Does Psychotherapy Also Pass Through the Body?: Mind, Nervous System, and Body as an Integrated System in Clinical Practice

Article written in collaboration with @osteopata_dilettamacchi

Abstract

Western psychotherapeutic tradition has long privileged work on the mind understood as a cognitive and verbal dimension. However, findings from affective neuroscience, somatic psychology, and trauma research have progressively reshaped this picture, restoring the body to a central role in emotional experience and therapeutic change. This article provides a theoretical review of the main scientific contributions supporting an integrated mind-body model, with reference to the Polyvagal Theory (Porges, 2011), the concept of embodiment (Damasio, 1994; van der Kolk, 2014), body-oriented therapeutic approaches, and the possible role of osteopathic work in supporting physiological and emotional regulation.

Introduction

For over a century, psychotherapy has found its privileged domain in the spoken word: the clinical interview, the therapeutic relationship, interpretation, cognitive restructuring. This centrality of language and thought reflects a dualistic conception of the human being — a Cartesian inheritance that separates res cogitans from res extensa — in which the mind is considered the primary locus of psychological suffering and, consequently, the main object of therapeutic intervention.

In recent decades, however, a convergence of disciplines — affective neuroscience, somatic psychology, mind-body medicine, and trauma research — has profoundly challenged this paradigm. The discovery that emotions have an irreducible bodily basis (Damasio, 1994), that trauma is encoded in the body before it can be consciously narrated (van der Kolk, 2014), and that the autonomic nervous system regulates states of safety and danger in a hierarchical manner (Porges, 2011) has opened new theoretical and clinical horizons.

This article aims to explore these perspectives, outlining an integrated model in which the mind, body, and nervous system are not separate entities but aspects of a single adaptive system. The main theoretical frameworks will be discussed, along with corresponding psychotherapeutic approaches and the potential contribution of body-based practices — such as osteopathy — to the emotional regulation process.

Beyond the Mind-Body Dualism: The Neuroscientific Foundations

Emotions Are Embodied: Damasio's Contribution

Neuroscientist Antonio Damasio provided, with Descartes' Error (1994), one of the most robust critiques of mind-body dualism in contemporary neuroscientific literature. Through the study of patients with lesions to the ventromedial prefrontal cortex, Damasio demonstrated that emotions are not irrational accessories to thought, but necessary conditions for decision-making and the construction of the self.

Damasio's theory of somatic markers holds that every emotional experience is accompanied by physiological modifications — changes in heart rate, muscle tension, breathing, posture — that the brain registers and uses as guiding signals in reasoning and action. From this perspective, separating emotions from bodily sensations is not only conceptually mistaken, but neurologically impossible (Damasio, 1994, 2003).

Affective Neuroscience and Motivational Systems

Alongside Damasio's work, Jaak Panksepp's research in affective neuroscience identified seven primary emotional systems — SEEKING, RAGE, FEAR, LUST, CARE, PANIC/GRIEF, PLAY — deeply rooted in the subcortical structures of the brain and shared with other mammals (Panksepp & Biven, 2012). These systems are activated by environmental stimuli before the prefrontal cortex can process their meaning, implying that many emotional and behavioral responses occur below the threshold of reflective consciousness.

These findings have direct implications for clinical practice: if primary emotions are subcortical and bodily, an intervention working exclusively at the cognitive-verbal level may not reach the processing levels where they originate (Panksepp & Biven, 2012; Schore, 2019).

Affective Regulation and the Role of the Autonomic Nervous System

Allan Schore, neuropsychoanalyst and researcher, has developed over three decades a theory of affective regulation integrating developmental neurobiology, attachment theory, and clinical practice (Schore, 2019). According to Schore, emotional regulation develops in the early years of life through attunement between the infant and the caregiver, mediated by the autonomic nervous system and the right cerebral hemisphere. Early traumatic experiences — as well as disruptions in the attachment bond — leave traces not only cognitive but also physiological, influencing the capacity to regulate internal states throughout life.

Therapeutic work, from this perspective, must necessarily include the bodily dimension and intersubjective co-regulation between therapist and patient, as it is through this channel that change in the neural structures of emotional regulation occurs (Schore, 2019).

