Authenticity here does not mean unrestricted disclosure or saying everything one feels. It means that the client can increasingly remain in contact with experience, values and agency while responding to the actual relationship. A boundary can be authentic; so can chosen privacy. Connection can be authentic; so can proportionate distance. The relevant distinction is not between participation and withdrawal in themselves, but between chosen action and action automatically organised by shame.

This therapeutic enactment provides several forms of learning. The client discovers that difference need not automatically destroy connection, that embarrassment can be survived, that misunderstanding may be repaired and that a relationship can contain two perspectives. Equally, the therapist’s response may reveal that the client’s concern is valid. The aim is not to force every experiment into a reassuring conclusion. Authenticity requires contact with reality, including disappointment, limitation and the need for protection.

Values as Directions That Become Known Through Living

Values provide an organising alternative to the Pendulum, but they should not become another perfectionistic standard. Within contextual behavioural traditions, values are commonly understood as chosen qualities or directions of action rather than outcomes that can be permanently completed (Hayes, Strosahl and Wilson, 2012). In the present formulation, values help answer a specific question: If shame did not make the entire decision, what way of relating would matter here?

The answer may involve honesty, connection, curiosity, courage, care, creativity, self-respect or justice. Yet values are not always fully accessible before action. A person whose preferences have been organised around approval may genuinely not know what they like. Someone who has survived through compliance may struggle to distinguish care from self-erasure. Values clarification therefore cannot be confined to selecting admirable words.

Values become differentiated through lived experiments. The person notices which actions produce vitality, integrity, grief, relief, resentment or connection. They discover that a presumed value was inherited from a family or social role, while an overlooked interest becomes personally meaningful. New likes and dislikes emerge. Boundaries become more specific. The person learns not only what they wish to approach but what they no longer consent to organise their life around.

This is why authenticity is both discovered and developed. It is discovered because the person attends more carefully to felt experience, history, need and desire. It is developed because preferences and capacities change through action, relationship and reflection. The emerging self is neither arbitrary nor predetermined.

Values-consistent action is not always the outward opposite of the Pendulum behaviour. Leaving a dangerous relationship may resemble avoidance while expressing self-protection. Working intensely on a meaningful task may resemble overcompensation while expressing creativity or commitment. Yielding in an unimportant disagreement may resemble capitulation while reflecting generosity or proportion. Function, context and choice matter more than appearance.

The relevant alternative is therefore not necessarily the visible opposite of the existing behaviour, but action that differs from the function of the shame-based strategy. The person does not automatically obey the command to prove, hide or surrender. They choose a response proportionate to present reality and connected to what matters.

A Clinical Illustration: From Protective Performance to Values-Guided Participation

“Anna” is a fictionalised composite constructed from several clinically similar cases. Identifying details, circumstances and sequences of events have been altered and combined to protect confidentiality. She had long experienced anxiety in social and interpersonal situations, although her difficulties did not fully meet the diagnostic criteria for social anxiety disorder. Her question at the meeting was not an isolated success. It marked the beginning of a broader inquiry into how she related to her work, her therapy and herself.

In anticipation of shame, Anna moved towards overcompensation. She prepared excessively, mentally rehearsed every sentence and attempted to eliminate the possibility of error. She volunteered for additional work so that her value would be unquestionable and monitored other people’s expressions for evidence that she had performed well. When certainty or approval could not be secured, she moved towards avoidance: delaying a contribution, weakening what she wanted to say or remaining silent. Afterwards she capitulated, attacking herself and treating her silence or imperfection as proof that she was weak and incapable.

These apparently contradictory responses belonged to the same protective system. Overcompensation attempted to disprove the shame-based account; avoidance prevented its anticipated exposure; capitulation surrendered to it as though it were established fact. Anna also recognised their bodily organisation: urgency, muscular tension and rapid internal rehearsal while proving; constriction and reduced voice while hiding; heaviness and diminished agency while surrendering.

The pattern entered therapy. Anna prepared detailed accounts, searched for the “right” insight and worried about disappointing the therapist. When an interpretation did not fit, she often nodded rather than disagreeing. Therapy could therefore become another place in which she performed competence while remaining partly unknown.

Anna began with two provisional values: honesty and participation. They were provisional because she did not yet know precisely what they would require or what further preferences they might reveal. A recurring therapeutic question was:

If shame and self-doubt did not have the final say, how would I want to relate in this moment?

In imagery, Anna pictured telling the therapist that a recent exercise had felt too structured. Her first imagined sequence ended with the therapist becoming defensive and Anna apologising. The scene was slowed. She noticed the urge to protect the therapist, allowed a longer exhalation and rehearsed one sentence: “I understood the purpose, but I felt less connected to you while we were doing it.” She imagined curiosity, misunderstanding and partial disagreement, and practised remaining present rather than overexplaining, withdrawing or conceding that her experience was wrong.

Anna then said the sentence in the session. The therapist acknowledged the disconnection and invited further discussion. More important than reassurance was Anna’s discovery that she could express a difference, remain physiologically activated and continue relating. She had not performed confidence. She had enacted honesty while uncertain, and the therapeutic relationship had become a real site of rehearsal and revision.

Her subsequent daily experiments developed from the first meeting question. In a later discussion, she expressed a preference about the direction of a project without assembling an exhaustive defence. On another occasion, she declined an additional task rather than using indispensability to secure her position. Neither action felt natural at first. Both were consistent with participation that did not require self-abandonment.

The results were mixed. One colleague welcomed her view; another disagreed. Her boundary was accepted, although she spent part of the evening wanting to reverse it. Reflection focused not only on whether other people approved but on what Anna noticed about herself. She felt interested when collaboration allowed ideas to be developed openly, depleted by status-driven competition and resentful when care became compulsory availability. These reactions were not treated as unquestionable instructions, but as information that chronic approval-seeking had previously obscured.

Across subsequent experiments, Anna’s values became more specific. “Honesty” came to include not pretending agreement. “Participation” meant contributing without performing perfection and allowing others to carry responsibility. Self-respect came to include recoverable limits. She discovered satisfaction in mentoring less experienced colleagues and less interest than she had assumed in advancement organised around visibility and competition. New likes, dislikes, emotions and boundaries did not appear because a finished authentic self had finally been uncovered. They emerged as Anna created enough behavioural and relational space to encounter them.

Anna continued to move towards all three Pendulum positions. Integration did not mean their disappearance, nor did a functionally alternative response require her to occupy the other extreme. She was not asked to replace silence with dominance, compliance with reflexive disagreement or overwork with disengagement. The developing alternative was flexible participation: neither proving, hiding nor surrendering.

Her emerging self-understanding was not, I am finally confident and authentic. It was more credible:

I can notice the urge to prove, hide or surrender and still choose how I want to participate.

A Values-Guided Cycle of Behavioural Experimentation

The therapeutic process is better understood as an iterative cycle than as a fixed sequence applied identically to every client. It begins by recognising a movement towards overcompensation, avoidance or capitulation and identifying the affective threat, prediction, bodily organisation, attentional pattern and relational function involved. The therapist and client then clarify an emerging value without converting it into an idealised identity: I want to relate with honesty is more workable than I must become a completely authentic person.

Present-tense, multisensory imagery can bring the anticipated situation and its difficulties into tolerable contact. The image includes the Pendulum impulse, the values-consistent response, uncertain outcomes and the possibility of recovery rather than scripting compulsory success. The value is translated into one observable response—a sentence, boundary, request, pause or form of participation—and rehearsed through voice, posture, movement and attention. Regulation supports sufficient capacity for learning; it does not require complete calm.

Where relevant, the response can first be enacted within the therapeutic relationship through honesty, disagreement, need, boundary or repair. Because the relationship has real consequences, this encounter cannot be reduced to role-play. The response is then tested in a graded situation in everyday life: one that matters enough to activate the established prediction while remaining sufficiently manageable for observation and recovery.

Reflection compares what was predicted with what occurred, while also attending to bodily recovery, relational consequences, emerging preferences and unexpected meanings. Elements of the response can be retained, modified or rejected. Repetition across settings may increase the capacity’s availability, provided that experimentation remains responsive rather than becoming another rigid rule.

The cycle culminates provisionally in authorship. Here, authorship means recognising a response as something the person has chosen, enacted and incorporated into an evolving understanding of themselves, rather than merely something performed in response to therapeutic instruction or external expectation. The action is connected to a credible account of self: A part of me anticipated shame, and I was also capable of acting according to what mattered. The person owns the action without treating it as evidence of permanent transformation or a completed identity. That authorship then informs the next experiment rather than completing the process.

Authenticity and the Development of the Integrated-Self

Authenticity is sometimes imagined as perfect correspondence between inner feeling and outward behaviour. Such a definition is neither clinically realistic nor ethically sufficient. People contain competing wishes, affects and obligations. Privacy is not necessarily falseness; restraint is not necessarily capitulation; adaptation is not necessarily masking. Authenticity requires context and proportion.

Within this article, an authentic life refers to an increasingly coherent relationship among experience, values and chosen action. The person can recognise fear without allowing fear to impersonate identity, acknowledge shame without accepting its global verdict, and respond to relationship without automatically proving, hiding or surrendering.

Authenticity and integration are therefore related but not identical. Authenticity concerns how experience, values and chosen action are brought into relationship in a particular life. Integration concerns the breadth, connection and flexible availability of the person’s repertoire.

The Integrated-Self refers to the wider and more connected repertoire that develops through this process. Different affects, needs, roles, values and action tendencies can be acknowledged without one protective position controlling the whole response. Integration does not replace the Pendulum with a permanently confident character. It expands what the person can recognise, tolerate, choose and enact.

The person’s identity is therefore not treated as a statement to be installed through repetition. Rehearsal provides experiences; experience generates affective, relational and practical information; reflection organises meaning; and meaning influences subsequent imagination and action. Development remains recursive. What is imagined is tested against reality, and reality revises what is imagined.

This account also leaves room for surprise. A person may discover that a long-pursued goal belonged largely to overcompensation. They may experience anger where compliance previously obscured it, grief when avoidance recedes, or pleasure in an activity they had dismissed. A more authentic life is not simply a calmer version of the old one. It may involve new relationships, interests, boundaries and values.

The phrase reinventing oneself is useful if it does not imply discarding history or manufacturing an ideal persona. Reinvention can mean reorganising the relationship with what has been inherited: preserving capacities that remain valuable, relinquishing responses that have become restrictive and developing possibilities that earlier environments did not permit.

When Values-Guided Experiments Become Another Performance

Embodied rehearsal is not inherently liberating. It can reproduce the Pendulum when it is used to demand acceptable performance.

Rehearsal can become masking when the person is encouraged to conceal distress, fatigue, disability or neurodivergent difference in order to satisfy social expectations.

Values can become overcompensation when they are converted into moral standards the person must perform perfectly. Courage does not require maximal exposure; compassion does not require self-erasure; authenticity does not require indiscriminate disclosure.

Imagery can become coercive when the therapist supplies an ideal future that reflects therapeutic preference rather than the client’s emerging direction.

Functionally alternative action can become flooding when the person is pushed into overwhelming exposure without sufficient consent, preparation or capacity for recovery.

Relational rehearsal can become compliance when the therapist interprets agreement, emotional expression or apparent closeness as evidence of progress while overlooking the client’s fear of displeasing them.

Trauma survivors may already have extensive experience of performing compliance while internally mobilised, frozen or dissociated. Inviting further enactment without attending to power, consent and bodily cues risks repeating the very pattern therapy intends to change. Regulation and relational safety are not optional preliminaries to “real” action; they are part of the conditions under which action can remain chosen and learnable.

