mental-health

Can Martial Arts Training Make a Difference to Mental Health?

October 23, 2026October 23, 2026 NeuroAffective-CBT

Matching Movement to the Individual Through Regulation, Agency and Meaning

Daniel Mirea and Chris People (23 October 2026)
| The NeuroAffective-CBT® Journal |

Introduction

Combat training and mental health hardly seem to belong in the same sentence. The connection is counterintuitive. Combat suggests aggression, confrontation and the possibility of harm. Concerns about injury, including brain injury in activities involving head contact, are real and deserve attention (Neidecker et al., 2019). Why, then, consider martial arts within a discussion of psychological wellbeing?

To a keen observer, the answer may emerge through the training itself. What becomes apparent is how much attention is given to the art: learning movement, judging distance, coordinating effort, responding to another person and exercising control. In a supportive training environment, these abilities develop gradually, with the intensity and physical demands adjusted as the participant gains familiarity and skill.

Martial arts also have a substantial interpersonal dimension. Individual practice is important, but partner exercises introduce something different: another person whose movement, timing and response cannot always be fully predicted. The participant must attend, interpret and act while remaining aware of their own reactions. They may need to communicate a limit, request a slower pace, accept correction or manage the frustration of getting something wrong.

Breathing is often part of this learning. In some traditions, explicit instruction in breathing accompanies the development of posture, movement and control from an early stage. Japanese martial traditions may direct focused attention towards the hara, while Chinese practices such as Tai Chi emphasise the lower dantian, traditionally understood as a centre of vital energy (Mai, 2015; National Qigong Association, 2025). These concepts provide ways of organising attention around the abdomen, breathing and coordinated movement. Breathing becomes something to notice and coordinate with action, particularly as effort and intensity change.

Attention, bodily awareness, breathing, gradual engagement with discomfort and responsiveness to others are also familiar concerns within mindfulness and emotional regulation approaches. Their presence in martial arts makes the clinical connection worth exploring. What might a participant be learning psychologically while practising physically? Could these experiences be connected more deliberately with therapeutic goals?

Our observations and individual experiences suggest that participants can learn more than the execution of a technique. Someone who initially responds with excessive tension, hurried movement or withdrawal may gradually become more able to pause, direct attention, adjust effort and choose what to do next. Another may discover that asking for help or expressing a boundary allows participation to continue. These experiences may acquire psychological significance even when neither instructor nor participant describes them in therapeutic language.

From a NeuroAffective-CBT perspective, lifestyle interventions are an essential part of promoting health and resilience. We propose that appropriately selected martial arts training may provide a practical setting for rehearsing regulation and agency. The relevant learning will differ between individuals. It may involve remaining engaged while uncomfortable, responding less harshly to mistakes, exercising restraint or recognising when to stop. These possibilities depend on the training environment, the quality of instruction and the meaning the person gives to participation.

Matching movement to the individual is therefore central. Preferences, physical capacity, cultural meaning, access and recovery all influence whether an activity is suitable and sustainable. The same exercise may offer one person an experience of capability while becoming another demand through which someone else judges or punishes themselves. Understanding that difference belongs within therapeutic formulation.

This selective narrative review brings together exercise and martial arts research with clinical reasoning and observations from training. Drawing on NeuroAffective-CBT alongside established cognitive behavioural approaches, we examine how chosen and adapted participation might support attention, coping self-instruction, assertiveness, mastery and belonging. A hypothetical clinical illustration shows how physical practice can be connected with a specific prediction, collaborative review and an experiment outside training.

The wider exercise literature supports therapeutic relevance, while evidence specific to martial arts remains heterogeneous. Our observations inform the proposed applications rather than establish their effectiveness. The question is how particular forms of training, matched to the individual and delivered within suitable conditions, might support mental health and whether what is learned during practice becomes available in everyday life.

Keywords: martial arts; combat sports; lifestyle interventions; cognitive behavioural therapy; NeuroAffective-CBT; emotional regulation; agency; psychological flexibility; therapeutic learning.

Martial Arts and the Cultivation of Mind and Body

Organised combat practices have a documented history extending across millennia and cultures. Wrestling entered the ancient Olympic programme in 708 BCE, boxing in 688 BCE and pankration, which combined striking and wrestling, in 648 BCE. These dates concern their inclusion in the Games rather than the origins of combat practice, but they demonstrate the longstanding place of fighting skills within organised physical culture (Foundation of the Hellenic World, n.d.).

The history of Chinese martial arts provides a further connection between physical practice, cultural meaning and self-cultivation. Shahar (2008) documents the involvement of Shaolin monks in seventh-century military events and traces the subsequent development of their martial traditions. This history encompasses armed and unarmed practices, religious commitments and relationships with political institutions. Later developments also connected martial practice with therapeutic purposes. Shaolin represents one important tradition within a diverse history, illustrating how fighting skills could become associated with broader understandings of health, discipline and personal development.

In the twentieth century, Bruce Lee brought the relationship between martial practice and personal philosophy to a wide international audience. His reflections emphasised adaptability, self-expression and learning through experience. His water metaphor presented responsiveness as an alternative to rigidly imposing a predetermined form. These ideas offer a philosophical connection with contemporary interests in psychological flexibility and agency, although Lee was articulating a philosophy of practice rather than a clinical treatment model (Bruce Lee Enterprises, n.d.).

Accounts of Lee’s recovery following a serious back injury add a personal dimension to this relationship. His family describes pain and emotional difficulty, extensive study, rest and a cautious return to movement. This account illustrates purposeful engagement with physical limitation, bringing reflection, learning and action together. It remains a biographical account rather than evidence that determination or self-instruction alone repaired the injury (Bruce Lee Enterprises, 2017).

Clinical interest in these connections also has an established history. Fuller (1988) discussed parallels between martial arts and psychotherapeutic concepts, including possible clinical applications. Twemlow and Sacco (1998) described therapeutic applications with adolescents presenting with violent behaviour. These contributions provide a foundation for asking how particular experiences within training might become relevant to an individual’s psychological difficulties and treatment goals.

Beyond the instruction to exercise

Recommending exercise can leave the main therapeutic problem untouched. A person may understand that movement could help and still feel unable to enter a gym, tolerate being a beginner or return after a difficult first session. Shame, fatigue, anticipated judgement and practical barriers can make an apparently simple recommendation difficult to act upon.

