










































The Physiology of Psychotherapy


Graduate Student Journal of Psychology                                                                        Copyright 2009 by the Department of Counseling & Clinical Psychology  
2009, Vol. 11                                                                                                                   Teachers College, Columbia University                          

 
 

The Physiology of Psychotherapy: Past, Present, and Future 
 

John Thomas Huber II 
University of Detroit Mercy  

 
This paper will first locate the physical science of psychology in its historical context and explore the 
attempt of past eras to devise medical treatments for the mind. Next, present research and clinical 
applications for the biology of mental disorders will be summarized, with emphasis on the importance 
of the mirror neuron system. Lastly, overall conclusions will be drawn, and their implications for a 
truly holistic physiology-informed psychotherapy of the future will be discussed. This paper will 
ultimately suggest that while promising studies have been conducted on the subject, a considerable 
amount of work remains in order to surpass the soft embryonic stage of research development and to 
solidify its position in the science of clinical practice.  
 

The physiology of psychotherapy is a highly relevant 
issue today. For countless scientist-practitioners and 
practitioner-scholars who uphold both sides of their 
respective Boulder and Vail training models, the scientific 
interconnection of the mind and body is still searching for 
the right outlet of expression in case conceptualization and 
clinical practice. Since psychotherapy is an instrument of 
self-revelation and health-promotion that is capable of 
benefiting many facets of human life, it must navigate a 
delicate balance of movement from unconsciousness to 
consciousness, from the force of self-constriction to the 
choice of self-liberation, and from poor bodily conditions to 
positive physical health. Given an assumption of the mind 
and body as two sides of the same coin, clinicians have often 
striven in psychotherapy to equally value their clients’ 
mental and physical lives. However, throughout their 
training in graduate school and beyond, clinicians frequently 
accumulate as many new questions pertaining to the function 
of the physical body in “psychotherapy” designed for the 
mind as they discover answers. These various questions are 
often incarnations of just one basic inquiry, “What is 
palpably happening to the patient in a treatment with 
tangible results?” In the following paper, the answer will be 
sought through an examination of the physiology of 
psychotherapy with respect to; (1) the history of psychology, 
(2) the evolution of different brain regions, (3) the state of 
present research, (4) its clinical application to mental 
disorders, (5) the importance of the mirror neuron system, 
and (6) unique implications for the future.   

While most may agree that therapists help their patients 
cope with or conquer some life problem, it is difficult to 
explain how without reference to the nebulous process of 
loose word exchanges in talk therapy. For better or worse, 
these loose word exchanges comprise a foggy process 
forever wedged in the illicit border between subjective art 
and objective science. The physician Laurence Farmer1 
(1950) once denounced the role of clinical therapist as being 

                                                 
Correspondence: John Thomas Huber II, thomashuber_2@yahoo.com 

an “ill defined psychologist” (p. 175) with poor pseudo-
medical training. It might, therefore, be meaningful in one’s 
education to explore the less visible, underlying 
neurobiology of psychotherapeutic change, given that proper 
technique can literally alter the patient’s body and correct 
physiological malfunction. Gilbert (1995) once argued that 
the field of psychology was in a fragile state of 
disequilibrium from its fragmented uni-dimensional theories 
opposing body versus mind, and he challenged the field to 
finally adopt a truly integrative “biopsychosocial” (p. 136) 
worldview.  Now almost a decade into the 21st century, 
Gilbert’s plea has gained great ground, and popular opinion 
in the psychotherapy community is more supportive than 
ever of a genuinely comprehensive, holistic framework for 
humanity.   

 
Historical Roots in the Past 

 
Most societies, beginning from the 5th century B.C. and 

onward, have recognized a primitive anatomical fact: the 
brain is the biological apparatus of the mind (Lewis, 1992). 
In approximately the 4th century B.C., the Greek physician 
Hippocrates proposed his humoral theory of brain 
functioning that stated bodily fluids, or physiological 
humors, are responsible for the psychological disorders of 
the mind (Durand & Barlow, 2000). By the time of the 17th 
century, philosopher René Descartes had combined 
Renaissance ideas with Scientific Revolution notions to form 
his Cartesian dualism, which effectively divorced the mind 
from the body as a separate entity for study (Leahey, 2001). 
Although he was unable to reconcile the seamless interaction 
of the body and brain with the mind and soul, Descartes 
resorted to speculations about the pineal gland as their 
intermediary site, and he even wrote one of the first texts on 
the subject of physiological psychology, L’Homme (Leahey, 
2001). Centuries later, the exact relationship between the 
“brain” and “mind” was still incompletely known, and Freud 
noted that “data do not include any direct relation between 
these two terminal points of our knowledge” (quoted in 

3 



HUBER 
 

 4 

Cappas, Andres-Hyman, & Davidson, 2005, p. 374). 
Incremental advances in the physiological sciences today, 
however, are beginning to illuminate much of the mysterious 
brain-mind interaction (Lewis, 1992). 

