This paper (2022) makes a case for using Compassion Focused Therapy (CFT) in tandem with psilocybin for the treatment of depression. The authors present a framework for using CFT as well as the rationale for selecting CFT, the compatibility of CFT and psilocybin-therapy, an overview of the psilocybin-assisted CFT protocol, the study protocol, and limitations to this approach.
Psilocybin-assisted psychotherapy, i.e., psilocybin treatment with psychological support, has demonstrated the efficacy of psilocybin to reduce depressive symptoms. However, in clinical trials, the structure of psilocybin-assisted psychotherapy is primarily based on preparation, navigation (support during dosing sessions), and integration. For psychotherapeutic guidance, the application of this structure is favoured over the usage of theoretical models. The applied psychotherapeutic models may be of critical importance if the effects are augmented due to the psychologically insightful experiences during the navigation and integration sessions. One of the important next steps is to provide therapists with guidance on how to provide psilocybin-assisted psychotherapy. We present an integrated protocol for psilocybin-assisted psychotherapy for depression based on the theoretical model and psychotherapeutic framework of Compassion Focused Therapy (CFT). We hypothesize that CFT can provide the theoretical model and compassion practices that will reinforce the experiences during the navigation and follow-up therapy sessions. In this paper, we describe the rationale for selecting CFT, the compatibility of CFT and psilocybin-therapy, an overview of the psilocybin-assisted CFT protocol, the study protocol, and limitations to this approach.
Major depressive disorder remains highly prevalent and burdensome, and current psychotherapies and pharmacotherapies leave many patients without remission. Pots and colleagues note that psilocybin has emerged as a promising intervention for depression: it can alter glutamate signalling in key brain regions, produce changes in self-experience, and increase feelings of connectedness. Clinical trials using psilocybin with psychological support commonly adopt a preparatory–navigation–integration structure, but the psychotherapeutic content has often been non‑directive or minimally specified, and the contribution of an explicit psychotherapeutic model to clinical benefit is unclear. This paper sets out to embed psilocybin-assisted psychotherapy for depression within the theoretical and practical framework of Compassion Focused Therapy (CFT). The study aim is to present the rationale for selecting CFT, describe the compatibility of CFT with psilocybin-assisted therapy, and provide an operationalised treatment protocol and study design suggestions to examine its efficacy and feasibility. The authors propose that CFT practices may reinforce therapeutic processes during navigation (dosing) and integration, thereby enhancing clinical outcomes for depression.
Papers cited by this study that are also in Blossom
Barrett, F. S., Doss, M. K., Sepeda, N. D. et al. · Scientific Reports (2020)
Bogenschutz, M. P., Forcehimes, A. A., Pommy, J. A. et al. · Journal of Psychopharmacology (2015)
Carhart-Harris, R. L., Goodwin, G. M. · Neuropsychopharmacology (2017)
Carhart-Harris, R. L., Bolstridge, M., Rucker, J. et al. · Lancet Psychiatry (2016)
Rather than reporting an empirical trial, Pots and colleagues describe the development of a manualised psilocybin‑assisted CFT protocol. The protocol was constructed from established psychedelic-assisted psychotherapy structures and CFT theory, and comprises 13 therapist‑led sessions. Each session contains therapist instructions, psychoeducation, an in‑session experiential exercise derived from CFT (for example soothing rhythm breathing), and homework (the protocol asks participants to practise roughly 2 hours per week); homework adherence is checked at the start of each session. The treatment is organised into three blocks. Preparatory sessions (sessions 1–3) teach the CFT conceptualisation of depression (including the ‘‘Tricky Brain’’ metaphor and the three‑circles model of threat, drive and soothing systems), introduce soothing rhythm breathing and compassion‑focused body practices, and begin work on building a compassionate self and on working with internal parts. At the end of the third preparatory session an intention for the first psilocybin navigation session is formulated; preparation for the second navigation session integrates learnings from the first. Navigation (psilocybin administration) sessions are conducted using a non‑directive stance and music playlists. Therapists allow self‑directed meaning‑making while using CFT formulations to support participants in bringing the compassionate self into difficult material and in relating to emerging parts. The CFT case conceptualisation is iteratively updated based on material from navigation sessions. Integration sessions combine debriefing of the psychedelic experience with explicit CFT exercises (compassionate attention, compassionate behaviour, compassionate imagery) and CFT homework tasks such as compassionate thought‑records, letter writing, and worksheets addressing the inner critic. The authors articulate a CFT therapeutic stance emphasising safety, non‑judgement, experiential learning, and tolerance of distress. For empirical evaluation, they propose a three‑arm randomised clinical trial comparing psilocybin‑assisted CFT, psilocybin with non‑directive psychological support, and a psilocybin‑only condition with minimal support (with safety measures in the latter). As an alternative for resource‑limited settings they suggest single case experimental designs, notably multiple baseline designs. Planned outcome measurement includes the GRID‑HAMD as primary outcome, and secondary measures such as the Mental Health Continuum‑Short Form (MHC‑SF), Compassion Engagement and Action Scales (CEAS), Types of Positive Affect Scale (TPAS, Safe Positive Affect subscale), Fears of Compassion Scales (FCS), and heart rate variability (HRV). Assessments are proposed at baseline, pre‑psilocybin sessions (week 4 and week 7) and at follow‑up (week 10). The authors also describe plans to develop a therapist manual and training based on contemporary CFT resources, but do not specify training duration or competency metrics.