Scientific and Conceptual Limits

This article offers a conceptual formulation rather than evidence for a uniquely validated NA-CBT mechanism. Grounded cognition, mental imagery research, psychodrama and behavioural experimentation provide relevant but distinct bodies of knowledge. Their conceptual convergence does not prove that a particular sequence produces an Integrated-Self.

Performed, imagined and lived experiences may overlap in perceptual, motor and affective processes, but they are not interchangeable. Context, consequence, relationship, agency and autobiographical meaning affect what is learned. A successful rehearsal in therapy may not generalise; a values-consistent action may receive a painful response; repetition may consolidate rigidity if it occurs without reflection and adaptation.

Likewise, neuroplasticity is a general property of the nervous system, not evidence that every imagined or repeated action produces therapeutic change. Claims concerning neurological encoding, simulation or reconsolidation require specification of the process measured, the population studied, the conditions and the durability of any effect.

The Pendulum-Effect Formulation also requires empirical development. Its value in the present article is heuristic: it organises observable movement among three protective positions and supports collaborative selection of an alternative response. Future research should examine the formulation’s reliability, clinical utility and incremental contribution beyond established CBT, contextual behavioural and experiential approaches.

Conclusion

Authenticity need not be fully known before values-consistent action begins. Equally, it cannot be manufactured by counterfeiting confidence or performing an ideal identity. The person is not asked to suppress shame or behave as though vulnerability has disappeared. They are invited to recognise how shame may already be organising a restricted and repeatedly enacted repertoire.

Overcompensation rehearses the need to prove worth. Avoidance rehearses the danger of being seen. Capitulation rehearses the apparent truth of the shame-based account. Because these strategies are enacted cognitively, bodily and relationally, their familiarity may be mistaken for authenticity.

Values-guided behavioural experiments can redirect this capacity for repeated enactment. Imagery makes a different response conceivable. Embodied rehearsal gives it voice, posture, movement and affective relevance. The therapeutic relationship allows it to be attempted with another person, while graded action in everyday life tests it beyond the therapy room. Reflection, recovery and repetition help the person evaluate what occurred, recognise authorship and relate the experience to a developing autobiographical understanding.

Through this process, the person may discover preferences, boundaries, relationships and values that could not be fully known while life was organised around proving, hiding or surrendering. Authenticity is therefore neither simply found before action nor installed through performance. It is discovered and developed as imagined possibilities are embodied, lived, evaluated and revised. The Integrated-Self does not denote a permanently confident or completed identity. It describes an increasingly connected and flexible repertoire in which affects, needs, values and action tendencies can be acknowledged without one protective position automatically controlling the whole response.

The central therapeutic question is therefore not, How can I convincingly pretend to be someone else? It is:

If shame did not have the final say, what way of living would I be willing to imagine, test and gradually make my own?

References

Barsalou, L.W. (2008) ‘Grounded cognition’, Annual Review of Psychology, 59, pp. 617–645. https://doi.org/10.1146/annurev.psych.59.103006.093639

Berghs, M., Prick, A.J.C., Vissers, C. and van Hooren, S. (2022) ‘Drama therapy for children and adolescents with psychosocial problems: a systematic review on effects, means, therapeutic attitude, and supposed mechanisms of change’, Children, 9(9), 1358. https://doi.org/10.3390/children9091358

Cole, S.N., Smith, D.M., Ragan, K., Suurmond, R. and Armitage, C.J. (2021) ‘Synthesizing the effects of mental simulation on behavior change: systematic review and multilevel meta-analysis’, Psychonomic Bulletin & Review, 28(5), pp. 1514–1537. https://doi.org/10.3758/s13423-021-01880-6

Cruz, A., Sales, C.M.D., Alves, P. and Moita, G. (2018) ‘The core techniques of Morenian psychodrama: a systematic review of the literature’, Frontiers in Psychology, 9, 1263. https://doi.org/10.3389/fpsyg.2018.01263

Greenberger, D. and Padesky, C.A. (2016) Mind Over Mood: Change How You Feel by Changing the Way You Think. 2nd edn. New York: Guilford Press.

Hayes, S.C., Strosahl, K.D. and Wilson, K.G. (2012) Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd edn. New York: Guilford Press.

Holmes, E.A. and Mathews, A. (2010) ‘Mental imagery in emotion and emotional disorders’, Clinical Psychology Review, 30(3), pp. 349–362. https://doi.org/10.1016/j.cpr.2010.01.001

Ji, J.L., Burnett Heyes, S., MacLeod, C. and Holmes, E.A. (2016) ‘Emotional mental imagery as simulation of reality: fear and beyond—a tribute to Peter Lang’, Behavior Therapy, 47(5), pp. 702–719. https://doi.org/10.1016/j.beth.2015.11.004

Ji, J.L., Geiles, D. and Saulsman, L.M. (2021) ‘Mental imagery-based episodic simulation amplifies motivation and behavioural engagement in planned reward activities’, Behaviour Research and Therapy, 145, 103947. https://doi.org/10.1016/j.brat.2021.103947

Jiang, L., Alizadeh, F. and Cui, W. (2023) ‘Effectiveness of drama-based intervention in improving mental health and well-being: a systematic review and meta-analysis during the COVID-19 pandemic and post-pandemic period’, Healthcare, 11(6), 839. https://doi.org/10.3390/healthcare11060839

Mirea, D. (2026) ‘Beyond “Fake It Till You Make It”: The Pendulum-Effect, Embodied Rehearsal and the Development of the Integrated-Self’, The NeuroAffective-CBT® Journal, 3 September. Available at: https://neuroaffectivecbt.com/2026/09/03/beyond-fake-it-till-you-make-it-the-pendulum-effect-embodied-rehearsal-and-the-development-of-the-integrated-self/ (Accessed: 12 September 2026).

Moreno, J.L. (1946) Psychodrama: First Volume. Beacon, NY: Beacon House.

Moreno, J.L. (1947) The Theatre of Spontaneity. Beacon, NY: Beacon House.

Moreno, J.L. (1955) ‘Theory of spontaneity-creativity’, Sociometry, 18(4), pp. 105–118. https://doi.org/10.2307/2785848

Moreno, J.L. (1961) ‘The role concept: a bridge between psychiatry and sociology’, American Journal of Psychiatry, 118(6), pp. 518–523.

Moreno, J.L. (1965) ‘Therapeutic vehicles and the concept of surplus reality’, Group Psychotherapy, 18, pp. 211–216. https://doi.org/10.12926/ek7xhv15

Niedenthal, P.M. (2007) ‘Embodying emotion’, Science, 316(5827), pp. 1002–1005. https://doi.org/10.1126/science.1136930

Stanislavski, K. (2008) An Actor’s Work: A Student’s Diary. Translated and edited by J. Benedetti. London: Routledge.

Stanislavski, K. (2009) An Actor’s Work on a Role. Translated and edited by J. Benedetti. London: Routledge.

Vygotsky, L.S. (1999) ‘On the problem of the psychology of the actor’s creative work’, in Rieber, R.W. (ed.) The Collected Works of L. S. Vygotsky, Volume 6: Scientific Legacy. New York: Kluwer Academic/Plenum, pp. 237–244. (Original work published 1932.)


Confidentiality and composite-case statement

“Anna” is a fictionalised composite constructed from several clinically similar cases and is not a single client presented under a pseudonym. Identifying details, circumstances and sequences of events have been altered and combined to protect confidentiality. The illustration does not represent the complete treatment history of any individual client.

Copyright

© 2026 Daniel Mirea. All rights reserved.

Beyond ‘Fake It Till You Make It’: The Pendulum-Effect, Embodied Rehearsal and the Development of the Integrated-Self

Daniel Mirea (September, 2026)
| The NeuroAffective-CBT® Journal | 

Central proposition: We do not always need to feel confident before acting courageously. Carefully graded action can provide an embodied rehearsal through which affect tolerance, agency and self-trust may gradually develop.

She Knew What She Wanted to Say

Anna had prepared for the meeting more thoroughly than anyone else in the room.

She had read the papers twice, highlighted the relevant figures and anticipated several questions her colleagues might ask. The night before, she had rehearsed different versions of what she wanted to say. By the time the meeting began, there was little about the subject that she did not understand.

Yet when the opportunity to contribute arrived, Anna remained silent.

She felt the change in her body before she could put it into words. Her chest tightened, her throat seemed to narrow and her shoulders became rigid. While another colleague was speaking, Anna stopped listening fully and began monitoring herself.

When should I come in? What if I misunderstand the question? What if they realise that I am not as capable as they think?

She waited for the moment when she would feel certain enough to speak. It did not come.

When a colleague made a point similar to the one Anna had prepared, she nodded in agreement and told herself that there was no longer any reason to contribute. For a few seconds, she felt relieved. The danger of being exposed had passed.

The relief did not last. After the meeting, Anna replayed the conversation, criticised herself for remaining silent and treated the incident as evidence about her identity. She was no longer thinking, I found it difficult to speak in that meeting. She was thinking, I am weak. I am inadequate. This is who I am.

Her response was to prepare even more intensely for the next meeting.

Anna’s colleagues would probably have described her as conscientious, capable and exceptionally well prepared. They would not have seen the cycle beneath her competence: the attempt to overcome self-doubt through perfectionism, the withdrawal when certainty remained impossible and the self-attack that followed.

These responses were understandable in the context of Anna’s history. She had learned early that approval followed achievement and that mistakes attracted criticism. Careful preparation had helped her succeed; monitoring other people had helped her detect changes in mood; silence had sometimes protected her from humiliation. The difficulty was that these strategies had become so thoroughly rehearsed that they felt less like strategies and more like aspects of her personality.

When Anna entered therapy, she said that she wanted to become more confident. What she meant was that she wanted the anxiety to disappear before she acted. She imagined that confident people spoke because they felt certain, while she remained silent because something essential was missing within her.

Her first therapeutic experiment was deliberately modest. She was not asked to dominate a meeting, deliver a flawless presentation or behave as though she felt no anxiety. She was asked to prepare one genuine question and raise it within the first ten minutes.

Before rehearsing the question, Anna noticed what happened when she imagined herself speaking: her shoulders lifted, her jaw tightened and she felt an urge to delay. Rather than treating these reactions as proof that she should remain silent, she practised orienting towards the room, feeling the support of the chair and allowing a slower exhalation.

She then rehearsed the question aloud. At first, her voice was quiet and apologetic, and she prefaced the question with several explanations designed to protect her from being wrong. Gradually, she experimented with saying the same words more simply. She was not pretending to be another person. She was using her own voice to practise a response that her established protective system rarely permitted.

At the next meeting, Anna’s chest tightened again. The familiar prediction returned: Wait until you are completely certain.

This time, she asked the question.

She did not experience a sudden transformation. She did not feel fearless and nobody applauded. The question was answered and the meeting continued.

That ordinary continuation mattered. Anna had spoken while feeling activated. Nobody responded with contempt. Her body mobilised and then began to recover. Her specific prediction of humiliation had not occurred, but neither had she proved that criticism would never happen. She had learned something more credible: uncertainty did not make participation impossible.

This was not ‘faking it’. The anxiety was real, the bodily activation was real and the old prediction was still present. The action was also real.

Perhaps the more useful instruction is therefore:

Do not fake the feeling. Practise the action, remain connected to the body, observe what happens and allow the experience to revise what seems possible.

Anna’s experience will accompany the ideas that follow. Her movement between perfectionistic overpreparation, avoidance and self-attack illustrates the Pendulum-Effect Formulation. Her use of voice, posture, attention and action shows why rehearsal is more than positive thinking. Most importantly, her increasing ability to participate while remaining connected to her experience demonstrates how an unfamiliar response may gradually become available within the Integrated-Self.