Historically, the revolution in the physiological sciences 
at the inception of the 20th century occurred in tandem with 
Freud’s revolution in the psychological sciences. Freud 
completed his medical training at the time of the earliest 
investigations into the neurological configuration of the 
brain, and his own research on brain physiology is what 
ultimately narrowed his focus to unconscious phenomenon 
(Mitchell & Black, 1995). Thereafter, he propounded the 
first ever psychotherapy to systematically study and mend 
the mind.  With his method wholly unknown to the rest of 
the world, though, Freud felt compelled to justify 
psychotherapy as a valid science that was important in its 
own right independent of medical science. As a result, he 
adamantly opposed the medicalization of psychotherapy and 
strove to definitively dissociate psychotherapy from his very 
own training background in neurophysiology (Mitchell & 
Black, 1995). Even until the last quarter of the 20th century, 
many psychologists still interpreted Freud as having 
exclusively endorsed the study of behavior over the study of 
biology (Innes, 1971). Consequently, these psychologists 
largely ignored or neglected the neuro-physiological aspects 
of psychotherapy practice.  On the other end of the clinical 
spectrum were the medical physicians who dismissed 
psychotherapy as mere pseudo-medical chicanery, which the 
psychiatrist Gabbard (2001) called, “a remnant of persistent 
Cartesian thinking that has led many skeptics to think that 
psychotherapy may be nothing more than balm for the 
‘worried well’” (p. 1). Schore (1997) inquired, “A century 
after Freud’s project: Is a rapprochement between 
psychoanalysis and neurobiology at hand?” and reiterated a 
rare admission by Freud himself that “we shall have to find a 
contact point with biology” (p. 807).  Indeed, the century 
subsequent to Freud’s era has constructed just such a bridge 
between biology and psychotherapy and, given the recent 
trend toward multidisciplinary science, the marriage of 
physiology and psychotherapy is no doubt one emerging 
example of the current scientific zeitgeist. 

 
Evolution of the Brain 

 
Considering humanity to be the culmination of 670 

million years of animal evolution on the 5-billion-year-old 
earth (Palmer & Palmer, 2002), it is unsurprising that 
adaptation, or balanced flexibility, is the natural design for 
improving fitness between an individual specimen and its 
environment (Bernard, Mills, Swenson, & Walsh, 2005). 
Psychotherapy may, in fact, be defined as the installation of 
balanced adaptation through mediation of the lower default 
brain circuits, or survival instincts, with the higher cortical 
supra-system circuits, or centers of introspection (Viamontes 
& Beitman, 2006a). In other words, depending on the 
patient’s problem to be addressed, psychotherapy 
disentangles the internal conflicts between evolution-

embedded id impulses and social herd-imposed superego 
restraints to promote negotiation and tolerance of these 
through the self-aware ego, all of which was Freud’s 
tripartite interpretation of and testament to Charles Darwin’s 
evolutionary theory (Hall, 1961; Leahey, 2001). Treatment 
with the animalistic id instincts involves the hypothalamus, 
limbic system, and cingulate gyrus-nucleus accumbens 
region of the brain for emotion formation, the pleasure of 
reward or the fear of punishment, and simplistic stimulus-
response situations (Ito, 1998; Viamontes & Beitman, 
2006b). For the societal superego conscience, treatment 
involves the parietolateral portion of the association cortex 
and the orbitofrontal-amygdalar region of the brain for 
sensorimotor processing and socio-emotional self-regulation 
(Ito, 1998; Viamontes & Beitman, 2006b). And, treatment 
with the human’s ego self-representation involves the 
association cortex, sensorimotor cortex, and dorsolateral 
prefrontal region of the brain for executive control 
functioning, verbal abstraction, and analytical thinking (Ito, 
1998; Viamontes & Beitman, 2006b). The neocortex is one 
of the most important portions of the human brain which 
distinguishes it from lower animal brains, and the prefrontal 
cortex contains 30% of the human neocortex, thereby 
permitting humans the capacity for goal-directed action, 
expanded memory, and evaluation of future consequences 
(Viamontes & Beitman, 2006b).  Furthermore, the middle 
pre-frontal region of the brain is responsible for body 
regulation of the sympathetic and parasympathetic 
autonomic nervous systems, fear extinction, impulse 
inhibition, interpersonal communication, autobiographical 
knowledge, body awareness, self-reflective insights, 
empathy or perspective-taking, and pro-social concerns 
(Siegel, 2006). 