This article does not report new trial data or empirical results; rather, it synthesises rationale and provides a treatment protocol. Pots and colleagues summarise prior findings that motivate their approach: earlier clinical studies have found moderate to large antidepressant effects of psilocybin in people with cancer‑related distress and in major depressive disorder, alongside generally promising tolerability. They also note literature suggesting that psilocybin can reduce negative affect and associated neural correlates, increase positive affect and social connectedness, and produce increases in self‑compassion and reductions in self‑criticism similar to those seen after compassion practices. Regarding CFT evidence, the authors cite meta‑analytic findings that compassion‑based interventions produce moderate to large effects on depression and well‑being across clinical and non‑clinical samples. No empirical evaluation of the presented psilocybin‑assisted CFT protocol is included in the extracted text, so there are no within‑paper effect sizes, response rates, or adverse‑event summaries to report.
Pots and colleagues argue that integrating CFT with psilocybin administration could strengthen therapeutic gains by providing participants with conceptual understanding and practical compassion skills to interpret and integrate psychedelic experiences. They propose that CFT and psilocybin may act synergistically because both stimulate affiliative or ‘‘soothing’’ systems, increase social connectedness, and reduce threat‑based responding; CFT offers structured practices to sustain and translate acute psychedelic insights into everyday changes in cognition, affect and behaviour. The authors position their protocol relative to alternative psychotherapeutic frameworks (for example CBT or ACT), emphasising that while these approaches change the relationship to thoughts and emotions, CFT specifically targets the cultivation of compassion and social safeness, which may be especially relevant for individuals high in shame and self‑criticism. They also note that some people with insecure attachment styles and high self‑criticism can find compassion practices challenging or distressing, and that affiliation‑focused interventions (including oxytocin or, plausibly, psychedelics) may have variable effects depending on attachment and self‑evaluative style; similar vulnerabilities might arise during psilocybin‑assisted CFT. Key limitations acknowledged by the authors include uncertainty about how much psychotherapeutic guidance is necessary to realise psilocybin's antidepressant effects and the absence of data on a potential dose–response relationship between psychotherapy intensity and outcomes. They caution that the protocol was developed specifically for psilocybin and depression and should not be generalised to other psychedelics or indications without further study. The authors further recognise that specific therapist competencies required to deliver psilocybin‑assisted CFT have not been empirically defined and that training programmes will be needed. Finally, they call for research comparing different therapeutic models and examining mechanisms of change and patient‑level moderators (for example attachment style or physiological characteristics) to determine which protocols best suit which patients.
The paper presents a manualised psilocybin‑assisted Compassion Focused Therapy protocol intended to fill a gap in guidance for psychotherapeutic content in psychedelic treatment for depression. Pots and colleagues conclude that the integrative CFT framework may enhance psilocybin therapy by fostering compassion, social connectedness and social safeness, and recommend empirical testing of the protocol. They propose feasible study designs (a three‑armed RCT or single case experimental designs) and advocate development of therapist training and a treatment manual as next steps.