The Polyvagal Theory: A New Map of the Nervous System

Among the most influential contributions of the past three decades in psychotherapy and neuroscience, the Polyvagal Theory by Stephen Porges (1994, 2011) holds a prominent place. Starting from a phylogenetic reinterpretation of the vagus nerve — the tenth cranial nerve, innervating most of the internal organs — Porges proposed a hierarchical model of the autonomic nervous system articulated in three evolutionary levels:

• The ventral vagal system (myelinated, evolutionarily newer): associated with states of safety, social connection, curiosity, and openness. It regulates facial expression, vocal tone, and listening.

• The sympathetic system: activated in response to perceived danger. It mobilizes the organism's resources for the fight-or-flight response.

• The dorsal vagal system (unmyelinated, evolutionarily older): activated in response to extreme or inescapable threats. It produces immobilization, freeze response, and dissociation.

This hierarchy has profound implications for clinical work: the behaviors of withdrawal, dissociation, or apathy that a patient brings to therapy are not signs of resistance or moral failing, but adaptive responses of the autonomic nervous system to situations perceived as threatening (Porges, 2011). The concept of neuroception — the unconscious evaluation of safety or danger that the nervous system performs before consciousness intervenes — explains why many patients find themselves in states of activation or shutdown without being able to rationally understand the cause.

For the clinician, creating conditions of physiological safety — through vocal tone, bodily presence, and the rhythm of the relationship — becomes a prerequisite for any meaningful psychological processing (Dana, 2018; Porges, 2011).

The Concept of Embodiment

The term embodiment refers to the fundamental condition by which the human subject does not have a body, but is a body (Merleau-Ponty, 1945/2003). This principle, initially elaborated by philosophical phenomenology, has been progressively integrated into psychology and neuroscience, becoming one of the core concepts of contemporary somatic psychology.

In clinical settings, embodiment refers to the capacity to perceive, inhabit, and regulate bodily sensations as an integral part of the healing process. Trauma research has shown that traumatic experiences compromise precisely this capacity: the body is perceived as a place of danger, dissociated from conscious experience, or chaotically hyperactivated (van der Kolk, 2014).

Bessel van der Kolk, in his influential volume The Body Keeps the Score (2014), documents how trauma leaves traces in subcortical structures and in the autonomic nervous system, often inaccessible to verbal narrative. The very title of the book synthesizes the central idea: the body keeps account of traumatic experiences even when the mind can no longer access them.

The therapeutic implications are direct: a treatment working exclusively with language and cognition may leave intact the implicit and bodily memory of trauma. It is necessary to include interventions that work directly with physical sensations, posture, breathing, and movement (Levine, 2010; Ogden et al., 2006).

Top-Down and Bottom-Up: Two Directions of Therapeutic Change

The distinction between top-down and bottom-up processing has become an important conceptual reference in body-oriented psychotherapy.

• Top-down processing proceeds from the cortex toward subcortical structures: it encompasses cognitive processes, reflection, language, interpretation, and mentalization. This is the preferred pathway of traditional approaches such as cognitive-behavioral therapy and classical psychoanalysis.

• Bottom-up processing moves in the opposite direction: it starts from bodily sensations, physiological regulation, and the autonomic nervous system, rising toward the cortex. This is the preferred pathway of somatic approaches.

Neuroscientific research has shown that in traumatic presentations — and more generally in states of high emotional arousal — the prefrontal cortex may be temporarily 'offline,' unable to exercise its regulatory functions (van der Kolk, 2014). In these states, top-down work is limited in its effectiveness: the patient may rationally understand their situation but be unable to regulate the bodily response. For this reason, bottom-up interventions — working directly with physiology — can open up processing spaces that would otherwise be inaccessible (Levine, 2010; Ogden et al., 2006).

Body-Oriented Psychotherapeutic Approaches

Somatic Experiencing

Somatic Experiencing (SE) is a psychotherapeutic approach developed by Peter Levine beginning in the 1970s and systematized in the volume Waking the Tiger (Levine, 1997). Levine observed that animals in the wild — despite being continuously exposed to dangerous situations — rarely develop post-traumatic symptoms equivalent to those in humans. The reason, according to Levine, lies in animals' capacity to complete the stress response cycle through physical movements (trembling, shaking, fleeing), while in human beings this cycle is often interrupted by cognitive and social responses.

SE works through titration — the gradual exposure to bodily sensations associated with trauma — and pendulation — the oscillation between states of activation and resources of calm — to facilitate the completion of blocked response cycles and the regulation of the autonomic nervous system (Levine, 2010).