Clinical work therefore needs to address how participation becomes possible and what the person learns through it. A correction might be interpreted as evidence of inadequacy or as ordinary assistance in learning. Asking for a pause might feel humiliating or become an experience of effective choice.

The same activity can serve different functions. Training may support curiosity and connection, reinforce punitive standards or provide temporary escape from distress. Its therapeutic significance depends on the person’s formulation and experience. Salkovskis et al. (2023) describe therapy in terms of a shared understanding that is tested to enable more flexible responding. Applied to movement, this directs attention to the expectations being examined and the responses being practised.

Established approaches such as graded engagement, behavioural experiments and coping rehearsal provide methods for connecting physical practice with psychological learning. NeuroAffective-CBT offers one organising perspective for considering bodily regulation, protective responses and embodied rehearsal within this work.

Scope and approach

This selective narrative review is intended primarily for clinicians working with adults. Sources are brought together according to their relevance to exercise outcomes, martial arts and boxing, participation and candidate psychological processes. Systematic reviews and meta-analyses inform the evidence overview; selected trials and conceptual publications address particular clinical questions. The synthesis is purposive and does not claim exhaustive coverage or an independent formal quality appraisal.

General exercise findings are distinguished from evidence concerning particular disciplines and interventions. Outcomes are also distinguished from the mechanisms proposed to explain them. NeuroAffective-CBT publications provide conceptual and practitioner perspectives rather than independent empirical validation of the integrated approach.

The clinical proposals additionally draw on the authors’ observations and individual experiences of training. These inform hypothesis development rather than constitute systematically collected outcome data. The worked illustration is hypothetical, and no original patient data are reported.

What participants actually do

Martial arts and combat sports overlap, but neither label defines a uniform intervention. Traditional forms, non-contact boxing, recreational grappling and competitive mixed martial arts involve different movements, expectations and exposures. A practice may emphasise cultural tradition, self-defence, fitness or competition.

For clinical interpretation, important distinctions concern contact, sparring, exertion, instruction and freedom to stop. Shadowboxing and pad work can use striking movements without participants receiving blows. Grappling involves close physical contact and its own injury exposures. Recreational training and competition can differ substantially even within one club.

The learning environment matters alongside these physical ingredients. An instructor who welcomes questions and adapts tasks creates different opportunities from one who treats uncertainty or stopping as weakness. Community membership, traditional philosophy and shared rituals may matter in some settings and be absent in others.

An individualised recommendation therefore needs to specify what the person will do, with whom, under which conditions and for what purpose. The clinical applications discussed here concern mainly recreational training and adapted non-contact activities. Contact and competition remain separate choices rather than necessary stages of therapeutic progress.

What the exercise evidence supports

Physical activity has a substantial evidence base in mental health. Singh et al. (2023) brought together 97 systematic reviews covering 1,039 trials and 128,119 participants, reporting improvements in depression, anxiety and psychological distress across varied adult populations. However, 77 reviews received a critically low AMSTAR-2 methodological quality rating. These ratings concern the reviews rather than 77 individual trials.

Noetel et al. (2024) found benefits for several exercise modalities in depression, including walking or jogging, yoga and strength training, with confidence in estimates limited by study quality and other uncertainties. Gordon et al. (2018) identified an average reduction in depressive symptoms across 33 resistance-training trials involving 1,877 participants.

The evidence supports considering several forms of movement while leaving their selection and delivery open to individual planning. An advantage over inactivity or usual care may reflect structure, encouragement, expectation and social contact as well as exertion. Comparison with another credible activity asks a more specific question about relative benefit.

White et al. (2024) reviewed 247 studies examining mediators and moderators of the relationship between physical activity and mental health. Their synthesis identified support for self-esteem, self-efficacy, physical self-worth and social connection, with more qualified support for mastery and mindfulness. Most included studies were observational. These findings identify plausible processes for investigation while leaving uncertainty about causal pathways in an individual client.

Evidence specific to martial arts and boxing

Moore et al. (2020) synthesised 14 studies and reported a small pooled benefit for wellbeing and a moderate pooled effect on internalising mental health outcomes. Heterogeneity was substantial, particularly for internalising outcomes, and the pooled aggression finding was not statistically significant.

Ciaccioni et al. (2024) reviewed 72 observational adult studies, comprising 70 cross-sectional and two longitudinal studies. Findings varied across self-related, emotional and cognitive outcomes. The designs limit conclusions about whether differences resulted from training, pre-existing characteristics or continued participation by people who found the activity helpful.

Non-contact boxing is a closer comparison for interventions using pads, bags and combinations. Bozdarov et al. (2023) identified 16 studies across diverse populations and delivery formats. In 56%, boxing was supplemented by components such as mentoring, mindfulness or psychological strategies. The review maps promising applications, but the mixture of designs and combined interventions prevents a firm estimate of boxing’s independent contribution.

Weiss et al. (2025) provide a recent clinical example. Their 24-person pilot examined taekwondo and mindfulness within a dialectical behaviour therapy intensive outpatient programme. Participants reported favourable acceptability and immediate affective changes. The small within-subject study, conducted during ongoing treatment, supports feasibility and further investigation.

Together, these findings support studying specified practices in defined contexts. They leave open which components contribute to change and how outcomes compare with other meaningful activities.

Lifestyle interventions within NeuroAffective-CBT

Lifestyle interventions address recurring conditions of daily life that affect wellbeing and participation. Sleep, movement, nutrition, hydration and recovery can influence one another. Fatigue may reduce the capacity to attend a class, while an excessively demanding training schedule may interfere with rest. These conditions belong within formulation when they contribute to difficulties or limit engagement with treatment.

Within NeuroAffective-CBT (NA-CBT), TED refers to Tiredness–Exercise–Diet. Mirea’s exercise discussion emphasises individualisation and meaningful participation (Mirea, 2025a), while the applied TED account places sleep, movement and nutrition within therapeutic planning (Mirea, 2025b). Practical questions include whether the person is sufficiently rested, whether the activity fits their capacity and whether training supports daily life or becomes another demand they feel compelled to meet.

Mirea’s (2026) Pendulum-Effect account describes avoidance, overcompensation and capitulation as protective responses within a formulation concerned with shame. In training, these might appear as withdrawing when mistakes become visible, exercising punitively to prove worth or accepting an identity of permanent incapability. Embodied rehearsal offers a proposed way of practising a different response while difficult experience remains present.