Major depression is a prevalent disorder that has a large impact on quality of life and is associated with high rates of comorbidity and increased mortality. Current treatment approaches for depression, including psychotherapies and pharmacotherapies, are effective but leave significant room for improvement since remission is only achieved for less than half of the treated patients. More recently, psilocybin has gained attention as a new paradigm in the treatment of depression. Psilocybin, a classic hallucinogen, effects glutamate levels in key areas of the brain, including the medial prefrontal cortex and hippocampus that are associated with positive changes in self-experience and increased feelings of unity with others and one's surroundings. Distortions of self-experience may be an important mechanism to target in the treatment of depression. Several studies have demonstrated the efficacy of psilocybin with moderate to large effect sizes in patients with life-threatening cancer and depressive symptoms, and in patients with major depressive disorder. These findings also show promising tolerability data, eliciting head-to-head comparative efficacy studies with current treatments (e.g., current pharmacotherapies). Furthermore, psilocybin has a lower risk for addiction and harmful neurological effects compared to other novel interventions such as ketamine. Psilocybin treatment with psychological support, structured in preparation-, navigation-and integration sessions, has shown to act rapidly and to have long-lasting effects on depression. A recent review of psychotherapeutic components in psilocybin-assisted psychotherapy found that psychotherapy was primarily given in the preparation and integration sessions, and that psychotherapy mostly consisted of a non-directive approach and music therapy. The core elements of supportive psychotherapy are calmness, empathy, personal support, and reassurance. Some studies have combined psilocybin with Cognitive Behavioral Treatment (CBT) for smoking cessation, Acceptance and Commitment Therapy (ACT) for treatmentresistant depression, or Motivational Enhancement Therapy (MET) for alcohol dependence. In most studies, the therapeutic content is often neither reported nor examined. Therefore, it remains unclear how psychotherapy affects the patient's experience. However, it has been suggested that the offered psychotherapeutic model enhances the personal and meaningful experiences, and thereby the antidepressant effects, of psilocybin-assisted treatment. One of the important next steps is to provide therapists with guidance on how to provide psilocybin-assisted psychotherapy, including the development of treatment protocols, and support that with research into the possible added value of psychotherapy or psychological support to the effect of psilocybin for depression. A recently developed therapeutic approach that is of particular interest for psilocybin-assisted therapy is Compassion-Focused Therapy (CFT;. CFT provides patients with a rationale and practices that might enhance the effects of psilocybin-assisted therapy by increasing connectedness, compassion for self, and compassion for others. CFT is based on evolutionary psychology and attachment theory and stimulates the affiliative or "rest and digest" system. It enables insight into the interplay of the lack of care and compassion, especially early in life, and underlying mental health problems, and shows how developing compassion can act as a psychotherapeutic process and promote social connection and social safeness. Previous studies suggest that certain substances, including psilocybin, can produce similar increases in self-compassion and reductions in self-criticism as compassionate practices. Likewise, research shows that psilocybinassisted psychotherapy may decrease negative affect and the neural correlates of negative affectand increase connection and acceptance, similar to the proposed working of the affiliative system within CFT. We believe that CFT may be a relevant psychotherapeutic model to help to improve the understanding of the experiences during administration or navigation and integration sessions, while at the same time providing meaningful practices that help the integrative process. Therefore, the aim of the current article is to provide a CFT framework in which psilocybin-assisted psychotherapy can be embedded.
