Journal of Contextual Behavioral Science 15 (2020) 12–19

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Psilocybin-assisted therapy of major depressive disorder using Acceptance T

and Commitment Therapy as a therapeutic frame
Jordan Sloshowera,b,∗, Jeffrey Gussc, Robert Krausea,d, Ryan M. Wallacea, Monnica T. Williamse,
Sara Reede, Matthew D. Skintaf
a
Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
b
Department of Psychiatry, VA Connecticut Healthcare System, West Haven, CT, USA
c
Department of Psychiatry, New York University School of Medicine, New York, NY, USA
d
Yale School of Nursing, New Haven, CT, USA
e
Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA
f
Department of Psychology, Roosevelt University, Chicago, IL, USA

ARTICLE INFO ABSTRACT

Keywords: Psychedelic-assisted therapy is based on the premise that psychedelic substances can act as catalysts or adjuncts
Psilocybin to psychotherapeutic processes. Recent clinical trials involving psychedelic-assisted therapy have generally
Psychedelic employed a similar three-part structure consisting of preparation, support during the dosing sessions, and
Psychotherapy subsequent “integration.” However, the content of these sessions and the frame through which the therapists
Acceptance and commitment therapy
approach participants and understand the clinical process has thus far been inconsistent among studies. In
Depression
Major depressive disorder
designing a manualized therapy protocol for a small clinical trial of psilocybin-assisted therapy for major de-
pressive disorder, our group sought to delineate an explicit and replicable, evidence-based model that in-
tentionally builds upon both the neurobiological actions of the medication and the phenomenology of the drug
experience. Having identified considerable concordance in proposed mechanisms of change between Acceptance
and Commitment Therapy (ACT) and psilocybin therapy, we employed ACT as an overarching psychother-
apeutic framework. We hypothesize that the psilocybin experience can provide direct experiential contact with
ACT processes that increase psychological flexibility, and that these deeply felt experiences may in turn be
reinforced during ACT-informed follow-up therapy sessions. In this paper, we describe the rationale for selecting
ACT, areas of potential synergism between ACT and psilocybin-therapy, the basic structure of our treatment
model, and limitations to this approach.

1. Introduction to models of psychedelic-assisted therapy which point research slowed substantially (Belouin & Henningfield,
2018). In recent years, there has been a revitalization of interest in the
The classical psychedelics are a group of substances that produce therapeutic use of psychedelic substances and multiple lines of evidence
characteristic alterations in cognition, perception, and emotion pri- suggest they have the potential to induce clinically beneficial changes
marily through agonism of serotonin 5HT-2A receptors in the brain in a variety of mental disorders (Garcia-Romeu, Kersgaard, & Addy,
(Nichols, 2004). This set of substances includes lysergic acid diethyla- 2016).
mide (LSD), psilocybin, dimethyltryptamine (DMT), and mescaline While a variety of biological and psychological mechanisms of ac-
among others. The term psychedelic, coined in 1957 by Humphrey tion for psychedelic therapy have been proposed, most researchers and
Osmond, means “mind-manifesting” in Greek and refers to the capacity therapists have operated under the assumption that the powerful sub-
of these substances to broaden awareness of and interest in one's inner jective and experiential effects of psychedelic substances play an im-
life (Osmond, 1957). Throughout the 1950s and 1960s, researchers portant role in therapeutic outcome, in addition to their direct phar-
investigated the therapeutic potential of psychedelic substances until macologic effects. It is well-established that subjective effects are highly
their classification into the most restrictively regulated drug schedule of variable and seem to be strongly influenced by psychological and en-
the United States Controlled Substances Act (Schedule I) in 1970, at vironmental factors, commonly referred to as “set and setting” (Leary,

∗
Corresponding author. Yale School of Medicine, Department of Psychiatry, 300 George St., Suite 901, New Haven, CT, 06511, USA.
E-mail address: jordan.sloshower@yale.edu (J. Sloshower).

https://doi.org/10.1016/j.jcbs.2019.11.002
Received 1 May 2019; Received in revised form 21 October 2019; Accepted 5 November 2019
2212-1447/ Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.
J. Sloshower, et al. Journal of Contextual Behavioral Science 15 (2020) 12–19