From Pretence to Rehearsal

The phrase ‘fake it till you make it’ is memorable because it reverses a common assumption: that an internal state must arrive before action becomes possible. When I feel confident, I will speak. When my anxiety disappears, I will travel. When I believe I am worthy, I will allow myself to be visible.

Waiting for the preferred feeling can, however, become part of the avoidance cycle. The person receives little corrective information, the feared situation remains unfamiliar and the old self-concept is repeatedly confirmed.

The alternative is not dishonesty. A person can acknowledge, ‘I feel anxious and part of me expects rejection’, while also practising one behaviour associated with agency: making eye contact, expressing a preference, asking a question or remaining present long enough to discover what happens. Confidence may be incomplete, but the action is genuine.

This distinction matters clinically. Pretence requires the person to deny or conceal their experience. Rehearsal asks them to remain in contact with that experience while trying a response that has previously been inhibited. It is not a demand to feel differently on command; it is an opportunity to discover whether feeling anxious, ashamed or uncertain necessarily determines what happens next.

Why Embodiment Still Matters

Some traditional psychological language implies a one-way sequence in which thought creates emotion and the body merely displays the result. Embodied and grounded approaches complicate this picture. Cognitive and affective processes draw upon perception, movement, interoception and situated interaction with the environment. Bodily activity therefore participates in experience rather than serving only as its outward consequence (Barsalou, 2008; Niedenthal, 2007).

Anna’s bodily activation, threat predictions, shame, narrowed attention and silence formed an interacting state. Her tightening chest did not simply report a conclusion her mind had already reached; it contributed to an experience in which participation felt dangerous and withdrawal felt protective.

This does not mean that changing posture automatically transforms identity, or that imagination, performance and lived reality are neurologically interchangeable. Bodily manipulations can influence emotional experience, but their effects may be small, variable and dependent upon context. Research on facial feedback provides a useful warning: the overall effect appears detectable but modest, and outcomes differ according to the task and the emotional experience being measured (Coles, Larsen and Lench, 2019; Coles et al., 2022).

Embodied rehearsal makes a more limited and clinically useful claim. When a person rehearses a boundary or asks a question aloud, the intervention involves more than substituting one thought for another. The person must use their actual voice, regulate breath and muscular activation, direct attention outwards, tolerate the affect evoked by being visible and recover afterwards. The body is neither a shortcut nor a programmable prop; it is part of the situation in which new action and learning become possible.

Acting as Rehearsal Rather Than Pretence

Theatre makes the embodied nature of psychological experience unusually visible. An actor does not learn a role through abstract interpretation alone. The role is organised repeatedly through voice, breath, posture, timing, movement, attention, relationships and responses to the environment. Through rehearsal, the actor temporarily inhabits a behavioural and affective configuration that may initially feel unfamiliar.

Lev Vygotsky recognised that acting raises a psychologically important question: must actors genuinely experience the emotions they portray, or can emotion emerge through the organisation of performance? Discussing Stanislavski’s system and Diderot’s ‘paradox of the actor’, Vygotsky situated emotional experience within a wider relationship among role, action, social meaning, theatrical tradition and audience (Vygotsky, 1999; original work published 1932). His analysis cautions against treating performed and lived emotions as either completely separate or neurologically interchangeable.

Within a different clinical tradition, J. L. Moreno placed action, role and enactment at the centre of psychological change (Moreno, 1946, 1947). In psychodrama, clients do not merely describe an experience. They enter a structured dramatic space in which relationships, conflicts, memories and possible responses can be enacted. Role reversal, doubling, mirroring and role training allow previously unavailable perspectives and behavioural positions to be experienced, observed and rehearsed (Cruz et al., 2018; Moreno, 1946).

Moreno proposed that the self emerges through the roles a person develops and performs, describing role as a bridge between psychiatry, psychology and sociology (Moreno, 1946, 1961). Psychological development, from this perspective, does not require the discovery of one fixed and supposedly authentic identity concealed beneath behaviour. It may involve expanding the person’s role repertoire and increasing the capacity to respond spontaneously and creatively rather than remaining confined within rigid, overlearned patterns (Moreno, 1947, 1955).

A new role does not require a person to become somebody else. It may provide temporary access to an inhibited aspect of their existing repertoire. Someone organised around compliance may rehearse setting a boundary. Someone governed by shame may practise being visible. Someone who anticipates helplessness may experiment with acting from a position of agency.

What initially feels artificial may feel unfamiliar precisely because it contradicts an established protective pattern. A person who has spent years accommodating others may experience an ordinary boundary as unnatural. Someone accustomed to silence may describe speaking with authority as ‘not feeling like me’. Yet familiarity is not the same as authenticity. Sometimes what feels most familiar is simply what has been rehearsed for the longest.

Moreno’s concept of surplus reality is relevant here. The psychodramatic space allows a person to enact what did not happen, what has not yet happened or what could not safely be expressed in everyday life (Moreno, 1965). A boundary may finally be spoken or a more agentic position temporarily inhabited. The enactment is not equivalent to lived reality, but it may provide an experiential bridge between what the person currently predicts and what they may gradually become able to tolerate and perform.

Contemporary drama-based interventions employ related processes, including role, narrative, enactment, distancing and witnessed performance. Reviews report promising findings across psychosocial, emotional and behavioural outcomes, while also identifying considerable variation in populations, interventions, methods and study quality (Berghs et al., 2022; Jiang et al., 2023). These findings support careful clinical exploration; they do not establish that performance reliably installs safety, autonomy or a new identity within the nervous system.

From Psychodrama to Behavioural Rehearsal

Moreno was not the only early clinician to place action before emotional readiness. In Conditioned Reflex Therapy, Andrew Salter argued that change could be facilitated through deliberate practice of expressive and assertive behaviour, including speaking directly about feelings, using the first-person pronoun ‘I’, expressing disagreement and accepting praise (Salter, 1949). People were not expected to wait until they felt naturally assertive; behaviour was practised first, including beyond the consulting room, so that experience and interpersonal feedback could begin to modify established patterns.

Salter’s learning-based approach was theoretically distinct from Moreno’s emphasis on role, encounter and dramatic enactment, but both challenged the assumption that insight, confidence or emotional readiness must precede behaviour. Salter explained change through Pavlovian concepts of cortical excitation and inhibition; these ideas are historically important but are not established mechanisms within contemporary neuroscience.

Vygotsky, Moreno and Salter therefore provide different perspectives that can be brought into dialogue with a NeuroAffective-CBT® (NA-CBT) account of embodied rehearsal. They do not validate NA-CBT or establish its mechanisms. They help situate its central proposition within a longer history of understanding action, role and experience as mutually influential.

The Pendulum Beneath the Performance

The Pendulum-Effect Formulation identifies the protective pattern that restricts action; embodied rehearsal creates an opportunity to practise a different response; reflection and repetition allow that response gradually to become available within the Integrated-Self.

Figure 1. The Pendulum-Effect Formulation: Overcompensation, Avoidance and Capitulation represent different protective positions organised around a shared shame-based prediction. Embodied rehearsal, graded action, reflection and repetition provide an alternative agentic pathway through which a different response may gradually become available within the Integrated-Self.

In anticipation of shame, Anna moved towards Overcompensation: preparing excessively, mentally rehearsing every sentence and attempting to eliminate the possibility of error. When complete certainty remained unattainable, she shifted towards Avoidance: delaying her contribution, weakening what she wanted to say or remaining silent. After the meeting, she moved into Capitulation: attacking herself and treating her silence as proof that she was weak or incapable.

These apparently contradictory responses belonged to the same protective system. Overcompensation attempted to disprove the shame-based narrative. Avoidance prevented its anticipated exposure. Capitulation surrendered to it as though it were established fact. Each position offered some immediate regulation or certainty, but their repeated enactment maintained the shame-based understanding of the self.

The pendulum was expressed through the whole person. Overcompensation appeared as urgency, muscular tension, relentless preparation and vigilant monitoring of others. Avoidance appeared as restricted movement, a quieter voice, averted gaze and silence. Capitulation appeared as heaviness, reduced agency and repetitive self-attacking language. Thought, affect, attention, bodily organisation and behaviour reinforced one another.

Anna was not asked to argue her shame away or persuade herself that she was unquestionably competent. Instead, she was invited to test whether the internalised shame-based account represented the whole truth:

If the belief that I am inadequate were not allowed to make the entire decision, what would I do next?

If shame and self-doubt did not have the final say, what would I choose to do next?

These questions are consistent with Greenberger and Padesky’s use of acting as if, in which a person behaves experimentally in accordance with a more balanced alternative belief and observes the consequences (Greenberger and Padesky, 2016). Anna was not required to believe the alternative in advance; the action created an opportunity to gather information that her established shame-based belief and protective responses had previously restricted.

Asking one genuine question created a position that was neither overcompensating, avoidant nor capitulating. Anna participated without performing perfection. Her anxiety remained present, but it no longer determined the whole response.

In this application, acting as if did not require Anna to suppress her shame or convince herself that she was already confident, lovable or worthy. By enacting a valued response while shame remained active—and discovering that she could be visible, remain present and recover—Anna encountered embodied evidence that the shame-based prediction might not represent the whole truth about her. Through reflection and repetition, such experiences can gradually be incorporated into autobiographical identity and become increasingly available within the Integrated-Self.

The broader NA-CBT concept of the Integrated-Self has also been discussed in relation to NeuroAffective Narrative Reconsolidation, where experiences organised around threat and identity-disrupting meaning are revisited in the presence of regulation, agency and new autobiographical meaning (Mirea, 2026). The present article proposes a related, but not identical, process: embodied rehearsal may help the person discover that shame is an affective state accompanied by learned predictions, not an absolute description of identity.

The Pathway from Protective Pattern to Integrated-Self

The movement from a shame-organised protective pattern towards the Integrated-Self can be understood as an iterative sequence rather than a single technique. Although the stages are presented separately, therapy may move back and forth among them as experience generates new information.

1. Recognise the Pendulum movement

The Pendulum-Effect Formulation helps the person recognise how apparently different responses may be organised around the same affective threat. Attention is given not only to behaviour but also to affect, prediction, bodily organisation, attention and relational function.

The question shifts from What is wrong with me? to:

What is this response attempting to prevent, disprove or make certain?

For Anna, extensive preparation was not simply conscientiousness, silence was not simply passivity and self-attack was not simply low mood. Together, they formed a repeating attempt to manage anticipated shame. Overcompensation attempted to disprove inadequacy, avoidance prevented its anticipated exposure and capitulation treated the shame-based account as established fact.

2. Clarify an emerging value

Change requires more than moving away from anxiety or interrupting an unwanted behaviour. The person needs a direction in which they genuinely wish to move: participation, connection, curiosity, honesty, self-respect, courage or appropriate assertiveness.

A value should not become another idealised identity or perfectionistic standard. I want to relate with honesty is more workable than I must become a completely authentic person.

Anna’s emerging direction was participation. Her goal was not to appear impressive, eradicate anxiety or prove that she was competent. It was to contribute something genuine without abandoning herself. This direction provided a reason to act that did not depend upon feeling confident first.

3. Imagine the situation and its difficulties

Present-tense, multisensory imagery can evoke the anticipated situation before the person enters it (Hackmann, Bennett-Levy and Holmes, 2011; Holmes and Mathews, 2010). The image should include the Pendulum impulse, the values-consistent response, uncertain outcomes and recovery. Its purpose is to prepare for reality rather than script compulsory success.