The human’s frontal lobe began to evolve its 
proportionately greater size over the great apes’ frontal lobe 
about 20-25 million years ago, but has failed to evolve 
anymore in the past half-million years (Bernard et al., 2005). 
Since the prefrontal cortex is the anterior portion of the 
frontal lobe, the prefrontal cortex has remained largely the 
same for 500,000 years, too. There are three premier 
prefrontal cortex circuits in the brain, including the anterior 
cingulated circuit, the orbitofrontal circuit, and the 
dorsolateral circuit (Viamontes & Beitman, 2006b). While 
each of these brain circuits regulate specific parts of the 
patient’s mind during the psychotherapy process, in 
particular “the dorsolateral circuit is the entry point for 
verbal psychotherapeutic interventions” (Viamontes & 
Beitman, 2006b, p. 241), because of its integral role in 
executive control functions, higher-level logical reasoning, 
problem-solving, verbal abstraction, and behavioral 
modification from linguistic input. For instance, depressed 
people exhibit imbalanced reductions in blood circulation 
within the right dorsolateral prefrontal cortex as well as 
inferior parietal cortex (Viamontes & Beitman, 2006b) and, 
therefore, the clinician’s words spoken in psychotherapy 
directly impact and recalibrate the blood flow imbalances 
from this pivotal region of the brain. 



PHYSIOLOGY OF PSYCHOTHERAPY 
 

 5

Present Research and Applications 
 

Emotional disturbance, such as depression, is one of the 
most frequent complaints that causes people to seek 
treatment (Barrera, Torres, & Munoz, 2007), which is 
thought to assist them in better balancing their maladaptive 
moods. With magnetic resonance imaging (MRI) and single 
photon emission computed tomography (SPECT) imaging, 
psychodynamic psychotherapy for depression has been 
shown to increase the density of serotonin transporter 
(SERT) binding at the midbrain sites of the raphe nucleus, 
which then correlated with the alleviation of depressive 
symptomatology (Saarinen et al., 2005). Another SPECT 
study which included a 1-year-long psychodynamic 
psychotherapy treatment demonstrated increases and 
ultimate normalization of serotonin metabolism and uptake 
in a patient suffering from comorbid Major Depressive 
Disorder and Borderline Personality Disorder (Viinamaki, 
Kuikka, Tiihonen, & Lehtonen, 1998). Cognitive behavior 
therapy has indicated success in decreasing and normalizing 
thyroid hormone levels of thyroxine (T4) in depressed 
patients (Joffe, Segal, & Singer, 1996). In another study with 
persons affected by negative emotions, it was learned that 
having the patients rename their emotional circumstances in 
unemotional words effectively decreased their negative 
emotional state, which involved stimulation of the lateral and 
medial prefrontal cortices in conjunction with de-stimulation 
of the amygdala as well as medial orbitofrontal cortex 
(Viamontes & Beitman, 2006b). 

Imaging research has also demonstrated that the 
amygdala and orbitofrontal circuits, which help control 
emotional stability, can be successfully altered through the 
self-awareness thought processes within psychotherapy 
(Viamontes & Beitman, 2006b). Past research has shown 
that anxiety relief and decreases in parasympathetic heart 
measures, like heart rate and variability from 
electrocardiogram (EKG) recordings, are correlated during 
therapy with positive self-talk by patients, as well as 
correlated with simply speaking about the therapy when 
contrasted with patients’ critical self-evaluations (Anderson, 
1956). The psychotherapeutic journey from unresolved anger 
and internal rage to feelings of depression and sadness 
depends upon sympathetic system activation, such as an 
increase in temperature of fingers and skin conduction, 
whereas parasympathetic system arousal, like high 
consistency of heart rate variation of between-beat intervals, 
corresponds to sadness elicited before the inducement of 
anger in therapy (Rochman & Diamond, 2008). A 
physiological study of psychotherapy found that clients’ 
feelings of uncomfortable tension with the therapist were 
manifested in the client’s increased heart rate, whereas 
feelings of antagonism against the therapist were manifested 
in the client’s increased skin temperature (Dimascio, Boyd, 
& Greenblatt, 1957). 