Metzner, & Alpert, 1995). “Set” refers to the mindset and intention of experience. Thus, the clinician is not referred to as a “therapist” but
the individual prior to the experience. This includes their beliefs, hopes, instead is named a “sitter,” “guide,” “facilitator,” or “monitor.” Some
fears, traumas, personality and temperament, as well as their expecta- large-scale clinical trials of psilocybin treatment for major depressive
tions and fantasies about psychedelic experiences. In the context of disorder currently being implemented are employing nonspecific
clinical research, the participant's attitude toward the research setting, models of “psychological support” (Carhart-Harris et al., 2016). While
the medication, and the therapists, as well as expectations for relief also this decision reflects research priorities in drug efficacy trials aiming to
constitute important parts of the participant's set. “Setting” refers to the isolate drug effects from therapy effects, it also relates to the reality that
physical space and therapeutic environment in which one experiences it is not clear “how best to integrate the psychedelic experience into
the drug effects. This includes the therapists or guides, as well as factors treatment models designed to have specific therapeutic effects, for ex-
such as music, artwork, and safety equipment. Most clinical research ample, to ameliorate the symptoms of a specific disorder” (Bogenschutz
with psychedelics emphasizes the importance of set and setting to & Forcehimes, 2017). While we do not question the possibility that
maximize safety, reduce the risk of harmful experiences, and enhance psychological support models may facilitate he healing experiences
therapeutic response.1 with the potential for internally generated self-repair, we see numerous
The term “psychedelic-assisted therapy” refers to a particular mode compelling reasons to employ an explicit therapeutic modality in the
of using psychedelic substances in which the subjective and psycholo- psilocybin-assisted treatment of research participants with major de-
gical effects of the drug play a significant role in the psychotherapeutic pressive disorder.
intervention. Traditionally, psychedelic-assisted therapy is comprised First, we feel that an important therapeutic opportunity is lost when
of three parts: preparation before the psychedelic dosing sessions, a condition-specific treatment modality is not employed in the overall
support during dosing sessions, and integration sessions afterwards. course of psychedelic therapy for moderate to severe diagnosed mental
Preparatory sessions aim to accomplish several important tasks. disorders. Major depressive disorder is a complex, vexing, chronic
Therapists develop therapeutic rapport with the participant and provide condition that is best understood in neuroscientific and cognitive and
psychoeducation regarding the psychedelic experience and the ther- behavioral and social dimensions. Thus, the notion that a non-specific,
apeutic approach. Logistics for the dosing session are discussed and supportive psychosocial container is the best method to address such a
acceptable boundaries of interaction between the participant and the complex clinical situation seems highly specious, and reinforces a
therapist are delineated. Participants are also assisted in setting inten- “magic bullet” approach to psychedelic therapy. Whatever changes that
tions for their dosing sessions. Support refers to the largely nondirective spontaneously emerge from the intense psilocybin experience will in-
stance taken by therapists while accompanying participants during the evitably be met with deeply ingrained patterns of thinking and be-
drug session itself. In recent psilocybin clinical trials, therapists have having. These are unlikely to be permanently erased by even the most
generally encouraged participants to have an inward directed experi- intense psychedelic experience. Setting the groundwork for the psy-
ence and provided emotional support for engaging with difficult chedelic experience to reveal certain types of psychological processes
thoughts, sensations, or memories that arise. They also ensure safety and insights during preparatory sessions and reinforcing under-