Sensorimotor Psychotherapy

Sensorimotor Psychotherapy (SP) was developed by Pat Ogden beginning in the 1980s, integrating somatic psychology with attachment theory and cognitive approaches (Ogden et al., 2006). The approach focuses on the observation and modulation of sensorimotor responses — postures, gestures, movement impulses — as a gateway to trauma processing.

Unlike traditional therapy, in which the body is considered primarily as a vehicle for language, in SP the patient's bodily responses become the direct object of clinical inquiry. The therapist observes how the patient physically organizes their experience — contraction, collapse, bracing — and works to expand the repertoire of available physical responses, increasing what Ogden calls the window of tolerance (Ogden et al., 2006; Siegel, 1999).

Bioenergetic Analysis

Bioenergetic Analysis, developed by Alexander Lowen from the work of Wilhelm Reich, is one of the oldest body-based approaches to psychotherapy (Lowen, 1975). Reich had theorized that unresolved psychological conflicts crystallize in the body in the form of muscular armor — chronic tensions that restrict breathing, movement, and emotional expression.

Lowen developed this concept, adding specific exercises of grounding, muscular mobilization, and expression of blocked emotions. Although some of his theoretical formulations have required revision in light of contemporary neuroscience, the fundamental contribution of the approach — the recognition that the body is text and not merely context of psychological experience — remains clinically relevant (Lowen, 1975).

The Potential Contribution of Non-Psychotherapeutic Body Work

If regulation of the autonomic nervous system is a necessary condition for psychotherapeutic work, the question arises whether body-based practices that are not strictly psychotherapeutic can support this process.

Osteopathy — a manual discipline working on the structural and functional integrity of the body, tissue mobility, and fluid circulation — has shown in some preliminary studies positive effects on the autonomic nervous system. Osteopathic techniques such as craniosacral treatment and diaphragm manipulation appear to promote activation of the parasympathetic system and reduction of physiological hyperarousal states (Cerritelli et al., 2017).

From an integrative perspective, osteopathic work could represent a support to psychotherapy — not as a substitute, but as a parallel pathway acting somatically on physiological regulation, creating bodily conditions more favorable to emotional processing. It is important to emphasize that this perspective requires further research with methodologically rigorous designs, and that collaboration between professionals from different fields must occur in full respect of their respective competencies and professional boundaries.

Clinical Implications and Future Directions

The body of theoretical and empirical contributions examined converges toward several clinically relevant implications for psychotherapeutic practice:

• Physiological safety — mediated by the ventral vagal system and neuroception — is a prerequisite for any meaningful psychological processing. The therapist contributes to creating it through their own bodily presence, vocal tone, rhythm, and the quality of the relationship.

• The integration of bottom-up interventions — working with bodily sensations, breathing, posture, and movement — can expand therapeutic effectiveness, particularly in traumatic presentations and conditions of chronic emotional dysregulation.

• The concept of the window of tolerance (Siegel, 1999; Ogden et al., 2006) offers a useful operational framework for calibrating the patient's level of arousal during the session, avoiding both under-stimulation and over-stimulation.

• Interprofessional collaboration between psychotherapists and body-based practitioners — osteopaths, physiotherapists, yoga and mindfulness teachers — can represent an integrative resource in the care process, provided it occurs transparently, ethically grounded, and patient-centered.

Future research directions should include randomized controlled trials on somatic approaches, greater attention to the measurement of physiological outcomes (heart rate variability, markers of autonomic nervous system activation) alongside psychological ones, and the development of evidence-based mind-body integration protocols.

Conclusions

Psychotherapy does not pass through thoughts alone. Affective neuroscience, trauma research, and somatic psychology have demonstrated with increasing solidity that mind, body, and nervous system constitute an integrated system, in which therapeutic change necessarily involves all three dimensions.

The body is not a mere container of the mind, nor an epiphenomenon of psychological experience. It is, as Merleau-Ponty wrote (1945/2003), the very subject of perception and action: the place where emotions take form, traumas are inscribed, and healing — slowly — can occur.

Listening to the body in psychotherapy is not a trend, nor an anti-scientific deviation. It is, on the contrary, a coherent response to the evidence that contemporary science offers us about how the human being functions in their entirety. A therapist who integrates this awareness into their clinical practice has broader tools to accompany the patient toward that emotional regulation which is, ultimately, the heart of therapeutic change.

References

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