Anna imagined entering the meeting, noticing people turning towards her and feeling the first signs of activation. She became aware of her lifted shoulders, tightened jaw, restricted breathing and urge to delay. She also noticed the familiar prediction: If I speak without complete certainty, I will expose my inadequacy.

The image was not changed into a fantasy in which Anna felt completely calm and everyone responded warmly. Instead, she imagined remaining activated while orienting towards the room, feeling the support of the chair and allowing a slower exhalation. She also imagined several possible outcomes, including interest, indifference, misunderstanding and disagreement.

Imagery made the shame-based prediction observable while creating a provisional model of how Anna might respond differently.

4. Embody and rehearse one observable response

The emerging value is translated into voice, movement, posture, attention and action. The person may rehearse a sentence, question, boundary, request, pause or other form of participation while noticing the protective impulses that arise.

Anna practised asking her question aloud. At first, her voice was quiet and apologetic. She surrounded the question with explanations intended to protect her from being wrong. Through rehearsal, she noticed these movements and experimented with saying the same words more simply.

The purpose was not to manufacture confidence or produce a flawless performance. It was to make participation behaviourally and bodily available. Regulation supported sufficient capacity for learning; it did not require Anna to become completely calm before speaking.

5. Enact it within the therapeutic relationship

Where relevant, the therapy relationship provides an immediate opportunity to practise honesty, disagreement, need, boundary or repair. The consulting room is not merely a protected place in which the person prepares for relationships elsewhere. It is itself a real relationship in which the Pendulum may become visible.

Anna noticed that she also tried to perform competence in therapy. She prepared detailed accounts, searched for the “right” insight and sometimes agreed with interpretations that did not entirely fit. She worried that disagreement would disappoint the therapist or make her appear resistant.

In imagery and rehearsal, Anna practised telling the therapist that a recent exercise had felt too structured and that she had felt less connected during it. She then expressed this in the session. She remained physiologically activated, but she did not overexplain, withdraw or surrender her experience.

The significance of this moment did not depend solely upon receiving reassurance. Anna discovered that she could express a difference and continue relating. The therapeutic relationship became a real site of embodied rehearsal, feedback and revision rather than another setting in which she had to perform correctly.

6. Test it in everyday life

Rehearsal becomes therapeutically meaningful when it is translated, where safe and appropriate, into graded action. The situation should matter enough to activate the existing prediction but remain sufficiently manageable to permit observation and recovery.

Anna’s first task was deliberately modest: to prepare one genuine question and ask it within the first ten minutes of a meeting. The task activated her fear of exposure without requiring her to dominate the discussion or deliver a flawless presentation.

When the moment arrived, Anna’s chest tightened and the familiar instruction returned: Wait until you are completely certain.

This time, she asked the question. Her anxiety remained present, but it no longer determined the whole response.

7. Reflect, adapt and repeat

The outcome is not classified simply as success or failure. The person compares what was predicted with what occurred, observes how activation changed and considers what supported presence and recovery. Difficult or ambiguous outcomes must be included rather than converted into a compulsory success narrative.

Anna’s question was answered and the meeting continued. She did not experience a sudden transformation, but neither did the humiliation she had predicted occur. Her body mobilised and then began to recover.

Anna had not proved that she would never be criticised. She had learned something more credible: she could speak without complete certainty, tolerate the activation and recover afterwards.

The response was subsequently adapted and tested in other situations. Anna expressed a preference about the direction of a project, declined an additional responsibility and practised contributing without producing an exhaustive defence. Repetition across varied contexts helped make the capacity more accessible without converting it into another rigid rule.

8. Consolidate authorship and expand authenticity

Reflection connects the action with a credible autobiographical understanding of the self. The person is invited to recognise:

A part of me anticipated shame, and I was also capable of acting according to what mattered.

Anna had not merely watched a rehearsed role ask the question. It was her body that tolerated the visibility, her voice that produced the words and her agency that remained present while doubt continued. Consolidating authorship allowed the experience to become part of her developing self-understanding without requiring her to claim permanent transformation.

Within this article, the Integrated-Self refers to an increasingly connected and flexible repertoire in which different affects, needs, values and action tendencies can be acknowledged without one protective position automatically controlling the whole response. Integration does not replace anxiety with permanent confidence or install a new idealised character. It expands what the person can recognise, tolerate, choose and enact.

Anna’s emerging understanding was therefore not:

I am always confident.

It was more credible:

I can notice the urge to prove, hide or surrender and still choose how I want to participate.

Why Action Can Precede Motivation and Confidence

People often wait not only for confidence but also for motivation. Yet motivation is not always a prerequisite for action; it can also be an outcome of action. Behavioural activation, exposure, skills rehearsal and behavioural experiments all make use of the principle that experience can generate information unavailable through reflection alone.

The mechanism is not repetition by itself. Repetition without awareness may consolidate an existing pattern. Useful rehearsal involves a meaningful prediction, tolerable activation, observable action, attention to the outcome, recovery and reflection. If the task overwhelms the person, it may reinforce the expectation that the situation is unmanageable. If it is effortless and emotionally irrelevant, little new learning may occur. Grading is therefore not a concession to weakness but part of the learning design.

Motivation may increase when the person experiences even a small degree of authorship: I did something that mattered while the old feeling was still present. This differs from waiting passively for an internal state to grant permission. It also differs from coercing action in the name of progress. The target must remain personally meaningful, collaboratively chosen and open to revision.

Bringing Embodied Rehearsal into Practice

In practice, embodied rehearsal is developed collaboratively around a personally meaningful and observable response. The therapist and client anticipate how the protective pattern may appear, rehearse the response while allowing manageable activation to remain present and, where appropriate, test it through graded action in everyday life. What was predicted is then compared with what occurred, including how the person responded, recovered and understood their own agency. The process is adapted and repeated across contexts, not to perfect a new performance, but to help a previously inhibited response become increasingly available within the Integrated-Self.

When ‘Acting as If’ Becomes Harmful

Embodied rehearsal is not universally helpful. It becomes clinically problematic when it asks a person to deny reality, conceal distress or perform beyond their capacity. Several distinctions are essential:

  • Rehearsal versus masking: rehearsal expands choice; masking demands a socially acceptable performance while hiding need, fatigue or neurodivergent difference.
  • Courage versus flooding: graded action permits activation and recovery; flooding overwhelms regulation and may reinforce danger.
  • Aspiration versus deception: practising a skill differs from claiming competence, qualifications or safety that do not exist.
  • Embodiment versus emotional invalidation: posture, breathing or voice work should not be used to tell a distressed person that their feelings are incorrect.
  • Agency versus coercion: the person chooses the target action and retains permission to pause, modify or stop.

Trauma survivors may have extensive experience of performing compliance while internally mobilised, frozen or dissociated. Inviting further performance without attending to consent, relational safety and bodily cues risks repeating the problem. Regulation is not merely a preliminary exercise before the ‘real’ intervention; it is part of the conditions under which action can remain chosen and learnable.

A Necessary Scientific Caution

The language of neuroplasticity is sometimes used as though naming it proves a specific intervention. Neuroplasticity is a general property of the nervous system, not evidence that every repeated performance produces therapeutic change. Claims about neurological ‘encoding’ require precision: which process was measured, in which population, under what conditions and with what durability?

Performed and lived experiences may overlap in perceptual, motor and affective processes, but they are not interchangeable. Context, consequences, relationships, agency and autobiographical meaning matter. Theatre, psychodrama and role rehearsal may offer bridges to new experience; real-world generalisation still requires testing, reflection and consolidation.

Moreno’s work provides an important clinical and historical foundation for embodied rehearsal, while contemporary research on embodied and grounded cognition offers a partially compatible scientific context. The traditions can be brought into productive dialogue, but Morenian concepts should not retrospectively be presented as neuroscientific discoveries. Their relationship is one of conceptual convergence and clinical compatibility, not proof that contemporary neuroscience has directly validated Morenian theory or NA-CBT.

NA-CBT therefore uses neuroscience to constrain and enrich formulation, not to decorate it. Where evidence is indirect, the language should remain conceptual and provisional.

Rehearse—Do Not Pretend

‘Fake it till you make it’ becomes clinically useful only when pretence is replaced by carefully formulated rehearsal. People do not need to counterfeit confidence or suppress authentic distress. They can practise behaviours that express an emerging value while acknowledging the body’s protective response.

The Pendulum-Effect Formulation helps identify how overcompensation, avoidance and capitulation restrict action around a shared affective threat. Embodied rehearsal then gives the person a protected opportunity to use their own voice and body differently. Graded action carries the experiment into lived experience; reflection, recovery and repetition help establish whether the response can become more available across contexts.

Anna did not become somebody else. She did not eliminate uncertainty or install a permanently confident identity. She discovered that the anxious, self-protective part of her did not have to make every decision. Speaking became less foreign, recovery became more familiar and participation became a credible part of what she could do.

From an NA-CBT perspective, the therapeutic question is therefore not, ‘How can I convincingly pretend to be someone else?’ It is:

What response needs to be practised so that it can become more available within my Integrated-Self?

References

Barsalou, L.W. (2008) ‘Grounded cognition’, Annual Review of Psychology, 59, pp. 617–645. https://doi.org/10.1146/annurev.psych.59.103006.093639

Berghs, M., Prick, A.J.C., Vissers, C. and van Hooren, S. (2022) ‘Drama therapy for children and adolescents with psychosocial problems: a systematic review on effects, means, therapeutic attitude, and supposed mechanisms of change’, Children, 9(9), 1358. https://doi.org/10.3390/children9091358

Coles, N.A., Larsen, J.T. and Lench, H.C. (2019) ‘A meta-analysis of the facial feedback literature: effects of facial feedback on emotional experience are small and variable’, Psychological Bulletin, 145(6), pp. 610–651. https://doi.org/10.1037/bul0000194

Coles, N.A. et al. (2022) ‘A multi-lab test of the facial feedback hypothesis by the Many Smiles Collaboration’, Nature Human Behaviour, 6, pp. 1731–1742. https://doi.org/10.1038/s41562-022-01458-9

Cruz, A., Sales, C.M.D., Alves, P. and Moita, G. (2018) ‘The core techniques of Morenian psychodrama: a systematic review of the literature’, Frontiers in Psychology, 9, 1263. https://doi.org/10.3389/fpsyg.2018.01263

Greenberger, D. and Padesky, C.A. (2016) Mind Over Mood: Change How You Feel by Changing the Way You Think. 2nd edn. New York: Guilford Press.

Hackmann, A., Bennett-Levy, J. and Holmes, E.A. (2011) Oxford Guide to Imagery in Cognitive Therapy. Oxford: Oxford University Press. https://doi.org/10.1093/med:psych/9780199234028.001.0001

Holmes, E.A. and Mathews, A. (2010) ‘Mental imagery in emotion and emotional disorders’, Clinical Psychology Review, 30(3), pp. 349–362. https://doi.org/10.1016/j.cpr.2010.01.001

Jiang, L., Alizadeh, F. and Cui, W. (2023) ‘Effectiveness of drama-based intervention in improving mental health and well-being: a systematic review and meta-analysis during the COVID-19 pandemic and post-pandemic period’, Healthcare, 11(6), 839. https://doi.org/10.3390/healthcare11060839

Mirea, D. (2026) ‘NeuroAffective Narrative Reconsolidation: Integrating Traumatic Memories and the Development of the Integrated-Self in NeuroAffective-CBT’, NeuroAffective-CBT Online Journal, 5 March. Available at: article webpage (Accessed: 3 September 2026)

Moreno, J.L. (1946) Psychodrama: First Volume. Beacon, NY: Beacon House.