and assist the participant in meeting any immediate needs. The in- standings of content that emerges along specific therapeutic lines may
tegration phase usually begins the day after the dosing session and amplify and lengthen the duration of effect. As we will discuss, this is
involves thoroughly reviewing the participant's experience during the our intention for including ACT as a therapeutic frame in our study.
dosing session and, in some cases, applying therapeutic techniques to Second, failure to outline a coherent therapeutic approach with
reinforce particular aspects of the experience in order to sustain de- standardized therapy procedures presents a problem for controlled re-
sirable patterns of thought and behavior. In other words, integration search. Without selecting and implementing a particular therapeutic
can be understood as the continuation of a therapeutic process that approach, variability between study therapists' styles and interventions
began during preparation sessions, and intensified during a psychedelic goes unaccounted for, as each is likely to employ his or her own in-
experience.2 tuitive therapeutic modalities at different times and in different ways
While most clinical trials of psychedelic therapy have followed this with different participants. Thus, we believe it is more scientifically
basic model, the content of the preparation and integration sessions has rigorous to proactively outline a therapeutic approach and structure,
varied considerably among protocols, based on the condition being acknowledging there will be some inevitable variability in session
treated as well as the therapeutic orientation of the researchers and content, rather than to refrain from delineating these variables at all.
therapists. Importantly, some studies have employed non-specific sup- Third, we concur with the NIH-endorsed approach that research
portive psychotherapeutic models while others have incorporated ele- “interventions to change health behaviors ought to be guided by a
ments of evidence-based, condition-specific therapies. An example of hypothesis about why the behavior exists and how best to change it”
the latter is a study of psilocybin-assisted therapy for alcohol use dis- (Nielsen et al., 2018). Most psychotherapies provide answers to both of
order underway at New York University School of Medicine, which these questions. In the case of major depressive disorder, we have a
integrates elements of Motivational Enhancement Therapy into the fa- panoply of theories regarding etiology and treatment, reflecting the
miliar structure of preparation and integration sessions (Bogenschutz & evident truth that depression can be understood meaningfully within
Forcehimes, 2017). Numerous forms of psychosocial interventions many different discourses (Parker, 2005). For these reasons, at the very
could potentially be compatible or adaptable for use in psychedelic- beginning of our study, we deliberated on several empirically studied
assisted therapies, provided there is some theoretical synergism with depression treatments for our therapists to employ during the course of
the pharmacologic treatment to produce desired therapeutic outcomes. the study.
In contrast, supportive models of psychedelic therapy are not linked
to particular therapeutic orientations, nor do they target the specific 2. Selection process of therapeutic modality
disorder being treated. Instead, they provide containment, safety, and
clear guidelines to help participants navigate the psychedelic We began the process of constructing a therapy manual for psilo-
cybin-assisted therapy of depression by studying several manualized
therapies for depression that both had an evidence base and conceptual
1
See Johnson, Richards, and Griffiths (2008) for guidelines for maximizing overlap with psychedelic therapy. We specifically sought a therapeutic
safety and minimizing risk in human research studies with psychedelic sub- approach that would be facilitated by the effects of the psychedelic
stances. dosing sessions and also offer a structure for the preparation and in-
2
In this paper, we use the terminology “integration sessions” and “follow-up tegration sessions. The therapeutic modalities considered were: a)
sessions” interchangeably. Weissman and Klerman's Interpersonal Psychotherapy (IPT) for