Compassion focused therapy is specifically developed for and aimed at individuals who have a compromised capacity for experiencing and expressing affiliative motives and emotion to self and others. It is particularly suited for individuals characterized by the tendency to negatively evaluate and judge aspects of the self, such as patients with depression. Several meta-analyses demonstrate efficacy for compassionbased interventions in various (non)-clinical populations with moderate to large effects on depression and well-being. Compassion focused therapy was developed as a transdiagnostic model by Paul Gilbertin response to the observation that many of his chronic depressed clients, in particular those high in shame and self-criticism, did not benefit from traditional therapy. Although these clients were able to engage in cognitive and behavioral exercises, they weren't able to generate a self-compassionate inner voice.proposed a framework for the biological mechanisms underpinning compassion that is based on evolutionary biology. CFT takes an evolutionary functional view to emotionespecially the affiliative emotions and their competencies-and focuses on three major emotion regulation systems: (1) the threat protection system which responds to threat with defense strategies; (2) the drive-and resource-seeking system which links to achievement and acquiring of resources and rewards; and (3) the soothing and affiliation system which enables individuals to soothe, calm, and content themselves. The three major emotion regulation systems are displayed in Figure. Compassion is thus understood as an evolved motivational system designed to regulate negative emotions through attuning to the feelings of self and others, and expressing and communicating feelings of affiliation, warmth, and safeness (e.g.,. Within the framework of treating depression, harmonizing the emotion regulation system is essential as studies show that emotion regulation affects depressive symptoms via increasing rumination and decreasing reappraisal.evolutionary model suggests that the potential for compassion evolved with the affiliative system that is linked to the attachment system. CFT is underpinned by social mentality theory (SMT), which states that different mental states not only organize our minds but also shape our relationships. Both care seeking and care giving social mentalities are activated when one is relating to others (e.g., a crying child and a comforting mother), but can also be activated when relating to the self. Compassion, as a social mentality, can "flow" in three directions. First, there is the compassion we can feel for others; second, there is the compassion we can feel coming from others to ourselves, and thirdly there is the compassion we can direct to ourselves which is defined as selfcompassion. Each of these can be a focus in CFT. Research shows that the quality of care and affection received in childhood lays the foundation for being caring and compassionate as an adult. Imagining being cared for and receiving compassion has the same effects, as it stimulates the soothing system, helping individuals feel safe and calm. CFT emphasizes the significance of our affiliative system in reducing the activity in the threat-based protection system by allowing us to feel cared for and to be able to offer care to both ourselves and others. Accordingly, CFT targets both the psychological and the biological processes underpinning care and compassion. When combined these processes help to down-regulate the threat system and stimulate positive affect and a sense of social safeness. The primary aim of CFT is to help clients develop these caring processes and create a better sense of social connectedness to understand and respond to their distress from the perspective of a compassionate mind. Through the incorporation of a range of compassion-based skills, attributes, and qualities, clients become more distress aware and insightful, learning how to develop empathy and distress tolerance and how to take wise and compassionate action to address distress. Thus, in this model, the skill of giving or receiving compassion can be enhanced through therapy and generate experiences of being cared for and socially connected to (a) caring other(s).
Conventional Cognitive Behavioral Therapy (CBT) approaches to depression primarily target signs and symptoms of depression, but do not impact emotional, psychological and spiritual wellbeing as much as more recent approaches such as CFT. CFT focuses more on the persons' relationship to thought and emotion rather than on their content, and uses techniques and concepts derived from mindfulness, emotion focused therapy, psychodynamic therapy, and attachment theory. More specifically, CFT targets compassion as a psychotherapeutic process and effectively increases social connection and social safeness.showed that compassion can be cultivated through training compassion meditation and imagery, boosting the brain's resilience to suffering. This is important because part of the reason that compassion can be helpful is that it is activating particular physiological systems linked to caring, social connections, and feeling cared for Gilbert (2020),. Similar to CFT, psilocybin-assisted psychotherapy is aimed to increase openness and acceptance by creating space for people to tolerate and allow internal and external discomfort and enhancing compassion for self and others. Indeed, a study byshowed that psilocybin may decrease negative affect and the neural correlates of negative affect. One-month post-psilocybin administration, positive affect remained elevated and trait anxiety was reduced. They hypothesized that the reduction of negative affect may undermine ruminative processes that contribute to the development and maintenance of mood disorders. Further studies provide evidence that psilocybin has a significant effect on social connection, attachment, and feeling more connected to self, others, and nature/the world, similar to the proposed working of the soothing system within CFT (as described above). Furthermore, several authors (e.g.,have recommended that social connection as flows (from self, others, and the world), should be examined in future studies as they appear to form a central theme of patient's experiences. This also adds further rationale to the use of CFT as it facilitates the flow of compassion. As people with depression tend to operate from their threat system by having a negative affect and thoughts, providing psilocybin within the framework of CFT will stimulate the affiliative system and provide a positive and supposedly healing context of thoughts, feelings, and behaviors.
The current therapy protocol was constructed based on the basic structure of other psychedelic-assisted psychotherapy protocols. The included interventions and exercises were devised in conjunction with the CFT model. The psilocybin-assisted CFT protocol consists of 13 sessions (see Table). In the protocol, each session includes instructions for the therapist to guide the treatment session. Also, each session includes psychoeducation (e.g., the conceptualization of depression) followed by an insession experiential exercise (e.g., soothing rhythm breathing; see below for an explanation), which participants are also asked to practice on their own between sessions (2 h per week). Compliance with the homework sessions is assessed at the start of each session.