Moreno, J.L. (1947) The Theatre of Spontaneity. Beacon, NY: Beacon House.

Moreno, J.L. (1955) ‘Theory of spontaneity-creativity’, Sociometry, 18(4), pp. 105–118. https://doi.org/10.2307/2785848

Moreno, J.L. (1961) ‘The role concept: a bridge between psychiatry and sociology’, American Journal of Psychiatry, 118(6), pp. 518–523.

Moreno, J.L. (1965) ‘Therapeutic vehicles and the concept of surplus reality’, Group Psychotherapy, 18, pp. 211–216. https://doi.org/10.12926/ek7xhv15

Niedenthal, P.M. (2007) ‘Embodying emotion’, Science, 316(5827), pp. 1002–1005. https://doi.org/10.1126/science.1136930

Salter, A. (1949) Conditioned Reflex Therapy. New York: Creative Age Press.

Vygotsky, L.S. (1999) ‘On the problem of the psychology of the actor’s creative work’, in Rieber, R.W. (ed.) The Collected Works of L. S. Vygotsky, Volume 6: Scientific Legacy. New York: Kluwer Academic/Plenum, pp. 237–244. (Original work published 1932.)

Author’s Note

This article presents a conceptual NeuroAffective-CBT formulation intended for professional discussion and psychoeducation. It does not claim that embodied rehearsal is a stand-alone treatment or that the mechanisms proposed here have been uniquely validated for NA-CBT. Interventions should be adapted to individual formulation, consent, clinical risk and professional scope of practice.

Continue reading: Developing Authenticity Through Values-Guided Behavioural Experiments explores the next stage of Anna’s clinical illustration—from embodied possibility towards values, authorship and authentic living.

Beyond the Mirror: A NeuroAffective-CBT Case Study of Body Dysmorphic Disorder

Dr Oana Barnett (July, 2026)
| The NeuroAffective-CBT® Journal | 

Abstract

Body Dysmorphic Disorder (BDD) is a debilitating psychological condition characterised by persistent preoccupation with perceived defects in physical appearance, often resulting in significant emotional distress, functional impairment, and repetitive safety behaviours. Although cognitive-behavioural therapy (CBT) remains the recommended psychological intervention for BDD, many individuals continue to experience recurrent symptoms despite previous therapeutic gains.

This case study introduces NeuroAffective-CBT (NA-CBT) through the treatment of “Sophie”, a woman in her fifties presenting with longstanding Body Dysmorphic Disorder, chronic shame, recurrent depression, insomnia, social withdrawal, and increasing psychological distress following menopause, occupational loss, and repeated cosmetic procedures. Rather than conceptualising these difficulties as isolated symptoms, NA-CBT formulated them as interacting manifestations of increased neuroaffective load, arising through the dynamic relationship between physiology, affect, cognition, autobiographical memory, and interpersonal experience.

Grounded within the cognitive behavioural tradition, NA-CBT integrates contemporary neuroscience, affective science, lifestyle medicine, and behavioural psychology while maintaining the collaborative, structured and evidence-informed principles that characterise CBT (Beck, 1976, 2021; Clark & Beck, 2010). Central to this formulation is the TED (Tired–Exercise–Diet) framework, alongside the Body–Brain–Affect Triangle, which together provide a practical model for understanding how physiological regulation influences affective processing, cognitive interpretation, and psychological flexibility (Mirea, 2023, 2025a, 2025b).

Treatment focused on reducing neuroaffective load, strengthening physiological regulation, facilitating NeuroAffective Narrative Reconsolidation, and supporting the gradual emergence of a more coherent and compassionate Integrated-Self. Throughout therapy, the therapist repeatedly returned to a simple but clinically significant question:

“What might be maintaining your neuroaffective load, and what might help reduce it?”

Rather than replacing established cognitive behavioural models of Body Dysmorphic Disorder, NA-CBT extends them by integrating affective neuroscience and physiological regulation into psychological formulation and intervention. This case study illustrates how an integrated neuroaffective perspective may enhance therapeutic understanding and contribute to the treatment of complex presentations characterised by chronic shame, self-criticism, and recurrent emotional distress.

Keywords: Body Dysmorphic Disorder; Cognitive Behavioural Therapy; NeuroAffective-CBT; Affect; Neuroscience; TED; Lifestyle Interventions; Integrated-Self.

Introduction

Body Dysmorphic Disorder (BDD) is characterised by persistent preoccupation with perceived defects in physical appearance that are either unobservable or appear slight to others (American Psychiatric Association, 2022). These concerns are typically accompanied by repetitive behaviours such as mirror checking, camouflage, reassurance seeking, appearance comparisons, and avoidance of social situations. The condition frequently results in profound impairment across occupational, interpersonal, and emotional domains and is associated with elevated rates of depression, anxiety, social isolation, and suicidality (Phillips, 2005; Phillips et al., 2010).

Cognitive Behavioural Therapy (CBT) remains the recommended psychological treatment for Body Dysmorphic Disorder, with substantial evidence supporting interventions targeting dysfunctional appearance beliefs, selective attention, avoidance, and safety behaviours (Veale, 2004; Veale & Neziroglu, 2010; Wilhelm et al., 2013). Nevertheless, many individuals continue to experience recurring symptoms following successful therapy, particularly when significant life transitions, physiological changes, or cumulative adversity increase emotional vulnerability.

These observations invite an important clinical question: Is recurrence always evidence that previous therapy has failed? Or might it reflect a profound change in the physiological and affective conditions within which previously acquired psychological skills are now expected to operate?

NeuroAffective-CBT (NA-CBT) emerged from this question. NA-CBT belongs firmly within the broad family of cognitive behavioural therapies. It retains the structured formulation, collaborative empiricism, behavioural experimentation, and evidence-informed practice that have long characterised CBT (Beck, 1976; Beck, 2021; Clark & Beck, 2010). What distinguishes NA-CBT is not a departure from cognitive behavioural principles, but a greater depth of integration. It draws together contemporary neuroscience, affective science, physiology, attachment, and behavioural psychology within a unified cognitive behavioural formulation (Damasio, 1999; LeDoux, 2015; Panksepp, 1998; Mirea, 2018).

Here, philosophy meets science. The body meets the mind.

Rather than conceptualising emotional distress as existing solely within cognition, NA-CBT understands psychological experience as emerging through continuous interactions between physiology, affective systems, cognitive interpretation, autobiographical memory, and interpersonal relationships. Mind and body are therefore not treated as separate domains requiring different explanatory models, but as components of a single, dynamically regulated neuroaffective system (Barrett, 2017; Friston, 2010; Siegel, 2012).

This perspective does not replace existing CBT models of Body Dysmorphic Disorder. Instead, it extends them by asking an additional question:

What neuroaffective conditions allow these cognitive and behavioural processes to become more or less dominant?

The following case study illustrates how this formulation informed the treatment of a woman with longstanding Body Dysmorphic Disorder whose psychological difficulties unfolded against a backdrop of increasing physiological, relational, and emotional burden.

Case Presentation

Sophie was a woman in her early fifties who self-referred for psychological therapy following a significant deterioration in her emotional wellbeing. She had previously completed a course of Cognitive Behavioural Therapy several years earlier, during which she developed a good understanding of the cognitive and behavioural processes maintaining her appearance concerns. She described this therapy positively and reported that it had enabled her to manage her symptoms effectively for a number of years.

However, by the time she returned to therapy, Sophie no longer felt able to access the psychological flexibility she had previously achieved.

Over the intervening years, she had undergone several cosmetic procedures in the hope of correcting perceived flaws in her appearance. Rather than reducing her distress, these interventions intensified her preoccupation, leaving her feeling increasingly disfigured and emotionally devastated. She subsequently became involved in prolonged legal proceedings against one of the practitioners, describing the experience as deeply invalidating and reinforcing her conviction that she had been permanently damaged.

Alongside these experiences, Sophie’s life had changed considerably. She was now navigating menopause, persistent insomnia, increasing fatigue, and declining physical energy. She had lost her employment and found it difficult to secure another position. The increasing reliance on online meetings following the COVID-19 pandemic intensified her appearance concerns, as seeing herself on camera throughout the working day became a persistent source of anxiety and self-monitoring. She frequently turned her camera off whenever possible and described feeling acutely self-conscious whenever she was visible on screen.

Socially, Sophie reported becoming increasingly isolated. Although married, she experienced growing emotional distance within her relationship and described feeling profoundly alone. Her family of origin remained abroad, limiting opportunities for support. She also spoke with increasing sadness about never having had children, describing this as a source of grief that had become more salient as she grew older.

Despite continuing to use many of the cognitive strategies she had learned previously, Sophie experienced overwhelming shame, chronic self-criticism, increasing avoidance, disrupted sleep, emotional exhaustion, and persistent beliefs that she was fundamentally defective. She no longer described herself as simply feeling unattractive.She described feeling broken.

From a conventional CBT perspective, these changes might reasonably be understood as an exacerbation of existing Body Dysmorphic Disorder following multiple adverse life events. From a NeuroAffective-CBT perspective, however, a different question emerged:

What had changed within Sophie’s neuroaffective system that made previously effective psychological strategies increasingly difficult to access?

Developmental Experiences and the Emergence of the Integrated-Self

Sophie’s appearance concerns did not emerge in isolation. As therapy progressed, it became increasingly apparent that her relationship with beauty, worth, and belonging had developed within a family environment in which physical appearance carried considerable emotional significance.

She described growing up with the implicit understanding that beauty was more than an aesthetic quality—it reflected character, value, and lovability. Family conversations frequently centred on appearance, and those considered physically attractive appeared to receive greater admiration, attention, and warmth. Beauty became quietly associated with being “a good person”, while ordinary appearance felt synonymous with being overlooked.

One figure came to symbolise this experience throughout Sophie’s childhood.

Her cousin was widely regarded within the family as exceptionally beautiful. Sophie recalled adults openly commenting on her cousin’s appearance with admiration and delight, describing her as special, elegant, and somehow different from everyone else. As a young girl, Sophie became convinced that if she could somehow become beautiful enough, she too might receive the same affection, recognition, and emotional closeness from her mother and older sister.

Although this belief was never explicitly stated, it gradually became woven into her understanding of herself and others.

Beauty became associated with safety.Acceptance became conditional. Worth became something that had to be earned.

From a NeuroAffective-CBT perspective, these experiences contributed to the development of Deeply Rooted Beliefs (DRBs) concerning identity, acceptance, and interpersonal value. Unlike automatic thoughts, DRBs are understood as emotionally organised assumptions that develop over repeated affective experiences and gradually shape how individuals interpret themselves, others, and the world (Beck, 1976; Mirea, 2018). These beliefs rarely operate at the level of deliberate reasoning. Instead, they become embedded within autobiographical memory, affective prediction, and patterns of physiological responding.

One childhood memory remained particularly vivid throughout therapy.

Sophie recalled accompanying her cousin into a shop during adolescence. Her cousin secretly stole an item before leaving the store. Moments later, the shop assistant stopped Sophie, accusing her of the theft. Despite Sophie’s repeated insistence that she had done nothing wrong, the accusation continued. What remained most emotionally significant was not the theft itself, but the explanation she believed lay behind the accusation.

She recalled the shop assistant commenting that her cousin “looked too beautiful” to have stolen anything, whereas Sophie, with her darker features, “looked like the sort of person who would.” Whether these words were remembered verbatim or reconstructed over time became less important than the emotional meaning they continued to hold.

For Sophie, the experience crystallised a painful conclusion:

“People see something bad in me before they know me.”

The memory became one of the earliest examples of shame becoming organised not around behaviour, but around identity.