As a result, intentionally impacting bodily markers, such 
as deliberately decreasing clients’ body temperature and 
reducing their heart rate among other vital signs, may be a 

relevant auxiliary goal of treatment. The “process of therapy 
may need to involve working through the anger to reach the 
pain” (Rochman & Diamond, 2008, p. 103), such that certain 
sympathetic system deactivations correlate with the process 
of arousing buried rage and then gently opening the patient 
to their associated sorrow. However, the reverse direction 
does not effectively decrease sympathetic activity, by first 
shifting from initial sadness to later anger (Rochman & 
Diamond, 2008), and should therefore be avoided by 
psychotherapists. In addition, when research subjects 
verbally discussed their feelings of rage, their sympathetic 
activity changes correlated with their self-reports of rage 
intensity, whereas when patients suffered silently without 
verbalizing depressive feelings, their parasympathetic system 
increases corresponded to their self-reports of depression 
intensity (Rochman & Diamond, 2008). Given the 
neurological corollaries of emotional verbalization, 
psychoanalytic authors have declared that defense 
mechanisms, such as regression and repression, can be 
neurologically located at the brain sites of neurotransmitters 
with aversive, noradrenergic, and serotonergic reward 
stations (Heilbrunn, 1979). 

Self-awareness is dependent in psychotherapy upon the 
right prefrontal cortical region, although transcranial 
magnetic stimulation of this brain region interrupts self-
awareness, which evolved alongside the right hemisphere 
and its cognitive capacities (Guise et al., 2007). It has been 
noted, however, that disturbances of self-awareness and first-
hand perspectives in the right prefrontal cortical region do 
not impede other-awareness or second-person perspectives 
(Guise et al., 2007). Thus, this region is implicated in the 
ability of patients to understand the therapist’s perspective 
when he or she empathically interprets to the patient, based 
upon the therapist’s own right prefrontal cortical region for 
understanding the patient’s perspective. Furthermore, 
functional imaging research has demonstrated that 
stimulation of the left prefrontal cortex region is 
indispensable in the semantic processing of first-person 
perspectives as well as second-person perspectives, although 
the medial prefrontal cortex region is connected to self-
reference features in the human memory system (Heatherton, 
Macrae, & Kelley, 2004). The path of memory consolidation 
resulting in greater adjustment of synaptic plasticity is the 
main mechanism of information acquisition, retention, and 
storage for what is learned in psychological treatment 
(Liggan & Kay, 1999). Therefore, psychotherapy that 
stimulates left regions as well as medial regions of the 
prefrontal cortex will be most successful in certain treatment 
cases, while other situations may demand more activation of 
the right region of the prefrontal cortex, as in the case of 
panic and phobias. 

One physiological study on psychotherapy for 
arachnophobia determined that linguistic-based cognitive 
therapy was effective through activation of the prefrontal 
cortex area, particularly on the right side, during exposure to 
spiders (Johanson, Risberg, Tucker, & Gustafson, 2006).  
Successful post-treatment patients, who earlier had both 



HUBER 
 

 6 

phobias and panic attacks in the presence of spiders, 
displayed an increase of regional cerebral blood flow in the 
dorso-lateral frontal cortex and enhancement of neocortical 
modulation for limbic reactions when in the later presence of 
spiders (Johanson et al., 2006). Successful post-treatment 
patients, who earlier had phobias with no panic attacks in the 
presence of spiders, displayed a decrease of regional cerebral 
blood flow in the prefrontal cortex, particularly in the right 
hemisphere, because they now demanded less strenuous self-
management of their reduced emotional response to the 
noxious stimuli of spiders (Johanson et al., 2006). For 
obsessive-compulsive disorder, behavior therapy engendered 
comparable reductions in cerebral metabolic rates of glucose 
in the right caudate nucleus as did pharmacological treatment 
with fluoxetine (Gabbard, 2000). In addition to the treatment 
of phobias, obsessions, and compulsions, the treatment of 
impulsive aggression (including violent offenses), the 
treatment of sexual compulsion, and the treatment of eating 
disorders may all rely upon activation of the prefrontal 
cortex (Carlson, 2007). Specifically, the treatment of 
impulsive aggression may entail the elevation of 
serotonergic input as well as serotonin transporters into the 
medial and ventral prefrontal cortex (Carlson, 2007). The 
treatment of sexual compulsion may entail the stimulation of 
the right prefrontal cortex, which could inhibit sexual arousal 
and prevent inappropriate stimulation of the limbic system.  
Lastly, the treatment of eating disorders may entail 
deactivation of the left medial prefrontal cortex, because this 
brain region appears over-activated in anorexic and bulimic 
persons (Carlson, 2007). 