This formulation helps distinguish occasions when demands should be reduced from occasions when a prediction maintaining avoidance could usefully be tested. Rest and adaptation may be appropriate on one occasion; on another, the useful learning may be that discomfort is compatible with chosen action.

Meichenbaum’s Roadmap to Resilience places physical resources alongside interpersonal, emotional, cognitive, behavioural and spiritual resources (Meichenbaum, n.d.). This broader account keeps strengths, relationships and meaning visible alongside physical capability.

Matching movement to the individual

Activity selection begins with interests and circumstances. What has the person enjoyed previously? Would they prefer technical learning, rhythm, independent practice, cooperation or competition? What does a particular sport represent to them? Physical health, disability and previous injury matter alongside cultural identity, cost, transport and the available training environment.

The useful psychological question is often what the person needs an opportunity to practise. Achievable progression may help someone who expects failure. A supportive class may provide opportunities to be seen trying and receive feedback. Partner work might allow someone to express a preference, while regular shared activity may offer structure and repeated contact to someone experiencing isolation.

These possibilities do not prescribe a sport for a diagnosis. One person with social anxiety may appreciate interaction organised around a shared task; another may initially prefer predictable individual instruction. Someone seeking confidence may find a suitable opportunity in martial arts, dance, climbing or resistance training. Formulation clarifies what confidence means and how the setting might help develop it.

Personal meaning and enjoyment also matter for continuation. Teixeira et al. (2012) reviewed 66 studies of exercise through self-determination theory. Their findings supported relationships between autonomous motivation and participation, with enjoyment and intrinsic motivation particularly relevant to longer-term adherence. Much of the evidence was observational.

Interest may develop through skill, companionship or discovering that movement feels different from what was anticipated. Initial discomfort does not necessarily indicate a poor match, while persistent difficulty should remain open to review. Choosing another instructor, format or activity can be a successful outcome of collaborative planning.

Why martial arts may be a useful resource

Martial arts can bring technical learning, bodily effort and interpersonal negotiation into the same activity. Depending on the practice, participants must manage distance, coordinate movement, respond to another person and communicate the intensity they are willing to accept. These features can make questions of capability, control and boundaries immediately available for reflection.

Their significance remains individual. Someone who habitually withdraws may value discovering that they can take up space and act decisively. A person who overcompensates through excessive effort may benefit from practising restraint, accepting correction or stopping at an agreed point. Another may find predictable partner work an accessible route into cooperation and connection.

These are proposed learning opportunities. Their usefulness depends on preference, instruction and interpretation. The range of available formats also allows adaptation: individual non-contact practice, recreational group training and partner exercises need not involve the same demands.

The clinical rationale rests on the fit between these opportunities and the person’s formulation. Martial practice becomes informative when it allows relevant responses to be practised and reviewed.

Confidence, shame and responses to mistakes

Confidence may develop through supported action. A simple movement becomes a short combination, and repetition makes progress visible. Someone expecting complete failure may discover that they can learn part of a task and return after difficulty.

Technical mastery, specific self-efficacy and global self-worth nevertheless remain distinguishable. A person can acquire skill while continuing to interpret mistakes as evidence of inadequacy. Shame and self-criticism therefore warrant attention when relevant to the formulation. Compassion-focused therapy provides one example of explicitly addressing these difficulties (Leaviss and Uttley, 2015).

Training offers frequent encounters with being inexperienced. Sequences are forgotten and coordination develops unevenly. A behavioural experiment could examine a prediction that an ordinary mistake will lead to rejection. It requires an agreed prediction, suitable practice and review of what happened, including the participant’s interpretation and protective strategies.

Progression can vary through complexity, speed, effort or social visibility. These dimensions need not increase together. For someone whose worth depends on achievement, a useful task might involve receiving correction without self-attack or stopping at an agreed level.

Assertiveness can also be rehearsed through asking for clarification, requesting lighter contact or declining an additional round. The instructor’s response becomes part of the learning. Physical performance provides only a partial account of progress when the intended change concerns communicating a need or recovering from a mistake.

Manageable challenge and coping rehearsal

Exertion, uncertainty and frustration can provide occasions to practise coping. The first challenge may be entering the venue; later tasks might involve an unfamiliar combination or remaining engaged after an error.

Meichenbaum and Deffenbacher’s (1988) stress inoculation framework offers a useful structure: develop a shared understanding, acquire and rehearse coping skills, then apply and review them in relevant situations. This directs attention to preparation and coping choices before increasing demand.

Brief self-instructions such as “slow the sequence”, “ask for clarification” or “reset and try again” connect language with available actions. Hatzigeorgiadis et al. (2011) found that self-talk interventions improved sport performance. Their wider therapeutic contribution needs assessment against the intended clinical outcome.

Physical endurance, anxiety sensitivity and distress tolerance are distinct. LeBouthillier and Asmundson (2015) found that one aerobic exercise session reduced anxiety sensitivity without improving distress tolerance or intolerance of uncertainty. Their later four-week trial involving 48 participants reported benefits for distress tolerance and intolerance of uncertainty following resistance training (LeBouthillier and Asmundson, 2017). Different activities and doses may influence different processes.

Craske et al. (2014) emphasise expectancy violation and new learning within exposure rather than requiring fear to diminish during a session. Movement could provide a setting for such learning where a relevant fear has been identified. The task might examine whether activation can be experienced while retaining choice. Increased intensity alone is an inadequate measure of therapeutic progress.

Attention, flexibility and personal meaning

Movement sequences require attention to targets, balance, timing and instructions. A participant can notice distraction or self-criticism and return to the next action. This provides a concrete setting for attentional practice, with transfer beyond the task requiring review.

Acceptance and commitment therapy offers language for willingness, defusion and values-guided action. Macri and Rogge (2024) review psychological flexibility and inflexibility processes within ACT. Applied here, willingness might involve allowing embarrassment while trying a chosen task; defusion might involve noticing “everyone thinks I am useless” without treating it as an instruction to leave. Flexibility also includes adapting or declining when those choices serve the person’s goals.

Dialectical behaviour therapy distinguishes mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness (Chapman, 2006). These distinctions help specify whether a task concerns attending, modifying activation, enduring distress or communicating a need.

Absorption during training may provide welcome relief. Its function deserves review if movement becomes the only way to avoid painful thoughts. Psychological flexibility concerns the range of responses available, including the ability to rest and engage with difficulties elsewhere.