Many years later, this image continued to intrude unexpectedly. It frequently emerged before social situations, during work meetings, while shopping, and whenever Sophie felt herself being observed. Although intellectually she recognised the event belonged to the past, emotionally it continued to feel immediate. Her body responded as though the judgement were happening again in the present.

From a NeuroAffective-CBT perspective, such memories are understood not simply as autobiographical recollections but as emotionally encoded experiences that continue to influence present-day prediction and affective regulation (Lane et al., 2015; Brewin, 2014). Rather than remaining historical events, they become living templates through which new interpersonal experiences are interpreted.

Importantly, therapy did not conceptualise these experiences as evidence of a permanently fragmented self.

Instead, NA-CBT assumes that beneath layers of shame, fear, self-protection, and defensive adaptation lies an Integrated-Self, a coherent and compassionate sense of identity that has become increasingly difficult to access under conditions of sustained neuroaffective load (Mirea, 2018).

The therapeutic task therefore shifts. Rather than asking how the fragmented self can be repaired, NA-CBT asks:

What conditions might allow the Integrated Self to emerge more consistently?

This subtle change in formulation proved clinically important. It invited both therapist and client to become curious about the conditions supporting psychological integration, rather than focusing exclusively on pathology or symptom reduction.

Pause for Curiosity

Perhaps the most important question was no longer:

“Why does Sophie continue to experience Body Dysmorphic Disorder?”

Instead, therapy repeatedly returned to a different question:

“What might be maintaining Sophie’s neuroaffective load, and what might help reduce it?”

This question became a recurring anchor throughout therapy.

Rather than assuming that distress reflected psychological weakness or therapeutic failure, it invited curiosity about the interaction between physiology, affect, cognition, memory, relationships, and the broader context in which emotional regulation was taking place.

Within NeuroAffective-CBT, curiosity is not simply a therapeutic attitude.

It is a clinical intervention.

Neuroaffective Formulation

The developmental formulation helped explain why Sophie’s appearance concerns had become so emotionally significant. The next therapeutic question was equally important:

Why had these difficulties intensified now, after several years of relative stability?

Although Sophie retained many of the cognitive insights she had developed during her previous course of CBT, she increasingly described feeling unable to access them during periods of emotional distress. She understood that her thoughts were often biased, recognised many of her appearance-related safety behaviours, and could frequently identify alternative interpretations. Yet these skills no longer seemed sufficient to regulate the intensity of her emotional experience.

Rather than viewing this as evidence that therapy had failed, NA-CBT approached it as evidence that the neuroaffective conditions within which these cognitive skills operated had fundamentally changed.

Over recent years Sophie had experienced the cumulative impact of persistent insomnia, menopausal transition, occupational loss, increasing social isolation, repeated cosmetic procedures, prolonged legal proceedings, reduced physical activity, and the gradual erosion of interpersonal support. Each experience contributed not simply to “stress,” but to an increasing burden on the systems responsible for physiological regulation, emotional processing, and cognitive flexibility.

Within NeuroAffective-CBT, this accumulation is conceptualised as neuroaffective load (Mirea, 2018).

Neuroaffective load refers to the cumulative demands placed upon the integrated body-brain system through ongoing physiological dysregulation, affective activation, interpersonal adversity, cognitive burden, and environmental pressures. Unlike the broader concept of stress, neuroaffective load emphasises the dynamic interaction between bodily regulation and psychological functioning. It recognises that emotional suffering often emerges not from a single precipitating event but from the gradual accumulation of multiple interacting influences that reduce the nervous system’s capacity for flexible adaptation.

This distinction proved clinically meaningful.

When Sophie was invited to consider her difficulties through the lens of neuroaffective load, her experience began to make sense in a different way. Rather than concluding that she had “gone backwards” or that she had somehow lost the benefits of her previous therapy, she became increasingly able to understand why familiar psychological strategies were becoming harder to access.

Her brain had not forgotten what she had learned. It was working under very different physiological and affective conditions. This understanding became one of the most compassionate moments within therapy. Rather than asking,

“Why can’t I cope anymore?”

Sophie gradually found herself asking,

“What has happened to my system that makes coping so much harder?”

The question itself represented an important therapeutic shift.

Pause for Curiosity

Perhaps psychological resilience is not simply a characteristic that people possess.

Perhaps it is an emergent property of a nervous system that has sufficient physiological and emotional capacity to remain flexible.

If so, therapy may need to become curious not only about thoughts and behaviours, but about the conditions that either increase or reduce neuroaffective load.

This broader perspective also complements established cognitive behavioural models of Body Dysmorphic Disorder, which emphasise dysfunctional appearance beliefs, selective attention, mirror checking, reassurance seeking, avoidance, and safety behaviours in maintaining distress (Veale, 2004; Veale & Neziroglu, 2010; Phillips, 2005; Wilhelm et al., 2013). Rather than replacing these well-established formulations, NA-CBT seeks to extend them by incorporating physiological regulation, affective neuroscience, and predictive brain processes as interacting influences on these cognitive and behavioural maintenance cycles.

In doing so, the formulation broadens the therapeutic focus. The question is no longer solely,

“What thoughts maintain the problem?” but also,

“What neuroaffective conditions make these thoughts feel so compelling?”

Mind, Body, and the Foundations of Change

Many people enter psychotherapy believing that their emotional difficulties exist primarily “in the mind.” From a NeuroAffective-CBT perspective, this understanding is incomplete.

Mind and body form a single regulatory system. Thoughts influence physiology. Physiology influences affect. Affect shapes interpretation. Interpretation influences subsequent physiological responding.

Each component continuously influences the others within an ongoing cycle of prediction and regulation (Barrett, 2017; Damasio, 1999; Friston, 2010).

For this reason, NA-CBT integrates TED (Tired–Exercise–Diet) as a core stabilisation framework within psychotherapy (Mirea, 2023, 2025a, 2025b).

TED is not presented as a lifestyle programme or a substitute for psychological therapy. Nor does the NA-CBT therapist assume the role of a dietitian, physician, physiotherapist, or exercise professional. Instead, TED provides a psychologically informed framework through which clinicians explore how sleep, movement, nutrition, energy regulation, and everyday physiological functioning influence emotional experience and psychological flexibility. Where appropriate, clients are supported to access other healthcare professionals with specialist expertise in these areas.

This distinction is important. NeuroAffective-CBT is not practising medicine, nor is it reducing psychotherapy to lifestyle advice. Rather, it recognises that psychotherapy takes place within a living nervous system. Understanding how physiological regulation interacts with emotional processing enables the therapist to formulate distress more comprehensively and to collaborate with clients in reducing factors that unnecessarily increase neuroaffective load.

For Sophie, this became an essential component of therapy. Rather than viewing chronic fatigue, menopausal changes, insomnia, reduced physical activity, and nutritional habits as separate concerns to be addressed elsewhere, they became integrated into the psychological formulation. Together they provided important clues regarding the conditions under which shame intensified, emotional flexibility diminished, and appearance concerns became increasingly dominant.

Consequently, therapy frequently returned to one practical question:

What might be maintaining your neuroaffective load, and what might help reduce it?

This question gradually became the organising principle of treatment.

Rather than functioning as a checklist, it encouraged collaborative curiosity. It also translated naturally into collaborative goal setting. Together, therapist and Sophie began distinguishing between behaviours that appeared to maintain neuroaffective load and those that helped reduce neuroaffective load.

Visually, this was represented using two interconnected formulations.

The first resembled the familiar CBT vicious cycle, illustrating how poor sleep, inactivity, shame, social withdrawal, mirror checking, self-criticism, and avoidance interacted to perpetuate neuroaffective load.

Alongside this, therapist and client gradually constructed what Sophie came to call her virtuous flower. Each petal represented a small but meaningful influence that helped restore regulation: improved sleep routines, gentle movement, stretching, regular meals, meaningful social connection, compassionate self-reflection, behavioural experiments, and valued activity. No single intervention transformed her wellbeing. Collectively, however, they gradually altered the physiological and emotional context within which change became possible.

This visual distinction proved particularly helpful because it extended familiar CBT formulation without replacing it. Sophie immediately recognised its structure while simultaneously appreciating that the therapeutic focus had broadened beyond cognition alone.

The Body–Brain–Affect Triangle

Central to NeuroAffective-CBT is the Body–Brain–Affect Triangle, a formulation that conceptualises psychological functioning as a continuously interacting regulatory system rather than a sequence of isolated psychological events. Drawing upon affective neuroscience, predictive processing, and embodied cognition, the triangle proposes that physiological regulation, predictive brain processes, and primary affective systems are engaged in a constant reciprocal dialogue (Panksepp, 1998; Damasio, 1999; Friston, 2010; Barrett, 2017; LeDoux, 2015).

Within this model, none of the three components operates independently. A change within one corner of the triangle inevitably influences the others, often before conscious awareness emerges.

Body (Physiology)

The body provides the biological context within which psychological experience unfolds. Sleep, movement, nutrition, hormonal functioning, autonomic regulation, metabolic stability, chronic pain, illness, and fatigue all influence the nervous system’s capacity to regulate emotional experience.

From this perspective, physiology is not simply a background variable. It is an active participant in emotional life.

When physiological regulation becomes compromised through chronic sleep disruption, hormonal transition, nutritional imbalance, prolonged inactivity, or persistent stress, the nervous system becomes increasingly sensitive to perceived threat. Emotional reactions occur more readily, remain active for longer, and become progressively more difficult to regulate.

Brain (Prediction and Interpretation)

Within NeuroAffective-CBT, the brain is understood primarily as a predictive organ whose central evolutionary function is protection rather than objective perception (Friston, 2010; Barrett, 2017).

Long before conscious reasoning begins, the brain is continuously asking:

“Am I safe?”

“What is about to happen?”

“What should I prepare for?”

“How bad could this become?”

These predictions are shaped not only by conscious beliefs and interpretations but also by bodily sensations, previous emotional learning, autobiographical memory, attachment experiences, and current physiological state.

Consequently, individuals rarely respond to the world exactly as it is.

They respond to the brain’s best prediction of what is about to happen.

When physiology becomes dysregulated, these predictive systems become increasingly threat-sensitive. Neutral situations are more easily interpreted as dangerous. Ambiguous facial expressions appear rejecting. Minor imperfections become overwhelming evidence of failure. Shame becomes more readily activated and more difficult to regulate.

Affect (Primary Emotional Systems)

Affect represents the fast, evolutionarily conserved emotional systems that organise survival long before reflective thinking becomes possible (Panksepp, 1998; LeDoux, 2015).

Fear. Shame. Disgust. Anger. Relief.

These emotional systems rapidly orient attention towards information relevant to survival and social belonging. Only afterwards does cognition begin constructing explanations for what has already been felt.

Within NeuroAffective-CBT, cognition therefore remains critically important, but it is understood as the meaning-making layer built upon ongoing physiological and affective activity. Emotions are not simply generated by thoughts, nor are thoughts merely reactions to emotions. Each continuously shapes the other within an integrated regulatory system.

Differentiating Affect from Interpretation

One of the central therapeutic aims of NeuroAffective-CBT is helping clients distinguish between raw affect and interpretation.

Raw affect refers to the body’s immediate emotional signal—fear, shame, sadness, anger, or relief—generated rapidly in response to internal or external cues.

Interpretation refers to the meaning subsequently assigned to those emotional signals through prediction, memory, beliefs, and conscious reflection (Barrett, 2017; Damasio, 1999).

When affect and interpretation become fused, emotional experiences begin to feel absolute.

“I feel ashamed” gradually becomes “I am shameful.”

“I feel afraid” becomes “I am unsafe.”