There is research evidence to suggest that prefrontal and 
frontal region executive dysfunction may be in part 
responsible for low treatment success among substance 
abusers, because these patients’ neuro-cognitive capacities 
such as attention, impulse inhibition, language, novel 
learning, and goal planning are impaired (Weinstein & 
Shaffer, 1993). The neural substrates of the medial 
prefrontal, the orbitofrontal, and the premotor cortices are 
believed to be responsible for the sensorimotor regression 
symptoms known as catatonia, which many psychoanalysts 
consider a defense mechanism of schizophrenia (Northoff, 
Bermpohl, Schoeneich, & Boeker, 2007). Yet certain other 
difficulties, such as problems with basic attachment and 
interpersonal relatedness, may lead to the development of 
personality disorders, most notably Borderline Personality 
Disorder (BPD). For BPD, psychotherapy must address the 
mesocorticolimbic dopamine pathways, as well as the 
anterior hypothalamus vasopressin circuits connected to the 
nucleus accumbens and ventral tegmental area, in addition to 
the dorsal cingulate cortex, the middle insula, and the 
striatum (Fonagy & Bateman, 2006). These brain regions are 
wired to the prefrontal cortex, and “the prefrontal cortex may 
activate the reinforcement system when it detects that the 
animal’s behavior is resulting in progress toward a goal. But 
the prefrontal cortex is a target of dopaminergic neurons as 
well as a source of their control” (Carlson, 2007, p. 458). 
Positive attachments, like the therapeutic relationship, are 

essential to patient improvement (Cappas et al., 2005), and 
these intimate relationships activate the neuropeptide 
hormones oxytocin and vasopressin for attachment as well as 
the mesocorticolimbic dopaminergic pathways for positive 
self-reinforcement (Fonagy & Bateman, 2006). Hence, 
various psychological disorders require the therapist’s 
attention be paid to the most relevant brain sites from where 
dysfunctions arise and from where rewards for positive 
relationship behaviors accrue, which is typically the 
prefrontal cortex. 

While much remains to be learned about how the 
material “brain” manifests as the immaterial “mind” and, by 
consequence, what the physiology of psychotherapy is, 
significant technological advances have nevertheless been 
made. Although some neurobiological psychologists 
misconstrue contemporary research as a physiological 
rebuttal against and replacement for the allegedly antiquated 
notion of the unconscious (Grotstein, 1999), it is widely 
accepted that the brain perceives as well as processes 
unconscious and non-linguistic data (Cappas et al., 2005). It 
is further recognized that stimulation of the right prefrontal 
cortex alone provides non-linguistic knowledge of emotion 
from a patient’s or therapist’s voice intonation, rather than 
linguistic speech content (Carlson, 2007). Also, the anterior 
paracingulate cortex of the prefrontal cortical area is 
responsible for the comprehension of others’ intentions 
during social transactions (Walter et al., 2004) which, in the 
context of psychotherapy, are essential for the patient and 
therapist to mutually understand each other’s motives and 
the effects of perceived motives.  Finally, the inferior 
parietal cortex and right hemisphere prefrontal cortex are 
instrumentally involved with psychological identification, 
dis-identification, counter-identification, and projective 
identification mechanisms (Decety & Chaminade, 2003), and 
so must be treated by the clinician with surgical care. 
 