Within the psilocybin-assisted CFT protocol, CFT is the framework to provide the understanding of the nature of depression and its thoughts, feelings, and behaviors, as well as the psychedelic experiences. The goal of the preparatory sessions is for the therapists to help participants understand and respond to their distress from the perspective of a compassionate mind, generating an understanding that comes from an evolutionary perspective of the mind. Therefore, in the preparatory sessions (1-3), therapists will frame the conceptualization of depression based on the affiliative motives and emotions of the participant, and explain the concept of the so called "Tricky Brain." This tricky brain encompasses the notion that all human beings find themselves with an evolved brain and influential environments that we didn't choose but shaped our responses and behaviors. Within CFT, the concept of the tricky brain is used as a way to de-shame participants: "it is not our fault that we have this highly evolved brain that can create these fear states, nor is it our fault that we are born in these particular circumstances that gave us these learning behaviors." This concept of the tricky brain will be explored, as well as the fear of compassion. Therapists will explain the evolved functions of emotions by using the three circles model: the threat system, the drive system, and the soothing system, drawing them with examples from the life of the participant (see Figurefor a case example). Soothing rhythm breathing (i.e., a breathing technique with a style and rhythm of breathing that feels calming and soothing) and compassion focused body practices (i.e., exercises aimed at improving and utilizing body awareness to support a compassionate mindset) are taught in the sessions together with the therapist and are given as homework. During the first three preparatory sessions, the therapist pays close attention to the way the participant perceives him or herself, being attentive to the different emotional states that may lie underneath different affiliative motives and emotions, and to thoughts and feelings about the psychedelic experience. Exercises focusing on building a compassionate self and working with multiple "selves" or "parts" will be explored to give context to the daily life struggles of the participant. Within CFT, working with those parts is a therapeutic technique that helps people access and relate to the different emotional states they experience in their daily life from the perspective of the compassionate self. For example, while tuning into the thoughts, bodily feelings, action tendencies, memories, and needs of a particular part (i.e., anxious, sad, or angry) that comes up, the therapist can ask: "From the wisdom of the compassionate self, what is your view of that [anxious, sad, angry, . . .] part of you? What do you think it wants, and what do you think it fears? How would you like to relate to that part of you?" The compassionate self can relate to that particular self that is explored from the qualities of wisdom, strength, and commitment. At the end of the third preparatory session, the result of these explorations will be translated into an intention for the first psilocybin navigation session. The preparation for the second psilocybin navigation session will integrate the explorations with the insights and/or learnings from the first psilocybin navigation session.
The psilocybin navigation sessions are guided by a non-directive approach. The non-directive approach has been a core principle of psychedelic-assisted therapies as it enables a patient to adopt an uncritical approach concerning their own psychedelic experience(s) and engage in self-directed insight-finding and meaning-making processes. It allows the client to reconcile unconscious material in the order and nature in which it comes to the surface for healing. The navigation sessions will be guided with music generated by the therapist or curated psychedelic therapy playlists that are freely available (e.g., by Mendel Kaelen). Within the context of inner healing during the navigation session, one or multiple parts can come up. When the participant is being burdened or hindered by that particular self, the therapist will encourage the participant to look into their own inner experience for insights and guide him or her to go into the experience with their inner healing intelligence. The experience of the participant can be further guided from the understanding of CFT and working with different parts. The participant can be guided toward bringing in the compassionate self and relating to the different parts from the position of the compassionate self as explained above. The CFT case conceptualization is consistently held as a temporary framework of understanding and used iteratively as it occurs throughout all therapeutic encounters. Thus, the case conceptualization will continuously be updated by information from the navigation sessions.
Integration sessions are partly debriefing of the psychedelic experiences of the psilocybin navigation session, and partly psychotherapeutic CFT integration sessions. The debriefing focuses on recollecting the experiences of the psilocybin navigation session and the accompanying feelings. All psychotherapeutic sessions focus on deepening the compassionate self and applying compassionate skills in daily life. Participants are taught how to engage with themselves and others with compassion, teaching them the skills to develop the key aspects of compassion. For example, practices of compassionate attention help to refocus attention to positive attributes or skills, such as courage, kindness, or gratitude; practices of compassionate behavior focus on practicing new behavior with an encouraging, warm tone in their mind; and compassionate imagery practices focus on exploring the image of a compassionate self, including facial expressions, body postures, and voice tones. Exercises are done in sessions and given as homework: compassionate thought challenging records, as a way to reframe thoughts and feelings from the compassionate mind; compassionate letter writing, where participants will write about painful events from a compassionate reframing; worksheets that address the inner critic.