“I feel unattractivebecomes “I am fundamentally defective.”

Helping Sophie recognise this distinction became transformative. She gradually learned that the intensity of her emotional experience did not necessarily provide accurate information about objective reality. Instead, emotions increasingly became understood as important signals requiring curiosity rather than unquestioning acceptance.

Therapy repeatedly slowed these moments by returning to a more fundamental question:

What is your body signalling right now?

followed by..

Is your brain interpreting that signal in a way that accurately reflects the present?

These questions gradually interrupted the automatic fusion of affect and identity that had characterised Sophie’s experience for many years.

Therapeutic Process

The therapeutic process unfolded over approximately twelve months through weekly outpatient sessions. Although therapy retained the collaborative structure characteristic of Cognitive Behavioural Therapy, the emphasis gradually shifted from challenging isolated cognitions towards understanding the broader neuroaffective conditions within which those cognitions emerged.

From the outset, formulation became a collaborative process of curiosity rather than explanation. Rather than seeking a single underlying cause for Sophie’s distress, therapy explored how developmental experiences, current relationships, physiological regulation, affective responses, autobiographical memory, and behavioural patterns interacted to maintain her psychological difficulties.

Sophie’s previous CBT had equipped her with valuable cognitive skills. These were not discarded or replaced. Instead, they were revisited within a broader formulation that recognised why accessing these skills had become increasingly difficult under conditions of elevated neuroaffective load.

Behavioural experiments therefore remained central to therapy, but their purpose subtly expanded.

Rather than asking only, “What evidence supports this belief?” therapy increasingly asked,

“What happens to your emotional experience when your nervous system is more regulated?”

And “How does reducing neuroaffective load influence your ability to think differently?”

This shift was particularly evident when addressing mirror checking, avoidance, and appearance-focused behaviours.

Previously, behavioural experiments had focused primarily on testing catastrophic beliefs concerning Sophie’s appearance.

Within NA-CBT, these experiments continued, but they were carefully timed to coincide with periods of improved physiological regulation whenever possible. Sessions frequently explored the relationship between sleep quality, physical activity, emotional intensity, and the outcomes of behavioural experiments.

Over time, Sophie herself began noticing an important pattern. On days following adequate sleep, regular movement, and greater physiological stability, behavioural experiments felt challenging but manageable. Following several nights of poor sleep or heightened emotional exhaustion, identical experiments often felt overwhelming. This observation reinforced one of the central propositions of NA-CBT:

Psychological flexibility is not determined solely by cognitive skill. It is profoundly influenced by the physiological and affective conditions within which those skills are required.

Pause for Curiosity

Perhaps therapy becomes most effective not when clients think differently first…

…but when the conditions exist that allow different thinking to become possible.

NeuroAffective Narrative Reconsolidation (NNR)

As Sophie’s neuroaffective load gradually reduced, a notable shift began to emerge within therapy. She did not simply experience fewer distressing thoughts or engage in fewer appearance-related safety behaviours. Rather, she began relating to herself differently.

This change was subtle at first. Memories that had previously felt emotionally overwhelming became easier to approach. Shame remained present but no longer felt all-encompassing. Situations that once automatically confirmed long-held beliefs of defectiveness began to acquire alternative meanings.

Importantly, these changes did not arise through repeated attempts to replace “irrational thoughts” with more rational alternatives alone. Instead, they appeared to emerge as Sophie’s nervous system became increasingly able to tolerate emotional experience without immediately defaulting to threat-based prediction.

One memory proved particularly significant.

Throughout therapy, Sophie repeatedly returned to the childhood incident in which she had been accused of stealing after her cousin concealed an item in a shop. For many years she had experienced this memory not simply as an unfortunate childhood event but as compelling evidence that other people instinctively saw her as fundamentally bad, suspicious, or unworthy.

Earlier in life she had attempted to challenge this conclusion intellectually. She understood that the accusation had been unfair and recognised that many people would interpret the situation differently.

Yet this cognitive understanding had done little to alter the emotional meaning carried by the memory. Within NA-CBT, the therapeutic task therefore became different.

Rather than attempting to dispute the factual accuracy of the event, therapy sought to understand how its emotional significance had become organised within Sophie’s broader neuroaffective system.

The memory was no longer viewed in isolation. It became connected to a much wider developmental narrative. Repeated experiences in which beauty appeared to determine acceptance. The gradual belief that being attractive was necessary to deserve love. The experience of becoming increasingly invisible within important relationships. The emotional impact of repeated cosmetic procedures that left her feeling more flawed rather than less. The grief associated with childlessness. The loneliness she experienced within her marriage. The loss of work and identity. The exhaustion associated with chronic insomnia and menopause.

Together, these experiences formed an interconnected autobiographical narrative organised around a central expectation: “There is something fundamentally wrong with me.”

Within NeuroAffective-CBT, this process is conceptualised as NeuroAffective Narrative Reconsolidation (NNR).

NNR describes the gradual revision of emotionally organised autobiographical narratives through repeated experiences of physiological regulation, emotional safety, cognitive flexibility, and corrective interpersonal experience. Rather than focusing solely on changing individual beliefs, NNR seeks to reorganise the broader narrative structures through which people understand themselves, others, and the world. This understanding is consistent with contemporary theories of memory reconsolidation and emotional learning, which suggest that previously established emotional meanings remain open to revision when reactivated under conditions that permit new learning (Lane et al., 2015; Brewin, 2014; Arntz, 2012).

For Sophie, this process unfolded gradually rather than dramatically.

There was no single transformative session. Instead, countless small moments accumulated. She noticed herself remaining on camera for slightly longer during online meetings. She accepted invitations that she would previously have declined. She looked in the mirror without immediately searching for defects. She found herself walking outside without feeling compelled to hide behind sunglasses or heavy make-up. Most importantly, she became increasingly able to experience shame without allowing it to define her identity.

One session illustrated this particularly clearly. While discussing the childhood shop incident, Sophie paused and quietly said,

“I think I spent most of my life trying to prove that they were wrong.” ..“Maybe I don’t need to prove anything anymore.”

This moment was not interpreted as the disappearance of shame. Nor did it represent the complete resolution of Body Dysmorphic Disorder. Instead, it reflected a profound reorganisation of meaning. The memory remained but its emotional authority had changed. Rather than functioning as unquestioned evidence of personal defectiveness, it became recognised as one painful chapter within a much larger life story.

From that point onwards, the memory could be held with compassion rather than certainty.

The Emergence of the Integrated-Self

Throughout therapy, the central therapeutic aim was never to eliminate unwanted emotions or construct an idealised version of the self.

Instead, NA-CBT sought to create the neuroaffective conditions in which Sophie’s Integrated-Self could emerge more consistently.

The Integrated Self does not represent perfection, permanent happiness, or the absence of vulnerability.

Rather, it reflects an increasingly coherent experience of identity in which physiology, affect, cognition, behaviour, autobiographical memory, and interpersonal experience become more harmoniously aligned.

Within this state, emotional experiences remain meaningful without becoming overwhelming.

Thoughts remain influential without becoming absolute. The body becomes a source of information rather than threat. Relationships become opportunities for connection rather than continual evaluation. Most importantly, identity becomes less organised around protection and more organised around authenticity.

This distinction proved fundamental. Early in therapy, Sophie experienced herself almost entirely through the lens of shame. Later, she increasingly recognised shame as one emotional experience among many. The difference was profound as she no longer experienced what she felt as who she was. Instead, emotions became experiences that could be observed, understood, and responded to with increasing flexibility.

As the Integrated-Self became more accessible, behavioural change emerged naturally rather than through constant effort. Mirror checking reduced,  avoidance diminished and social engagement gradually increased. Self-care became motivated less by fear of judgement and more by genuine compassion for herself. Perhaps most significantly, therapy no longer revolved around repairing a defective person.

Instead, it focused on creating the biological, psychological, and relational conditions that allowed an already existing, though previously obscured, sense of self to become increasingly available.

Pause for Curiosity

Perhaps psychological change is not always about becoming someone new.

Perhaps it is about reducing the neuroaffective conditions that prevent people from becoming who they have always had the capacity to be.

Discussion

Sophie’s therapeutic journey illustrates one of the central propositions of NeuroAffective-CBT: the recurrence of psychological symptoms does not necessarily indicate that previous therapy has been unsuccessful. Rather, it may reflect profound changes in the neuroaffective context within which previously acquired psychological skills are now expected to operate.

Although Sophie retained many of the cognitive insights developed during her previous course of CBT, years of accumulating physiological, relational, occupational, and emotional adversity had fundamentally altered the conditions under which these skills were required. Menopause, persistent insomnia, occupational loss, social isolation, repeated cosmetic procedures, prolonged litigation, and unresolved grief collectively increased her neuroaffective load, reducing psychological flexibility despite preserved cognitive understanding.

Rather than conceptualising this deterioration as therapeutic failure, NA-CBT understood it as evidence that cognition does not operate independently of physiology and affect. Cognitive restructuring, behavioural experiments, and exposure remain essential components of evidence-based treatment (Beck, 1976, 2021; Clark & Beck, 2010). However, the effectiveness of these interventions may be influenced by the physiological and affective state within which they occur.

This broader formulation complements established cognitive behavioural models of Body Dysmorphic Disorder, which emphasise dysfunctional appearance beliefs, selective attention, mirror checking, avoidance, reassurance seeking, and safety behaviours in maintaining distress (Veale, 2004; Veale & Neziroglu, 2010; Phillips, 2005; Wilhelm et al., 2013). Rather than replacing these well-established models, NeuroAffective-CBT seeks to extend them by incorporating physiological regulation, predictive processing, and affective neuroscience into psychological formulation.

From this perspective, body dysmorphic symptoms are understood not only as products of maladaptive cognition and behaviour but also as emerging within an integrated body-brain system continuously attempting to predict, interpret, and respond to potential threat (Friston, 2010; Barrett, 2017). The brain’s primary evolutionary task is not objective reasoning but anticipation in the service of protection. Consequently, alterations in physiological regulation may significantly influence the intensity, persistence, and credibility of appearance-related beliefs.

Central to this formulation is the concept of neuroaffective load (Mirea, 2018). Unlike broader notions of stress, neuroaffective load refers to the cumulative interaction between physiological dysregulation, affective activation, cognitive burden, interpersonal adversity, and environmental demands. Sophie’s presentation illustrated how multiple seemingly independent difficulties gradually converged to create conditions in which shame, self-criticism, and avoidance became increasingly dominant.

The introduction of the TED (Tired–Exercise–Diet) framework provided a practical means of addressing these physiological influences within psychotherapy (Mirea, 2023, 2025a, 2025b). Importantly, TED is not intended to replace specialist medical, nutritional, or exercise interventions. Rather, it offers psychologists a psychologically informed framework through which physiological regulation becomes part of collaborative formulation. Where clinically appropriate, clients may be supported to access relevant healthcare professionals while psychotherapy continues to address the emotional and cognitive implications of physiological dysregulation.

One of the distinguishing features of NA-CBT is its explicit rejection of a traditional mind-body dichotomy. Rather than viewing biological and psychological processes as separate domains, NA-CBT conceptualises emotional experience as emerging through continuous interactions between physiology, affect, cognition, autobiographical memory, and interpersonal relationships (Damasio, 1999; Barrett, 2017; Siegel, 2012). The Body-Brain-Affect Triangle offers one way of organising these interactions clinically, helping therapists and clients appreciate how changes in one component inevitably influence the others.

