Psilocybin-Assisted Compassion Focused Therapy for Depression

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.

Abstract

“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.”

Authors: Wendy Pots & Farid Chakhssi

Summary

INTRODUCTION

Major depression is a prevalent disorder that has a large impact on quality of life and is associated with increased mortality.

Psilocybin, a classic hallucinogen, has gained attention as a new paradigm in the treatment of depression. It has shown promising tolerability data, and has a lower risk for addiction and harmful neurological effects compared to other novel interventions such as ketamine.

Psilocybin-assisted psychotherapy, structured in preparation-, navigation- and integration sessions, has shown to act rapidly and to have long-lasting effects on depression. The therapeutic content is often neither reported nor examined, and it remains unclear how psychotherapy affects the patient’s experience.

A recently developed therapeutic approach, Compassion-Focused Therapy (CFT), may enhance the effects of psilocybin-assisted psychotherapy by increasing connectedness, compassion for self, and compassion for others. CFT stimulates the affiliative system, which may be a relevant psychotherapeutic model for psilocybin-assisted psychotherapy.

COMPASSION FOCUSED THERAPY

Compassion focused therapy is specifically developed for individuals with a compromised capacity for experiencing and expressing affiliative motives and emotion to self and others, such as patients with depression.

Compassion focused therapy (CFT) was developed as a transdiagnostic model by Paul Gilbert in response to the observation that many chronic depressed clients did not benefit from traditional therapy. CFT focuses on three major emotion regulation systems: the threat protection system, the drive- and resource-seeking system, and the soothing and affiliation system.

Gilbert’s (1989) evolutionary model suggests that compassion evolved with the affiliative system, which is linked to the attachment system. Compassion can flow in three directions: caring for others, caring for oneself, and giving.

CFT targets both the psychological and the biological processes underpinning care and compassion, and uses these to help individuals feel safe and calm. This in turn helps to down-regulate the threat system and stimulate positive affect and a sense of social safeness.

CFT helps clients develop caring processes, create a better sense of social connectedness, and learn how to take wise and compassionate action to address distress.

RATIONALE FOR COMPASSION FOCUSED THERAPY AS A THERAPEUTIC MODEL IN PSILOCYBIN-ASSISTED PSYCHOTHERAPY

Conventional CBT approaches to depression primarily target signs and symptoms, but do not impact emotional, psychological and spiritual wellbeing as much as more recent approaches such as CFT. CFT targets compassion as a psychotherapeutic process and effectively increases social connection and social safeness.

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. This is similar to the proposed working of the soothing system within CFT.

PSILOCYBIN-ASSISTED COMPASSION FOCUSED THERAPY PROTOCOL

The current protocol for psilocybin-assisted CFT was constructed based on the basic structure of other psychedelic-assisted psychotherapy protocols. It consists of 13 sessions and includes psychoeducation and an insession experiential exercise.

Compassion Focused Therapy-Based Preparatory Sessions

Within the psilocybin-assisted CFT protocol, the therapists explain the concept of the tricky brain, which is a highly evolved brain that can create fear states. This concept is used to de-shame participants and help them understand and respond to their distress.

Soothing rhythm breathing and compassion focused body practices are taught in the sessions together with the therapist. During the first three preparatory sessions, the therapist will pay close attention to the way the participant perceives himself/herself, and will explore the different emotional states that lie underneath different affiliative motives and emotions. The therapist will then integrate the results of this exploration into the first navigation session.

Compassion Focused Therapy-Based Navigation Sessions

The psilocybin navigation sessions are guided by a non-directive approach, and the participant can be guided to go into the experience with their inner healing intelligence. The therapist will use a temporary framework of understanding, and will continuously update the framework by information from the navigation sessions.

Compassion Focused Therapy-Based Integration Sessions

The psilocybin navigation session is partly debriefing, partly psychotherapeutic CFT, and involves exercises to develop the compassionate self. These exercises include compassionate thought challenging records, compassionate letter writing, and worksheets that address the inner critic.

Therapeutic Stance

Although all psychotherapy sessions are didactic, all sessions contain exercises of CFT. CFT offers a safe therapeutic setting that tolerates distress and inner-criticism.

STUDY PROTOCOL AND THERAPIST TRAINING

Research indicates that psilocybin-assisted psychotherapy shows promising results for patients with depression. However, it is currently not clear whether psilocybin-assisted psychotherapy with non-directive psychological support or psilocybin-assisted psychotherapy with minimal support is more effective.

For settings where group designs are challenging or costly to perform, a single case experimental design (SCED) would be a feasible and appropriate design to measure the efficacy of the psilocybin-assisted CFT protocol for depression.

This study looked at the effects of a psilocybin-assisted CFT intervention on participants’ functioning. The results showed that the intervention was effective.

The Hamilton Depression Rating Scale (GRID-HAMD) is the primary outcome measure, and the Mental Health Continuum-Short Form (MHC-SF) is a secondary outcome measure.

To examine psilocybin-assisted CFT, we are devising a treatment manual and training for therapists based on recent CFT handbooks and/or manuals.

DISCUSSION

In this paper, we provided a framework for psilocybin-assisted psychotherapy for depression and discussed a new treatment protocol for therapists to work with clients within the field of psychedelic psychotherapy.

Psilocybin-assisted CFT circumvents challenges associated with the current standard approaches for depression. It also opens the possibility to tailor, adjust, or change the intervention to meet the needs of participants.

CFT is a suitable psychotherapeutic framework for psilocybin treatment of depression, but other approaches may also offer a relevant psychotherapeutic framework, such as CBT, ACT, or MET. CFT focuses on developing compassion and social connection as a mediator of change.

We believe that CFT is a suitable framework for psilocybin-assisted psychotherapy, as both therapies focus on stimulating connectedness and social safeness. Some individuals have difficulties with developing compassion, particularly those who have an insecure attachment style and high self-criticism. Psilocybin-assisted CFT may help to break through some of the fears, blocks, and resistances to compassion, especially for those who have an insecure attachment style and high self-criticism.

Limitations

The presented treatment protocol for psilocybin-assisted CFT holds promise, but some limitations also apply. Further research is needed to determine the dosage-effect of psychotherapy in psychedelic-assisted psychotherapy, and to determine the specific competencies needed to administer a psilocybin-assisted protocol for depression.

CONCLUSION AND FUTURE DIRECTIONS

This paper provides a psychotherapeutic framework for psilocybin-assisted CFT of depression. The efficacy of the protocol should be examined.