Mirror Neuron System 
 

One person’s mere observation of another’s emotional 
expression activates the same neural pathways in the 
observer’s brain as in the emotionally expressive person’s 
brain (Viamontes & Beitman, 2006a). Nerve cells known as 
“mirror neurons” enable the therapist to empathically 
experience the patient’s maladaptive emotional states 
(Carlson, 2007), while the therapist simultaneously attempts 
to balance these states through intentional activation of the 
patient’s mirror neuron system (MNS). Harvard biomedical 
imaging research has documented that cortical thinning of 
gray matter in the MNS region is associated with autism 
symptomatology and severity (Hadjikhani, Joseph, Snyder, 
& Tager-Flusberg, 2006), for which reason autism spectrum 
disorder (ASD) patients often lack the empathy and 
perspective-taking faculties imparted from the MNS 
(Martineau, Cochin, Magne, & Barthelemy, 2008; Oberman 
& Ramachandran, 2007). Italian neuroscience researchers, 
Rizzolatti and Gallese, were the first to haphazardly discover 
mirror neurons in the physiology of the brain and, 

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PHYSIOLOGY OF PSYCHOTHERAPY 
 

 7

surprisingly, this accident did not occur until the 1990s 
(Rothschild, 2004). The reason is that, although 
neuroscientists had identified empathy’s effect on the brain, 
no researcher had thought to search for empathy’s cause in 
the brain (Rothschild, 2004). But with the anatomical root of 
empathy now known to be the mirror neuron system, the 
MNS possesses the potential, in the opinion of famous 
neuroscientist V. S. Ramachandran, to usher in and welcome 
the next major Copernican-like revolution for psychology, 
similar to the previous revolutions of Darwin’s evolution and 
Freud’s psychoanalysis (Rothschild, 2004). 

The mirror neuron system, located in the fronto-parietal 
circuit, pre-motor cortex, and superior-temporal sulcus of the 
brain (Carr, Iacoboni, Dubeau, Mazziotta, & Lenzi, 2003; 
Martineau et al., 2008; Molnar-Szakacs, Kaplan, Greenfield, 
& Iacoboni, 2006), is what scientists depict as the 
neurological “execution-observation matching system…[of] 
action recognition” (Buccino, Binkofski, & Riggio, 2004, p. 
370). In other words, the MNS internally recreates and 
represents to the same degree of complexity the intricate 
qualities of the external world, and “the mirror neuron 
system provides a fairly accurate simulation process of 
observed actions, mimicking internally the level of motoric 
complexity” (Molnar-Szakacs et al., 2006, p. 923). 
Moreover, all behavioral action utilizes the exact same 
physiological substrates in the inferior parietal lobule as the 
internal perception of such action (Rizzolatti, Ferrari, Rozzi, 
& Fogassi, 2006), which has myriad ramifications for 
psychotherapy. For example, mirror neurons may explain the 
phenomenon of negative therapist experiences known as 
“compassion fatigue” and “vicarious trauma” when listening 
to patients’ profoundly abusive and painful life events 
(Rothschild, 2004).  Psychoanalytic writers have suggested 
that mirror neurons represent the neurological source of such 
psychological mechanisms as identification and imitation 
(Olds, 2006). Indeed, the fronto-parietal, pre-motor cortical, 
and superior-temporal mirror neurons contribute an entirely 
new element of understanding to the psychodynamics of 
altruism, attachment, displacement, empathy, introjection, 
projection, reaction formation, transference, and 
countertransference, among other phenomenon. Due to the 
mirror neuron system and its accordant internal motor 
simulation, the observation of others’ behavior can disrupt 
one’s own behavior (Shmuelof & Zohary, 2007), or can 
presumably improve one’s behavior if in psychotherapy, 
because the MNS permits humans to learn by action 
imitation and behavioral understanding (Rizzolatti & 
Craighero, 2004). 

The dysgranular field of the insular lobe has links not 
only to the main brain regions containing the MNS but also 
to the limbic system, thus interconnecting the compounded 
action-perception mechanism with the primary emotional 
processing operation (Carr et al., 2003).  Therapists must 
rely upon this insular lobe interconnection to produce their 
empathic resonance and subsequent response to patients in 
treatment. However, therapists must learn to engage their 
patients’ amygdalar zone, anterior insular circuit, and 

superior temporal sulcus, because these regions are more 
highly activated by the imitation of facial affect than by the 
mere observation of such emotional expression (Carr et al., 
2003). The therapist must, therefore, successfully model 
adaptive stability for emotionally imbalanced patients, who 
may need to imitate or introject the therapist’s affective 
behavior. The anterior insular circuit also helps supervise 
one’s motoric self-control and personal agency (Carr et al., 
2003), so that empathy might be intimately related to one’s 
executive sense of self. For example, socially-deficient 
patients may learn to empathize with others just as their 
therapist empathizes with them.   