Meaning should likewise be elicited directly. Practice may represent cooperation, capability or community membership; it may also become organised around punishment or approval. Park (2010) distinguishes efforts to make meaning from meanings actually achieved. Attendance and enjoyment therefore provide incomplete evidence of changes in longstanding beliefs or identity.

Bodily activation, breathing and recovery

Training may make breath-holding, muscular bracing, fatigue and rising arousal more noticeable. A participant can practise adjusting effort, recognising tension and responding to changing demands.

Competition research demonstrates that these demands can be accompanied by substantial physiological activation. Slimani et al. (2018) identified increases in cortisol, adrenaline and noradrenaline following striking combat events compared with pre-combat measurements. These findings concern acute responses to competition and cannot establish how every recreational participant experiences training or whether participation produces lasting improvements in regulation.

Our observations suggest that increasing familiarity may sometimes be accompanied by less unnecessary tension, more economical movement and better-paced effort. We propose that this can provide a setting for learning to act purposefully while activated. This interpretation concerns observable responses; particular hormone or neurotransmitter levels cannot be inferred from performance.

Sometimes the useful task involves reducing unnecessary activation. At other times, it involves discovering that activation is tolerable. Instructions should fit the therapeutic purpose and physical demand.

Breathing during movement differs from a separate paced-breathing practice. Balban et al. (2023) examined brief daily structured breathing protocols, including cyclic sighing, and reported effects on mood and respiratory rate. Fincham et al. (2023) found that coherent breathing at approximately 5.5 breaths per minute did not outperform a matched 12-breaths-per-minute practice on mental health and wellbeing outcomes in 400 participants. These studies concern particular breathing protocols rather than breathing instructions during striking combinations.

During exertion, ventilation must accommodate physical demand. Recovery breathing can be explored separately and reviewed for whether it supports participation. A practice may become restrictive if the person concludes that discomfort must disappear before action is possible.

Recovery also concerns how a session ends, rest between training days and responses to fatigue. These observations help establish whether exercise supports wider functioning or becomes punitive. Recovery should remain adaptable rather than become another performance standard.

Belonging, coaching and interpersonal boundaries

A supportive club can offer repeated contact around shared activity. Connection may develop without immediate personal disclosure. Predictable routines, recognition and constructive feedback may make participation easier, depending on the interpersonal environment.

For people with histories of coercion or interpersonal threat, proximity, commands, touch or unpredictability may carry particular significance. Preparation should establish what participation involves, available adaptations and how consent can be withdrawn. An instructor who respects a request can support learning that needs may be expressed without rejection.

A first step may involve contacting an instructor, observing a class or trying a short introduction. Review should address experience and interpretation. Did the anticipated difficulty occur? Did assistance feel useful or become further evidence of inadequacy? Was there interest or enjoyment?

An unpleasant experience may justify another setting. It should not automatically be interpreted as avoidance to overcome. The suitability of the environment remains part of the formulation.

A hypothetical clinical illustration

The following illustration describes proposed professional reasoning rather than an actual patient account.

An adult interested in boxing avoids asking for help at work and expects that expressing a need will provoke irritation. They also stop unfamiliar activities after mistakes, interpreting difficulty as evidence of incompetence. Assessment explores physical health, previous learning experiences, the meaning of bodily activation and whether current relationships contain actual hostility. It identifies strengths, including an interest in technical skills and previous occasions of effective communication.

A shared hypothesis is that remaining silent provides immediate relief while preventing learning about how others respond to reasonable requests. The client chooses a short non-contact introduction with an instructor who welcomes adaptation. The proposed experiment concerns requesting a slower pace during a manageable combination.

Before practice, clinician and client specify the prediction and rehearse a credible request. Afterwards, review examines whether the request was made, how the instructor responded and how that response was interpreted. If a respectful response is dismissed as “only because this is therapy”, the interpretation becomes a question to investigate. A dismissive response would require reconsideration of both the prediction and the suitability of the setting.

An agreed experiment outside training might involve asking a colleague to clarify an instruction. Review would distinguish willingness, actual behaviour and confidence, which may change at different rates. The example shows how a chosen physical activity can provide a setting for testing a prediction and rehearsing agency.

Evaluating learning beyond training

Evaluation should match the formulation. Technical competence, specific self-efficacy, global self-worth, self-critical responding and everyday participation are related but distinct outcomes. Session review can record predictions, coping choices, interpretation and actual behaviour. Suitable symptom or wellbeing measures can complement personally meaningful goals.

Learning outside training requires further opportunities for practice. Someone who returns to a drill after an error might revisit an activity they previously abandoned. A participant who communicates a limit may examine where else expressing a preference matters. These are further experiments with outcomes to review.

Follow-up should examine whether changes persist, whether participation continues and what happens during interruptions. Attendance, adaptations, adverse experiences and discontinuation provide information about fit. Missed sessions and fluctuating energy should be anticipated within a realistic routine.

The client’s explanation should remain distinguishable from the clinician’s inference. Reported improvement is valuable information, while causal conclusions require stronger evidence.

Physical risk and professional responsibilities

Contact combat sports introduce injury exposures requiring explicit consideration. Head impacts and concussion are material concerns; the Association of Ringside Physicians has emphasised the particular demands of concussion management in this setting (Neidecker et al., 2019).

Non-contact practice can provide movement and learning opportunities without making head contact part of the therapeutic task, but it is not injury-free. Grappling, kicking and pad work place demands on joints, balance and physical capacity.

Selection and progression should account for health, previous injury and current capacity, with appropriate professional input where needed. Participation should permit stopping and distinguish ordinary effort from pain or symptoms requiring reassessment.

Psychotherapy and martial arts instruction require separate competencies. A clinician using physical tasks needs relevant competence and suitable arrangements, or collaboration with a qualified instructor. Clear roles, informed consent, confidentiality and agreed communication help participants understand what is offered.

Combining roles requires attention to whether the person feels free to disagree or stop. Information shared with an instructor should be limited to what is needed for agreed coordination and shared with the client’s consent.

Limitations and research priorities

This selective review combines heterogeneous exercise findings, discipline-specific research and conceptual accounts. Its source selection may omit relevant evidence, and it provides no pooled estimate or formal appraisal of the literature as a whole. Observations and individual experiences inform the clinical proposal but do not establish treatment effectiveness.