Although all psychotherapy sessions are didactic, all sessions are equally experiential as they contain exercises of CFT. The therapeutic stance of CFT is to offer a safe therapeutic setting that will allow the participant to freely and safely explore the psychedelic realm and the therapeutic relationship, to tolerate the distress that accompanies a participant's journey and therapy, and to be non-judgmental and approach innercriticism with kindness.
Overall, research indicates that psilocybin-assisted psychotherapy shows promising results regarding the acceptability and effectiveness for patients with depression. However, it is currently not clear what psychotherapy or even standard psychological support adds to the effect of psilocybin for depression. This question could be addressed in a three-armed randomized clinical trial (RCT), comparing psilocybin-assisted CFT to psilocybin-assisted psychotherapy with non-directive psychological support (seeand psilocybinassisted psychotherapy with minimal support (psilocybin-only condition). In the psilocybin-only condition, because of potential adverse effects such as crying, sadness, or grief, some additional safety measures should be implemented. Before and during psilocybin administration trained research assistants guide participants and intervene when participants are in distress by providing verbal or physical reassurance (see. We hypothesize that both the psilocybin-CFT condition and the psilocybin-standard condition would have more favorable changes, compared to the psilocybin-only control condition, and that psilocybin-assisted CFT would result in a larger effect than psilocybin-assisted psychotherapy with non-directive psychological support. An alternative to a three-armed RCT for settings where group designs are challenging or costly to perform would be a single case experimental design (SCED). SCEDs are designs that do not require large groups while permitting to draw scientifically valid inferences about the effects of an intervention and their theoretical mechanisms. In particular, a single case multiple baseline design (which is a variant of a SCED) would be a feasible and appropriate design to measure the efficacy of the psilocybin-assisted CFT protocol for depression. In a multiple baseline design, data is repeatedly collected during a baseline phase on outcomes of interest (e.g., well-being or depression) to describe the level of functioning. After assuring that the functioning is stable in the baseline phase, the intervention will be introduced to the participant. Data collection is continued during the intervention, and if the intervention is effective, changes are expected in the outcomes of interest. This suggests that the intervention was responsible for the changes in the outcomes. By varying the length of the baseline for the participants (i.e., one participant will start after 2 weeks, whereas another participant after 3 weeks of gathering baseline data), the influence of other factors (such as time effects) is unlikely. The repeated change in outcomes in response to the introduction of the intervention demonstrates its efficacy. In other words, if changes in the participant's functioning occurred during or after the psilocybinassisted CFT intervention, these changes are seen as evidence of the effectiveness of the specific intervention. The proposed primary outcome measure is the Hamilton Depression Rating Scale (GRID-HAMD), in line with. Secondary outcome measures could be the Mental Health Continuum-Short Form (MHC-SF; focuses on emotional, psychological, and social well-being), Compassion Engagement and Action Scales (CEAS), the Types of Positive Affect Scale (TPAS; subscale Safe Positive Affect), and the Fears of Compassion Scales (FCS). Physiological assessment is measured with HRV assessment of resting state and activity state. All outcomes could be administered at baseline, before psilocybin sessions at week 4, and week 7, and at a follow-up session at week 10. To examine the psilocybin-assisted CFT protocol in a study, we are devising a treatment manual and training for therapists based on recent CFT handbooks and/or manuals. The goal of the training is to introduce therapists to the core principles of psychedelics and CFT and to train them how to use the therapist manual.