McWilliams (1999) has depicted psychotherapy as “the 
science of subjectivity, in which the analyst’s empathy is the 
primary tool of investigation” (p. 2). But not only does the 
therapist employ empathy as a fundamental tool of 
treatment, empathy also serves as its fundamental goal.  
Yalom (2003) suggested that clinicians must “help patients 
develop empathy for others” (p. 23) by enabling them to 
identify with and duplicate the empathy expressed by the 
therapist for the patient.  If empathy is regarded as a form of 
love, then “therapy is essentially an attempt to help the 
patient gain or regain his capacity for love” (Fromm, 1972, 
p. 84). This is congruent with Freud’s dual claims that 
therapy both cures the patient through the experience of love 
and creates love in the patient for others (McWilliams, 1999; 
Welwood, 2000). Given the contingency of psychotherapy 
on the MNS, effective treatment will equip patients’ mirror 
neuron systems to more appropriately reflect their feelings 
and empathically respond to other persons. 
 
Conclusion and Future Implications 
 

Hence, physiology-informed psychotherapy might be 
viewed as a form of socio-linguistic biofeedback, whereby 
the therapist’s mirror neuronal output constructs a closed 
feedback loop with the patient’s mirror neuronal input as 
part of a reciprocal chemical interaction cycle. Moreover, 
this model of treatment would understand the therapeutic 
relationship as a shared mindfulness meditation, in which 
both persons’ brain waves and body rhythms would 
symbiotically adapt and synchronously balance through 
clinically meaningful verbal or non-verbal exchanges to 
achieve homeostasis in the patient. The therapeutic 
atmosphere and environmental output offered by the 
clinician in the treatment room may also positively change 
the dormant gene expression of patients, by directing the 
transcriptional function of their protein manufacturing in 
relevant genes and guiding their synaptic interconnections 
(Gabbard, 2000). This would further serve to increase the 
stress threshold of one’s genetic vulnerabilities and help 
promote protective factors in people predisposed to mental 
illness (Gabbard, 2000), in accordance with the diathesis 
stress model. Both biofeedback, which predominantly 
engages the analytical and linear functions of the left 
hemisphere in the brain, and mindfulness meditation, which 
predominantly engages the contextual and intuitive functions 

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HUBER 
 

 8 

of the right hemisphere, comprise two different 
quintessential methods for pursuing neurobiological changes 
and similar treatment outcomes (Shapiro & Zifferblatt, 
1976). Eastern mindfulness “meditation and Western 
[bio]feedback and voluntary control produce the same end 
results” (p. 96), as noted in the psychiatric research of Tomio 
Hirai (1989) from the University of Tokyo. 

Mindfulness meditation, which has existed for more 
than 2 millennia but only in the last century became an 
object for scientific study outside of Eastern religions, may 
be defined as the sustained purposeful awareness of one’s 
present mental and physical experience with non-judgmental 
acceptance (Germer, Siegel, & Fulton, 2005). Several 
authors have designated the construct of mindfulness as 
among the most fundamental “common factors” of all 
successful psychotherapies, regardless of theoretical 
orientation (Germer et al., 2005; Martin, 1997; 2002), 
because the mindfulness process involves a deepening 
awareness of how the brain, body, and mind mutually 
interact to promote health or restoration at each entry point. 
Meditation techniques have been incorporated with great 
success into a number of extant treatments, including 
Cognitive-Behavioral Therapy (Hayes, Follette, & Linehan, 
2004; Roemer & Orsillo, 2002; Segal, Williams, & Teasdale, 
2002), Dialectical Behavior Therapy (Linehan, 1993; 
Robins, 2002), Rational Emotive Behavior Therapy 
(Whitfield, 2006), and Psychoanalytic-Psychodynamic 
Therapy (Fromm, Suzuki, & DeMartino, 1960; Molino, 
1998; Safran, 2003; Suler, 1993). The practice of 
mindfulness by therapists can even increase their empathic 
attunement with patients (Lesh, 1970; Shapiro, Schwartz, & 
Bonner, 1998) and, as a result, improve the affective 
performance of the therapist’s MNS and its emotional 
reverberation with the patient’s MNS.  Mindfulness works in 
large part through the de-automatization of habitually 
learned responses to particular punishment-reward 
contingencies, which is the same correctional mechanism 
operating in biofeedback training that promotes volitional 
control over preprogrammed, unconscious reactions (Bogart, 
1991; Brown, Ryan, & Creswell, 2007; Shapiro & 
Zifferblatt, 1976). Meditation exercise impacts blood 
pressure, brain waves, heart rate and variability, muscle 
tension, respiration patterns, skin temperature, and sweat 
gland activities all in a similar fashion to biofeedback (Hirai, 
1989; Lehrer, 2003; Zeier, 1984).  