Smith and Merwin (2021) describe interacting biological and behavioural pathways through which exercise may influence mental health. General findings concerning cognition, inflammation or neuroplasticity cannot establish that a particular martial arts programme produces the same changes or that those changes explain clinical improvement.

A useful comparative question is whether explicit formulation-guided instruction adds benefit to otherwise similar physical practice. Research could compare matched programmes with and without agreed psychological tasks, accounting for encouragement, contact time, progression and expectations. Comparisons with other meaningful activities could examine shared contributions such as mastery and social connection.

Individualisation also deserves study. Does matching preferences and therapeutic goals improve engagement? Which features of instruction influence participation? When should the initial choice be revised?

Prospective assessment should measure intended outcomes and candidate processes over time. Changes in proposed mechanisms should precede the outcomes they are intended to explain, with alternative explanations considered.

Carefully planned single-case experimental designs may help investigate delivery before larger trials. Follow-up, concurrent care, practitioner competence and less favourable experiences should be reported. Including people who discontinue or find the activity unsuitable would improve understanding of practical limits.

Conclusion

The available evidence suggests that martial arts training can support mental health for some participants, although benefits vary across practices, populations and training environments. Its place within individualised care depends on what participation offers the particular person.

Martial arts bring physical activity, technical learning and interpersonal exchange together, creating opportunities to practise choice during manageable challenge. Therapeutic goals may concern developing confidence, responding differently to mistakes, communicating limits, coping with activation or reconnecting with others. Clinical usefulness depends on matching these opportunities to the person’s formulation and reviewing what becomes available beyond training.

The wider exercise literature supports therapeutic relevance, while the specific outcomes and mechanisms of martial arts require further investigation. Our observations inform a clinical proposal: chosen and appropriately adapted practice may provide a setting in which people test expectations, develop agency and participate more fully in a life they value.

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About the Authors

Daniel Mirea is the founder of NeuroAffective-CBT, an accredited CBT therapist and a university lecturer. He is also a trained martial artist and a sports-psychotherapy consultant.

Chris People holds a black belt in traditional Japanese martial arts and teaching awards in combat sports and Brazilian martial arts. He trains both adults and children and is an accredited Hypno-CBT therapist and trainer. He is also undertaking training in psychotherapy.

Declaration of Interests and Article Scope

Daniel Mirea founded NeuroAffective-CBT, which provides a conceptual perspective discussed in this article. The clinical proposals draw partly on the authors’ observations and personal experiences of training. No original patient data are reported, and the clinical illustration is hypothetical.

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

September 3, 2026September 16, 2026 NeuroAffective-CBT

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?

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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.

The NeuroAffective-CBT Formulation of Pain: Understanding the Body–Brain–Affect Connection

June 1, 2026August 1, 2026 NeuroAffective-CBT

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

Pain is not simply a signal travelling from the body to the brain. It is a neuroaffective experience emerging from the continuous interaction between physiology, emotion, cognition, and context.

Abstract

Pain has traditionally been conceptualised as a direct consequence of tissue damage, whereby nociceptive signals travel from the body to the brain and are subsequently perceived as pain. However, contemporary neuroscience suggests that this explanation is incomplete. Modern pain science increasingly recognises pain as a multidimensional neurobiological and psychological experience that emerges from the continuous interaction between sensory information, emotional states, memory, learning, expectation, context, and prediction. This article explores the distinction between nociception and pain, reviews the role of spinal gating and descending modulation pathways, and examines how affective and cognitive processes contribute to the conscious experience of pain. Drawing upon developments in affective neuroscience, cognitive neuroscience, and contemporary pain research, the article proposes that pain is best understood as a neuroaffective phenomenon rather than a simple sensory event. A NeuroAffective-CBT® (NA-CBT®) perspective is presented, conceptualising pain as the product of an ongoing interaction between the body, brain, and affective systems. Understanding pain through this integrative framework may help clinicians and individuals alike appreciate why pain can persist in the absence of ongoing tissue damage and why effective treatment often requires a biopsychosocial and neuroaffective approach.

Keywords: Pain, Nociception, NeuroAffective-CBT®, Chronic Pain, Affective Neuroscience, Central Sensitisation, Predictive Processing, Pain Perception, Cognitive Behavioural Therapy, Neuroaffective Formulation

The Traditional View of Pain

Although pain has been extensively studied within medicine, neuroscience, and rehabilitation disciplines, discussions within psychotherapy have often focused primarily on symptom management rather than on understanding pain as a complex neuroaffective experience. From a NeuroAffective-CBT perspective, this distinction is important because many of the emotional difficulties presented in therapy involve physiological distress that is experienced, interpreted, and responded to in ways that closely resemble the mechanisms observed in pain itself.

Therefore, pain is not simply something we detect. It is something we experience. And experiences emerge from the continuous conversation between the body, the brain, and affect.

Most of us have been taught a relatively simple explanation of pain. You step on a nail. The injured tissue sends a pain signal through the nerves. The signal travels up the spinal cord.

The brain receives the message. You feel pain.

Simple. Logical. Intuitive.

And yet, although this explanation contains some truth, it is only part of the story.

Over the last several decades, advances in neuroscience, psychology, pain medicine, and affective neuroscience have fundamentally changed our understanding of pain. What we once believed to be a straightforward sensory process is now understood to be a far more complex interaction between the body, brain, emotions, memories, beliefs, expectations, and context.

In many ways, pain provides one of the clearest examples of how the body, brain, and affective systems continuously interact to shape our lived experience.

Most educational diagrams describe pain as a four-step process:

1. Detection of Potential Harm

Specialised nerve endings known as nociceptors detect potentially harmful stimuli such as:

Extreme heat
Excessive pressure
Tissue injury
Chemical irritation

These receptors are often described as “pain receptors,” although this is not entirely accurate.

Their actual role is to detect potential danger.

When activated, they send electrical signals through peripheral nerves toward the spinal cord.

2. The Spinal Gate

The signal reaches the spinal cord, where information is filtered before continuing toward the brain.

This concept originates from the famous Gate Control Theory of Pain, proposed by Ronald Melzack and Patrick Wall in 1965.

According to this theory, the spinal cord functions somewhat like a gatekeeper.

Some signals are allowed through. Others are dampened. Others may be amplified.