Another important contribution concerns the distinction between affect and interpretation. Throughout therapy, Sophie gradually learned to differentiate immediate emotional signals from the meanings subsequently assigned to them. This distinction allowed shame to become an emotional experience rather than a fixed identity. Increasingly, she recognised that intense emotional reactions were not necessarily accurate reflections of present reality but understandable responses generated within a nervous system organised around protection rather than objective perception (LeDoux, 2015; Panksepp, 1998).

These developments created the conditions for NeuroAffective Narrative Reconsolidation. Rather than focusing exclusively on modifying individual cognitions, therapy facilitated the gradual reorganisation of emotionally significant autobiographical narratives. Memories that had long functioned as unquestioned evidence of personal defectiveness became integrated into a broader, more compassionate life story. This process aligns conceptually with contemporary understandings of memory reconsolidation and emotional learning, suggesting that autobiographical narratives remain open to revision when reactivated under conditions of sufficient emotional safety and physiological regulation (Lane et al., 2015; Brewin, 2014; Arntz, 2012).

Perhaps most importantly, the therapeutic goal extended beyond symptom reduction. While reductions in appearance preoccupation, avoidance, and self-criticism were clinically meaningful, they were understood as consequences of a broader developmental process rather than endpoints in themselves. The overarching aim became the emergence of an Integrated-Self, a coherent experience of identity in which physiology, affect, cognition, autobiographical memory, behaviour, and relationships become increasingly aligned (Mirea, 2018).

Throughout treatment, one recurring question appeared to organise both formulation and intervention:

What might be maintaining your neuroaffective load, and what might help reduce it?

Although deceptively simple, this question repeatedly redirected attention away from self-blame and towards collaborative curiosity. It also proved highly transportable across therapeutic goals, helping distinguish behaviours that maintained neuroaffective load from those that gradually reduced it. In Sophie’s therapy, this distinction was represented visually through a traditional CBT vicious cycle alongside a complementary “virtuous flower”, illustrating the multiple pathways through which physiological regulation, valued action, behavioural flexibility, and compassionate self-care gradually supported psychological recovery.

Limitations

As a single case study, the present report cannot determine the efficacy of NeuroAffective-CBT or establish causal relationships between specific interventions and clinical outcomes. Improvements observed throughout therapy likely reflected the combined influence of multiple therapeutic, interpersonal, and contextual factors.

Accordingly, the present case should be viewed as an illustration of clinical formulation rather than evidence of treatment superiority. Future research should evaluate NA-CBT across a range of clinical presentations using controlled methodologies, examining both symptom outcomes and broader indicators of physiological regulation, emotional flexibility, identity integration, and quality of life.

Future Directions

Future developments within NeuroAffective-CBT should focus on systematic empirical evaluation of the model across anxiety disorders, obsessive-compulsive and related disorders, mood disorders, trauma-related presentations, and personality difficulties. In particular, research exploring interactions between physiological regulation, affective processing, and cognitive flexibility may further clarify the mechanisms through which neuroaffective load influences psychological functioning. Finally, future publications may expand the present work by exploring the theoretical foundations of NA-CBT in greater depth, alongside additional clinical illustrations across diverse diagnostic presentations.

Conclusion

This case study has presented NeuroAffective-CBT (NA-CBT) through the treatment of a woman with longstanding Body Dysmorphic Disorder whose difficulties evolved within the context of cumulative physiological, developmental, relational, and emotional adversity. Rather than conceptualising symptom recurrence as evidence of therapeutic failure, NA-CBT proposed that previously acquired psychological skills had become increasingly difficult to access because the neuroaffective conditions supporting their effective use had fundamentally changed.

Throughout therapy, formulation extended beyond cognition alone to consider the continuous interaction between physiology, affect, predictive brain processes, autobiographical memory, behaviour, and interpersonal experience. Concepts such as neuroaffective load, the TED (Tired–Exercise–Diet) framework, the Body–Brain–Affect Triangle, and NeuroAffective Narrative Reconsolidation provided an integrated framework through which Sophie’s presentation became increasingly understandable and clinically meaningful.

Importantly, NA-CBT does not seek to replace established cognitive behavioural models. Instead, it builds upon the considerable strengths of contemporary CBT by incorporating developments from affective neuroscience, predictive processing, embodied cognition, attachment theory, and lifestyle medicine into psychological formulation and intervention (Beck, 2021; Barrett, 2017; Friston, 2010). In doing so, it offers clinicians an expanded framework for understanding how physiological regulation, emotional processing, and cognitive flexibility continuously influence one another.

Perhaps the most significant shift within therapy concerned its ultimate aim.

Rather than striving simply to reduce symptoms, challenge distorted cognitions, or eliminate distress, treatment sought to create the biological, psychological, and relational conditions in which Sophie’s Integrated-Self could emerge more consistently. As neuroaffective load gradually reduced, shame became less defining, autobiographical memories acquired new meaning, behavioural flexibility increased, and compassion gradually replaced self-protection as the organising principle of her relationship with herself.

At its heart, NeuroAffective-CBT invites clinicians to become curious. Curious about the relationship between body and mind. Curious about the interaction between physiology and cognition. Curious about how affect shapes prediction before conscious thought has emerged. Curious about the stories people carry about themselves and the neuroaffective conditions that allow those stories to evolve.

Clinical Reflections

This case illustrates how broadening formulation beyond cognition alone may enrich clinical understanding without abandoning the principles of Cognitive Behavioural Therapy. The concepts presented within NA-CBT are intended to complement—not replace—existing evidence-based CBT models. Throughout treatment, curiosity functioned not merely as a therapeutic attitude but as an active clinical intervention, encouraging therapist and client to explore how physiology, affect, cognition, memory, and relationships continuously interacted.

For practising clinicians, the recurring question— What might be maintaining neuroaffective load, and what might help reduce it? —may provide a simple yet clinically useful organising principle that readily translates into collaborative formulation, treatment planning, behavioural goals, and relapse prevention.

Disclaimer

This case study is intended solely for educational and professional discussion purposes. It does not constitute clinical guidance, diagnosis, or treatment recommendations. Therapeutic approaches described should be implemented only by appropriately trained professionals within their scope of competence and adapted to the individual needs of each client. Readers are encouraged to consult relevant clinical guidelines, current evidence, and professional supervision when applying the concepts presented within this paper.

The image used in this article is an illustrative image only. This image is AI-generated and does not depict the actual client. It has been created solely to reflect the themes of this anonymised case study.

Ethics and Anonymisation Statement

All identifying client information has been altered to protect anonymity. The case has been substantially anonymised, and contextual details have been modified where necessary to minimise the possibility of identification while preserving the clinical relevance of the formulation. Informed consent was obtained for the use of anonymised clinical material for educational and dissemination purposes.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association.

Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical trials, basic studies, and research agenda. Journal of Experimental Psychopathology, 3(2), 189–208. https://doi.org/10.5127/jep.024211

Barrett, L. F. (2017). How emotions are made: The secret life of the brain. Houghton Mifflin Harcourt.

Barrett, L. F., & Simmons, W. K. (2015). Interoceptive predictions in the brain. Nature Reviews Neuroscience, 16(7), 419–429. https://doi.org/10.1038/nrn3950

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.

Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Brewin, C. R. (2014). Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. Psychological Bulletin, 140(1), 69–97. https://doi.org/10.1037/a0033722

Clark, A. (2013). Whatever next? Predictive brains, situated agents, and the future of cognitive science. Behavioral and Brain Sciences, 36(3), 181–204. https://doi.org/10.1017/S0140525X12000477

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. Guilford Press.

Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. Harcourt Brace.

Elsey, J. W. B., Van Ast, V. A., & Kindt, M. (2018). Human memory reconsolidation: A guiding framework and critical review. Neuroscience & Biobehavioral Reviews, 89, 1–19. https://doi.org/10.1016/j.neubiorev.2018.03.008

Firth, J., Solmi, M., Wootton, R. E., et al. (2020). A meta-review of lifestyle psychiatry: The role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry, 19(3), 360–380. https://doi.org/10.1002/wps.20773

Friston, K. (2010). The free-energy principle: A unified brain theory? Nature Reviews Neuroscience, 11(2), 127–138. https://doi.org/10.1038/nrn2787

Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2022). A process-based approach to psychological diagnosis and treatment. Current Directions in Psychological Science, 31(4), 343–350. https://doi.org/10.1177/09637214221089356

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clinical Psychological Science, 7(1), 37–50. https://doi.org/10.1177/2167702618772296

Hohwy, J. (2020). New directions in predictive processing. Mind & Language, 35(2), 209–223. https://doi.org/10.1111/mila.12281

Khalsa, S. S., Adolphs, R., Cameron, O. G., et al. (2018). Interoception and mental health: A roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3(6), 501–513. https://doi.org/10.1016/j.bpsc.2017.12.004

Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. S. (2015). Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science. Behavioral and Brain Sciences, 38, e1. https://doi.org/10.1017/S0140525X14000041

LeDoux, J. E. (2015). Anxious: Using the brain to understand and treat fear and anxiety. Viking.

Marx, W., Moseley, G., Berk, M., & Jacka, F. (2017). Nutritional psychiatry: The present state of the evidence. Proceedings of the Nutrition Society, 76(4), 427–436. https://doi.org/10.1017/S0029665117002026

Mirea, D. (2018, October 19). The underlayers of NeuroAffective-CBT®. NeuroAffective-CBT®. https://neuroaffectivecbt.com/2018/10/19/the-underlayers-of-neuroaffective-cbt/

Mirea, D. (2023, July 18). Tired, Exercise and Diet your way out of trouble: TED’s your best friend. NeuroAffective-CBT®. https://neuroaffectivecbt.com/2023/07/18/teds-your-best-friend/

Mirea, D. (2025, December 10). TED in NeuroAffective-CBT®: An applied self-regulation framework for enhancing emotional well-being through sleep, movement, and nutrition. NeuroAffective-CBT®. https://neuroaffectivecbt.com/2025/12/10/ted-in-neuroaffective-cbt-an-applied-self-regulation-framework-for-enhancing-emotional-well-being-through-sleep-movement-and-nutrition/

Mirea, D. (2025, December 17). The use of lifestyle interventions in psychotherapy. NeuroAffective-CBT®. https://neuroaffectivecbt.com/2025/12/17/the-use-of-lifestyle-interventions-in-psychotherapy/

Niedenthal, P. M. (2007). Embodying emotion. Science, 316(5827), 1002–1005. https://doi.org/10.1126/science.1136930

Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. Oxford University Press.

Pessoa, L. (2017). A network model of the emotional brain. Trends in Cognitive Sciences, 21(5), 357–371. https://doi.org/10.1016/j.tics.2017.03.002

Phillips, K. A. (2005). The broken mirror: Understanding and treating body dysmorphic disorder (Rev. ed.). Oxford University Press.

Phillips, K. A., Didie, E. R., Feusner, J., & Wilhelm, S. (2008). Body dysmorphic disorder: Treating an underrecognized disorder. American Journal of Psychiatry, 165(9), 1111–1118. https://doi.org/10.1176/appi.ajp.2008.08040500

Seth, A. K., & Friston, K. J. (2016). Active interoceptive inference and the emotional brain. Philosophical Transactions of the Royal Society B: Biological Sciences, 371(1708), 20160007. https://doi.org/10.1098/rstb.2016.0007

Siegel, D. J. (2012). The developing mind: How relationships and the brain interact to shape who we are (2nd ed.). Guilford Press.

Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1(1), 113–125. https://doi.org/10.1016/S1740-1445(03)00009-3

Veale, D., & Neziroglu, F. (2010). Body dysmorphic disorder: A treatment manual. Wiley-Blackwell.

Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). Cognitive behavioral therapy for body dysmorphic disorder: A treatment manual. Guilford Press.