Since its first experiments a half-century ago, 
biofeedback training has utilized computer equipment to 
relay information back in real-time to clients about their 
autonomic nervous system functions and directions for 
physiological change (Lehrer, 2003). Biofeedback may be 
viewed as the Cartesian convergence of clients’ first-person 
neurobiology and clinicians’ third-party perspective of 
external phenomena in therapy. As one clinician stated, “BF 
[biofeedback] modifies the basic client-therapist relationship, 
introducing a new dimension- the client’s physiology- as a 
3rd component of the important interactive processes” 
(Watral, 1984, p. 11). Biofeedback research, thus, becomes 

an efficient tool for optimizing the therapeutic alliance and 
behavioral techniques while studying the client's 
neurobiology during the process of psychological 
adjustment. The best current example of a professional 
discipline highlighting the physiology of psychotherapy is 
Applied Psychophysiology (AP), which divides its bipartite 
treatment approach into the complementary methods of 
biofeedback and meditation (Lehrer, 2003). But AP is 
concerned with preserving the ideological purity of its 
theory, and it considers traditional talk therapy to be a 
territory infringement. Prominent practitioner M. S. 
Schwartz (1999), for example, claimed that to simply 
compare Applied Psychophysiology with conventional 
psychotherapy would render AP “useless” (p. 8).  Until 
empirical evidence demonstrates so, in the words of 
practitioner J. P. Rosenfeld (1999), traditional psychotherapy 
interventions “are implicitly psycho-physiological 
interventions, but explicitly non-physiological” (p. 34). They 
therefore feel comfortable employing techniques from 
behavior and body-based treatments, yet reject talk therapies 
because they are apparently not physically conscious 
enough. Although the merits of such reasoning is debatable, 
it is nevertheless clear impetus for other treatment modalities 
to more “explicitly” address the neurobiological process 
supporting their clinical practice, so as to better facilitate the 
fateful matrimony of physiology with psychotherapy. 

Future research in this area may have influential 
repercussions for the greater integration of a truly holistic, 
physiology-informed psychotherapy of tomorrow. This 
might include concrete biological interventions that 
therapists can employ exclusively through verbalized words 
and non-verbal body language, as well as neurological 
insight into the patient’s transference and the therapist’s 
countertransference as the treatment process purposefully 
reinforces rather than blindly explores new mirror neuronal 
pathways. Now that the 20th century has established talk-
therapy as a credible linguistic technology, the 21st century 
cultural zeitgeist might be to better integrate the world's 
multidisciplinary sciences, in terms of the mental health 
profession, through a mutually enriching relationship 
between physiology and psychotherapy that produces 
improved bio-psycho-social benefits to clientele. 
Psychological problems can be addressed concomitantly 
from physiological perspectives, for instance, therapeutic 
engagement of the prefrontal cortex and frontal lobe regions 
are known to be critical for success in most treatments. 
Likewise, therapeutic activation of the neuropeptide 
hormones oxytocin and vasopressin for social attachment, as 
well as the mesocorticolimbic and prefrontal cortical 
dopaminergic pathways for positive reinforcement, also 
appear critical for treatment success. All of these biological 
processes constitute part of what is palpably happening to 
the patient in a treatment with tangible results, if one were to 
answer the opening question originally posed. This paper has 
examined the physiology of psychotherapy with respect to; 
(1) the history of psychology, (2) the evolution of different 
brain regions, (3) the state of present research, (4) its clinical 



PHYSIOLOGY OF PSYCHOTHERAPY 
 

 9

application to mental disorders, (5) the importance of the 
mirror neuron system, (6) and unique implications for the 
future. An abundance of promising trends can direct the 
trajectory for scientific progress in this arena, and clinicians 
can learn therapeutic techniques that impact the physical 
provinces of the brain and body as part of a genuinely 
comprehensive, physiology-informed psychotherapy of the 
new century, whose frontier is waiting to be pioneered. 

 
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