This explains why rubbing an injured area often reduces discomfort. Touch signals can partially compete with and inhibit nociceptive input at spinal cord level.

3. Modulation

Signals reaching higher centres of the nervous system can be increased or decreased by descending pathways from the brainstem.

In some situations, pain can be dramatically suppressed.

Examples include:

Soldiers injured in battle
Athletes finishing a race despite serious injuries
Emergency situations where survival is prioritised

Conversely, pain can also be amplified by stress, anxiety, fear, sleep deprivation, inflammation, or sensitisation.

4. Conscious Perception

If sufficient information reaches the brain, pain becomes consciously experienced.

This is where most simplified diagrams end.

However, this is also where the most interesting part of the story begins.

The Biggest Misunderstanding About Pain

Perhaps the most important discovery in modern pain science is this:

Pain signals are not actually pain.

The nerves do not carry pain itself.

They carry information.

They carry evidence.

They carry warning signals.

What travels through the nervous system is better described as:

Nociception

Nociception refers to the detection and transmission of potentially harmful stimuli.

Pain, however, is something different.

Pain is an experience.

And experiences are generated by the brain.

This distinction may sound subtle, but it changes everything.

Nociception Without Pain

Consider the following examples.

A footballer breaks a bone during an important match and continues playing.

A soldier is shot in combat and reports little or no pain until reaching safety.

An individual involved in a car accident walks around helping others before realising they are injured.

In all these situations:

The injury exists.

The nociceptive signals exist.

Yet the pain experience is significantly reduced or absent. The nervous system has decided that survival is currently more important than suffering.

Pain Without Injury

Now consider the opposite situation.

An individual experiences severe chronic pain despite normal scans and medical investigations.

Someone develops phantom limb pain after amputation.

A person with fibromyalgia experiences widespread pain despite no obvious tissue damage.

An individual suffers debilitating migraines despite no visible injury.

In these situations, pain exists. Yet tissue damage may be minimal or absent. Again, pain cannot simply be explained as a direct readout of injury.

Something else is happening.

The Brain Is Not Reading Pain

A common misconception is that the brain acts like a computer reading incoming messages. The reality is far more sophisticated.

Modern neuroscience increasingly supports the idea that the brain functions as a prediction machine. Rather than passively waiting for information, the brain continuously asks:

“What is happening?”

“How dangerous is it?”

“What should I do about it?”

Pain appears to emerge from the brain’s attempt to answer these questions.

The human brain rapidly combines incoming sensory information with previous experiences, memory, learning, expectations, emotional state, beliefs, current stress levels, and environmental context before constructing the experience we call pain.

Pain is therefore not merely detected. Pain is actively constructed by the brain based upon incoming information, prior learning, emotional state, and context.

Why Context Matters

Imagine stepping on the same object under different circumstances.

Scenario One:

You are walking barefoot through your garden.

You step on a sharp object unexpectedly.

Pain is immediate.

Scenario Two:

You are undergoing a medical procedure.

You know discomfort is expected.

You trust the clinician.

The same level of stimulation may feel significantly less painful.

Scenario Three:

You are highly anxious, exhausted, sleep deprived, and worried about your health.

The exact same physical stimulus may feel dramatically worse.

The tissue has not changed.

The brain’s interpretation has changed.

The Emotional Brain and Pain

One of the greatest limitations of many pain models is that they largely ignore emotion. Pain is not simply sensory. Pain is profoundly emotional. Several brain regions contribute to the experience.

Somatosensory Cortex

Helps determine (1) Where the pain is (2) How intense it is

Insula

Processes bodily awareness and internal sensations.

Anterior Cingulate Cortex

Contributes to suffering and distress.

Amygdala

Assesses threat and danger.

Generates fear responses.

Prefrontal Cortex

Adds meaning, interpretation, planning, and decision making.

Pain emerges through the interaction of all these systems rather than from a single pain centre.

There is no single location in the brain where pain exists.

Pain is a network phenomenon.

Fear Can Increase Pain

Imagine touching a hot stove.

The immediate pain serves an adaptive purpose.

You withdraw your hand.

Problem solved.

However, if the nervous system begins associating many harmless experiences with danger, pain can become amplified.

The more fearful we become of pain:

The more we monitor it
The more we anticipate it
The more attention we give it

The more significant it can become.

This does not mean the pain is imaginary.

It means the nervous system is becoming increasingly protective.

In many chronic pain conditions, the alarm system becomes overly sensitive.

The danger detector becomes too good at its job.

What Chronic Pain Teaches Us

Acute pain protects us.

Chronic pain often reflects protection that has become excessive.

The nervous system learns.

The brain learns.

The body learns.

Neural pathways become strengthened through repetition.

Eventually the system may begin generating pain responses disproportionate to actual tissue damage.

This process is often referred to as:

Central sensitisation
Neural amplification
Pain sensitisation

The pain remains real.

The suffering remains real.

The underlying mechanisms, however, are different from those involved in acute injury.

A NeuroAffective-CBT Perspective

Within NeuroAffective-CBT, pain can be understood through the interaction between three continuously communicating systems:

Body

The body provides physiological information.

This includes:

Injury
Inflammation
Hormonal changes
Sleep quality
Nutrition
Energy availability
Physical conditioning

Brain

The brain interprets incoming information.

It generates predictions based upon:

Previous experiences
Memory
Learning
Core beliefs
Expectations

Affect

Affective systems shape emotional meaning.

These include:

Fear
Shame
Anxiety
Helplessness
Anger
Grief

Together these systems create the subjective experience we call pain.

Within NeuroAffective-CBT, emotional pain and physical pain are not viewed as entirely separate phenomena. Both involve physiological activation, affective meaning-making, cognitive interpretation, and behavioural responses. Clients frequently describe emotional suffering using physical language: a heavy chest, a knot in the stomach, emotional exhaustion, pressure, tension, emptiness, or feeling broken. Understanding pain therefore provides an important framework for understanding emotional suffering itself.

The Core Principle of NeuroAffective-CBT

The Body influences the Brain.

The Brain influences Affect.

Affect influences Behaviour.

Behaviour influences Physiology.

When any part of this system becomes dysregulated, suffering may emerge.

When all parts of the system are addressed together, healing becomes possible.

Why This Matters Clinically

Understanding pain differently changes how we approach treatment.

Rather than asking only:

“Where is the damage?”