In this paper, we provided a CFT framework for psilocybinassisted psychotherapy for depression. We believe that such a framework is needed as it may enhance the efficacy of psilocybinassisted psychotherapy for depression. Offering a psychedelic experience within the framework of CFT will provide the tools and practices for participants to understand and integrate their psychedelic experiences into their daily life. CFT as a modality is particularly helpful as CFT inherently enhances compassion for self, others, and the world, social connection, and social safeness. Additionally, we also provided an overview of a new treatment protocol for therapists to work with clients within the field of psychedelic psychotherapy. The integrative approach of psilocybin-assisted CFT circumvents challenges that are associated with the current standard approaches for depression. In real world settings psychotherapies and pharmacotherapies are typically provided by different clinicians, sometimes even at different clinics. However, combining psychotherapy and pharmacotherapies in a collaborative manner is more effective than pharmacotherapy alone. The current integrative approach opens the possibility to tailor, adjust, or change the intervention to meet the needs of participants, and thus potentially increase the responsiveness of the participants. In the current protocol, we believe that CFT is a suitable psychotherapeutic framework for psilocybin treatment of depression. However, other approaches may also offer a relevant psychotherapeutic framework for psilocybin assistedpsychotherapy, such as CBT, ACT, or MET. For example, Acceptance and Commitment Therapy (ACT) has been suggested as a framework for major depressive disorders, wherein the focus of the therapy lies on increasing psychological flexibility. CFT as well as ACT focus on changing the relationship of the participants to their thoughts, sensations, and emotions. However, CFT focuses specifically on developing compassion and social connection as a mediator of change and this could be especially suitable for people who have a compromised capacity for experiencing and expressing affiliative motives and emotions, i.e., those with high levels of self-criticism and shame. Future research should examine different mechanisms of change in relation to participants' physiological characteristics and hopefully can give some guidelines on what treatment protocol best suits whom. We further believe that particularly CFT is suitable as the psychotherapeutic framework for psilocybin-assisted psychotherapy as it focuses on stimulating motivational systems that evolved to support caring connections. As both CFT and psilocybin-assisted therapy are stimulating connectedness and social safeness, they can augment each other and provide a solid framework for the treatment of depression. Research indicates that some individuals have difficulties with developing compassion, particularly those who have an insecure attachment style and high self-criticism. They can experience negative impacts of compassionate imagery, partly because compassion can stimulate the caring system which may have trauma memories. Likewise, in a study bythe authors studied the effects of intranasal oxytocin on compassion focused imagery (CFI). They found that participants higher in self-criticism, lower in self-reassurance, social safeness, and attachment security had fewer positive experiences of CFI under oxytocin than placebo, indicating that the effects of oxytocin on affiliation may depend on attachment and self-evaluative styles. It's possible that psilocybin-assisted psychotherapy can stimulate sadness in that particular group by relating to a deep interconnectedness through stimulating the 5-HT2A receptor pathways. Offering an integrated approach of psilocybin-assisted CFT has the potential to break through some of the fears, blocks, and resistances to compassion that are common in therapy, and therefore improve people's capacity to experience a sense of caring, connectedness, and compassion. Future studies should research the degree in which offering an integrated approach is augmenting the effect of each modality by itself, especially for those who have an insecure attachment style and high self-criticism.
The presented treatment protocol for psilocybin-assisted CFT holds promise, but some limitations also apply. First, it remains unclear if and how much therapeutic guidance is necessary for the effect of psilocybin on depression demonstrated in the recent clinical trials. The underlying assumption is that the navigation sessions (psilocybin administration) open a therapeutic window that disrupts the entrenched negative framework of thoughts, sensations, and emotions, allowing insights or experiential knowledge to arise, that-with psychotherapeutic guidance-can lead to an adjustment into a more balanced emotion regulation system. However, future research should examine the dosageeffect of psychotherapy in psychedelic-assisted psychotherapy. Now that psychotherapeutic treatment protocols are being published, different protocols could be compared in future studies to conditions were minimal (nonpsychotherapeutic) guidance or only psilocybin is offered. Secondly, this protocol was specifically developed as psilocybinassisted psychotherapy for depression. Generalization of this protocol to other symptoms is not recommended. Also, this treatment protocol should not be used with other psychedelics or medication. Third, we cannot make any claims about the specific competencies needed to administer a psilocybin-assisted protocol for depression. However, we believe, it is crucial for therapists to acquire training in the competencies that are regarded as essential for psychedelic-assisted psychotherapy.
This paper provides a psychotherapeutic framework for the psilocybin-assisted psychotherapy of depression. As treatment protocols have been scarce so far, the psilocybin-assisted CFT protocol not only fills a gap but also enhances the effectiveness of the psilocybin-assisted therapy. The efficacy of the protocol should be examined, and we have suggested a design that is feasible for interested researchers and/ or clinicians.
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Papers in Blossom that reference this study
Aicher, H. D., Wicki, I. A., Meling, D. et al. · Journal of Psychopharmacology (2025)
Simonsson, A., Simonsson, O., Chambers, R. et al. · Mindfulness (2023)