We might also ask:

What is the nervous system trying to protect?
What role is stress playing?
What role is sleep playing?
What role is fear playing?
What role is emotional suppression playing?
What role is avoidance playing?
What role is physical deconditioning playing?
What role is chronic activation of threat systems playing?

These questions do not invalidate physical explanations.

They expand them.

Pain Is Real, Even When Scans Are Normal

One of the most harmful misconceptions encountered in clinical practice is the belief that normal scans mean symptoms are “all in the mind.”

Nothing could be further from the truth.

Modern neuroscience demonstrates that:

Pain is real.
The nervous system is real.
Brain-based processing is real.
Emotional amplification is real.
Sensitisation is real.

The absence of visible tissue damage does not invalidate suffering.

It simply means the explanation may be more complex than originally assumed.

The Future of Pain Science

Pain science continues to evolve.

Increasingly, researchers are recognising the importance of integrating:

Neuroscience
Psychology
Physiology
Immunology
Lifestyle medicine
Sleep science
Exercise science
Nutritional psychiatry
Metabolic psychiatry

into a more comprehensive understanding of human suffering.

Pain cannot be fully understood through tissue damage alone.

Nor can it be fully understood through psychology alone.

The future almost certainly lies in integration.

A NeuroAffective-CBT Formulation of Pain

From a NeuroAffective-CBT perspective, pain cannot be fully understood through a purely biomedical model, nor can it be adequately explained through a purely psychological framework. Rather, pain emerges from the dynamic interaction between physiological processes, affective systems, and cognitive interpretation. This perspective is consistent with the NA-CBT Body–Brain–Affect Triangle, which proposes that emotional and behavioural experiences arise from the continuous bidirectional communication between bodily states, brain-based processing, and affective meaning-making systems.

Within this framework, the body provides ongoing physiological information regarding injury, inflammation, fatigue, energy availability, sleep quality, nutrition, hormonal changes, and physical conditioning. The brain continuously interprets this information through the lens of prior learning, autobiographical memory, expectations, beliefs, and threat predictions. Simultaneously, affective systems assign emotional meaning to incoming experiences, influencing whether bodily sensations are perceived as manageable, threatening, overwhelming, or catastrophic.

Consequently, pain is not viewed as a simple readout of tissue damage but rather as a neuroaffective experience generated by the interaction of these multiple systems.

The Role of Threat Perception

One of the central assumptions within NA-CBT is that the nervous system is fundamentally organised around safety and survival. The brain continuously evaluates internal and external information to determine the level of threat present in any given situation.

When a stimulus is interpreted as dangerous, the nervous system may increase vigilance, muscular tension, autonomic arousal, and pain sensitivity. Conversely, when safety cues are present, physiological regulation improves, threat responses diminish, and pain intensity may decrease.

Importantly, threat perception is not determined solely by objective reality. It is influenced by previous experiences, trauma histories, attachment experiences, health beliefs, social context, and emotional states.

Two individuals may therefore experience the same physical injury in dramatically different ways depending upon how their nervous systems interpret and respond to the event.

Trauma, Emotional Learning, and Pain Amplification

Traumatic experiences can significantly alter the way the nervous system responds to future threats. Individuals who have experienced chronic adversity, abuse, neglect, medical trauma, bullying, or emotionally invalidating environments may develop heightened sensitivity within threat-detection systems.

Over time, the nervous system may become increasingly efficient at detecting danger, sometimes responding to relatively minor stimuli as though they represent significant threats.

Within the NA-CBT model, unresolved trauma memories may continue to influence present-day physiological and emotional reactions long after the original event has passed. Pain can therefore become linked not only to tissue-based signals but also to fear networks, emotional memories, learned associations, and protective behavioural patterns.

This perspective aligns with contemporary research demonstrating the involvement of the amygdala, anterior cingulate cortex, insula, hippocampus, and prefrontal regions in both pain processing and emotional regulation.

The Influence of Shame and Anxiety

NA-CBT places particular emphasis on the role of shame-based emotional schemas and chronic anxiety in maintaining emotional distress and self-sabotaging patterns.

Shame frequently operates as a hidden amplifier of suffering.

Individuals who carry longstanding beliefs such as:

“I am weak.”
“I should be coping better.”
“There must be something seriously wrong with me.”
“Nobody understands what I am going through.”

may experience increased emotional distress alongside physical symptoms.

Similarly, chronic anxiety can maintain heightened physiological arousal, increased muscle tension, sleep disruption, hypervigilance, and persistent monitoring of bodily sensations. These processes may inadvertently reinforce pain pathways and increase the perceived intensity of symptoms.

From a neuroaffective perspective, emotional suffering and physical suffering often become intertwined, creating self-reinforcing cycles that can be difficult to break without targeted intervention.

The Original TED Model: Tired, Exercise, and Diet

A central component of the NeuroAffective-CBT framework is the original TED model, which focuses on three fundamental physiological domains that frequently influence emotional wellbeing, stress tolerance, cognitive functioning, and pain perception:

Tiredness, Exercise, and Diet.

Within NA-CBT, TED is often conceptualised as an individual’s internal physiological coach. Before attempting to understand complex emotional reactions, trauma responses, self-sabotaging behaviours, or chronic distress, clinicians are encouraged to assess the extent to which these three biological domains may be influencing the individual’s current functioning.

Tiredness

Sleep deprivation and chronic fatigue can significantly alter the way the nervous system processes both emotional and physical experiences.

Research consistently demonstrates that insufficient sleep is associated with:

Increased pain sensitivity
Reduced emotional regulation
Heightened threat perception
Increased anxiety and irritability
Poorer stress tolerance
Reduced cognitive flexibility
Greater physiological arousal

From a neuroaffective perspective, an exhausted nervous system is often a more reactive nervous system.

Individuals experiencing chronic pain frequently report poor sleep quality, whilst poor sleep itself can increase pain intensity, creating a self-perpetuating cycle of distress and physiological dysregulation.

For this reason, improving sleep and recovery is often considered a foundational intervention within the NA-CBT model before attempting more intensive emotional processing work.

Exercise

Physical activity plays a critical role in both emotional and physiological regulation.

Regular movement influences multiple systems associated with pain modulation, including:

Endorphin release
Stress regulation
Neuroplasticity
Cardiovascular health
Inflammatory processes
Mood regulation
Self-efficacy and resilience

Importantly, exercise may also help challenge fear-avoidance patterns commonly observed in chronic pain conditions.

Many individuals gradually reduce activity levels because movement becomes associated with discomfort or fear of injury. Whilst avoidance may provide short-term relief, prolonged inactivity can contribute to deconditioning, increased vulnerability, reduced confidence, and further sensitisation of the nervous system.

Within NA-CBT, exercise is therefore viewed not simply as a physical intervention but also as a psychological and neurobiological regulator capable of influencing both mood and pain perception.

Diet

Nutrition provides the biological foundation upon which the brain and body operate.

Emerging evidence from nutritional psychiatry, metabolic psychiatry, and neuroscience increasingly suggests that dietary factors may influence emotional wellbeing, inflammation, energy production, cognitive functioning, and stress resilience.

Poor nutritional habits may contribute to:

Fatigue
Metabolic dysfunction
Increased inflammation
Blood sugar instability
Reduced concentration
Mood fluctuations
Poor recovery capacity

From an NA-CBT perspective, diet is not viewed through a restrictive or purely weight-focused lens. Rather, it is considered a crucial component of physiological regulation that may influence how effectively the nervous system responds to both emotional and physical stressors.

TED and Pain Perception

The relevance of the TED model to pain becomes increasingly apparent when viewed through a neuroaffective lens.

An individual who is:

Chronically sleep deprived,
Physically deconditioned,
Nutritionally dysregulated,

may experience a nervous system that is more reactive, more vigilant, and more sensitive to both internal and external stressors.

Consequently, pain intensity may increase even when tissue damage remains unchanged.

Conversely, improvements in sleep, physical conditioning, and nutritional stability may help reduce physiological stress, improve emotional regulation, increase resilience, and support healthier pain modulation pathways.

Within the NeuroAffective-CBT framework, TED therefore represents far more than a lifestyle intervention.

It represents a foundational physiological platform upon which emotional regulation, cognitive flexibility, behavioural change, trauma processing, and recovery can occur.

When individuals begin addressing tiredness, exercise, and diet simultaneously, they are often not simply improving their physical health. They are creating the biological conditions necessary for the nervous system to feel safer, more regulated, and less protective.

From this perspective, the TED model becomes directly relevant to understanding why some individuals remain trapped within cycles of chronic pain, emotional distress, and physiological dysregulation, whilst others gradually move towards recovery and resilience.

Metabolic Health, Ketogenic Therapies and Pain

Over recent years, growing attention has been directed towards the relationship between metabolic health, inflammation, brain function, emotional wellbeing, and chronic illness. Whilst traditionally associated with weight management or epilepsy treatment, ketogenic therapies are increasingly being investigated for their potential effects on neurological, psychiatric, and inflammatory conditions.

As discussed in a recent NeuroAffective-CBT article exploring ketogenic therapies and mental health, emerging research suggests that metabolic dysfunction may influence psychological wellbeing through mechanisms involving inflammation, mitochondrial function, oxidative stress, insulin resistance, and energy metabolism within the brain.

This perspective aligns closely with one of the central assumptions of the NA-CBT model: the brain does not function independently from the body. Physiological dysregulation may influence emotional wellbeing, whilst emotional distress may simultaneously influence physiological functioning.

The relevance of this emerging field to pain should not be underestimated.

Many chronic pain conditions are now recognised to involve not only structural or tissue-based factors but also inflammatory processes, autonomic dysregulation, altered stress responses, sleep disturbance, and changes in central nervous system functioning. Increasingly, researchers are exploring whether metabolic interventions may influence some of these mechanisms.

As stated in the recent NeuroAffective-CBT review of ketogenic therapies:

“The question is not whether ketogenic therapies represent a miracle cure. The question is whether some of the benefits reported by patients may be explained by improvements in physiological regulation, inflammation, energy metabolism, sleep, cognition, and emotional stability.”

This is an important distinction.

Within NA-CBT, ketogenic diets are not conceptualised as psychological treatments. Rather, they may represent one example of how physiological interventions can potentially influence the Body–Brain–Affect system.

For some individuals, improvements in metabolic health may be associated with:

Reduced systemic inflammation
Improved energy regulation
Enhanced cognitive clarity
Better sleep quality
Reduced emotional volatility
Improved stress tolerance

All of which may indirectly influence the experience of pain.

Further research is required before definitive conclusions can be reached. However, the growing field of metabolic psychiatry reinforces a principle that sits at the heart of NeuroAffective-CBT®:

The body influences the brain. The brain influences affect. Affect influences behaviour. Behaviour influences physiology.

Understanding pain therefore requires us to look beyond symptoms alone and consider the broader physiological and emotional ecosystem within which those symptoms occur.

Towards an Integrated Understanding of Pain

The clinical implications of this model are significant.

Rather than asking solely:

“Where is the injury?“

NA-CBT® encourages clinicians and individuals to also ask:

What is the nervous system trying to protect?
What emotional meanings have become attached to the symptoms?
What role is fear playing?
What role is shame playing?
What role is avoidance playing?
What role is trauma playing?
What role are sleep, nutrition, and physical conditioning playing?
What factors are maintaining the brain’s prediction that danger remains present?

These questions do not deny the reality of pain.

Instead, they acknowledge the complexity of human suffering and provide a broader framework for understanding why pain may persist long after tissue healing has occurred.

Ultimately, the NeuroAffective-CBT® model views pain as a whole-person experience emerging from the continuous interaction between the body, brain, and affective systems. By addressing all three domains simultaneously, clinicians may be better positioned to help individuals reduce suffering, improve functioning, and develop a more integrated relationship with their physical and emotional experiences.

Final Thoughts

Perhaps the most important lesson from modern pain science is this:

Pain is not simply a signal travelling from the body to the brain.

Pain is a dynamic neurobiological experience emerging from the continuous interaction between bodily information, emotional states, prior learning, memory, beliefs, context, and prediction.

The body provides information.

The brain evaluates that information.

The affective system gives it meaning.

Together they create the conscious experience we call pain.

Understanding this complexity does not make pain less real.

If anything, it helps explain why pain can sometimes persist long after tissue healing has occurred, why emotions can influence symptoms, why stress can worsen discomfort, and why genuinely effective treatment often requires us to address the whole person rather than a single body part.

In many respects, pain may be one of the clearest demonstrations that human beings cannot be reduced to either mind or body alone.

We are, and always have been, an integrated neuroaffective system.

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