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J. Sloshower, et al. Journal of Contextual Behavioral Science 15 (2020) 12–19

Depression (Klerman, Weissman, Rounsaville, & Chevron, 1994); b)

Frankl's Logotherapy (Schulenberg, Hutzell, Nassif, & Rogina, 2008); c)
Mindfulness-Based Cognitive Therapy for Depression (Segal, Williams,
& Teasdale, 2018); and d) Acceptance and Commitment Therapy
(Zettle, 2007).
Our process involved outlining the following key factors for each
modality: the etiology of depression (how the causes of depression are
understood), the therapeutic mechanism(s) (how the therapy intends to
relieve depression), targeted outcomes, and the therapeutic approach.
Finally, we reflected upon how each modality may or may not relate to
core phenomenological aspects of psychedelic and “mystical-type ex-
periences” (see MacLean, Leoutsakos, Johnson, & Griffiths, 2012;
Studerus, Gamma, & Vollenweider, 2010).
This process led us to ultimately select Acceptance and Commitment
Therapy as our modality of choice. IPT generally conceives of depres-
sion as a result of problems in role functioning, role transition, or in-
terpersonal deficits. We chose not to include it in our model because it
is predominantly focused on external circumstances and actions.
Logotherapy is based on the idea that the search for meaning is at the
core of human suffering and that loss of meaning is a central factor in
psychopathology. While meaning-making is an important process in
psychedelic integration, we did not prioritize this approach as we felt
its intense focus on meaning and language might inadvertently re-
inforce depressive patterns of thought and behavior. Mindfulness-Based Fig. 1. The ACT Hexaflex. Copyright Steven C. Hayes. Used by permission.
Cognitive Therapy focuses on present moment awareness, acceptance of
all that arises in the mind, non-judgment of self, and self-transcendence. et al., 2011). This “hexaflex” model is outlined in Fig. 1. In contrast,
All of these elements seemed congruent with how the psilocybin ex- psychological inflexibility can be seen as functionally related to a range
perience may alleviate depressive cognition. However, ACT was se- of psychological problems, including depressive, anxiety, substance
lected because it contains these elements in addition to a behavioral disorders, and eating disorders (Levin et al., 2014). Within the frame-
approach consisting of exploration of personal values (often lost in work of treating depression, it can be helpful to consider that experi-
depression) and values-based action (also often deficient in depression). ential avoidance behaviors are better described as experiential escape;
The remainder of this paper will explore the conceptual overlaps be- rather than attempting to control contact with unwanted experiences,
tween ACT and psychedelic therapy, and how these may be harnessed the internal aspects of depression, such as guilt, shame, or painful
in the treatment of depressive disorders. memories of loss, lead to attempts to escape painful internal experi-
ences that are already present (Zettle, 2007). A detailed description of
3. Overview of Acceptance and Commitment Therapy how the processes of psychological inflexibility manifest in depression
is beyond the scope of this article. However, as a whole, this lens offers
ACT was developed through the integration of radical behaviorism a highly valuable description of problems encountered in depressed
with experiential and existential approaches intended to target trans- patients in a discourse that is humanistic and of higher heuristic value
diagnostic drivers of psychological distress. The FEAR acronym de- than DSM-5 descriptive diagnostic criteria; it offers a construct that
scribes the common targets that ACT is oriented toward: “fusion, eva- describes the effects of depression on thinking and behavior in ways
luation, avoidance, and reason giving” (Hayes, Strosahl, & Wilson, that are amenable to specific psychological interventions. Moreover,
2003). The common human experience of over-reliance on thoughts the evidence base for ACT in the treatment of depression is growing and
and beliefs over direct experiences (i.e., fusion), the evaluation of our several studies demonstrate that it is equally effective to traditional
experiences as wanted or unwanted, and attempts to avoid both ex- cognitive behavioral therapies (Forman, Herbert, Moitra, Yeomans, &
ternal and internal (e.g. thoughts, feelings, memories) antecedents of Geller, 2007; Zettle, 2015).
unwanted experiences can all amplify and create the experience of
suffering. Within the context of a culture that values the pursuit of
positive emotions over a life lived in accordance with one's values or a 4. Rationale: why ACT in psilocybin-assisted therapy of
sense of deeper meaning (Ryan, Huta, & Deci, 2008), attempts to con- depression
trol or avoid unpleasant internal states become a major source of un-
happiness and psychological distress (Hayes, Strosahl, & Wilson, 2011). In this section, we will describe how we conceived of ACT principles
Though derived within the behavioral tradition, there are a number of as complementary and synergistic with those of psilocybin therapy.
parallels that have been noted between ACT, mindfulness interventions, First, we will discuss how ACT and our conception of psilocybin therapy
and Buddhist philosophy (Hayes, 2002), including the concept of an share several key differences from traditional pharmacological ap-
observer mind or transcendent self, separate from the content of the mind proaches to depression (Sloshower, 2018). In the current era of biolo-
or conceptualizations of the self, that can be experienced. In ACT, such gical psychiatry, mental illnesses like depression, schizophrenia, as well
transcendent experiences are considered to arise from amplified contact as addictions, are often conceptualized as brain diseases resulting from
with the learned experience of the verbal relations I-you, here-there, aberrant neural circuitry and chemical imbalances. To address brain-
and now-then (McHugh, Stewart, & Almada, 2019). based pathology, psychiatrists primarily prescribe medications and
The central treatment target of ACT is the development of psycho- deliver other interventions, such as electroconvulsive therapy (ECT) or
logical flexibility, cultivated through six core processes: present-mo- transcranial magnetic stimulation (TMS), that target brain circuits, le-
ment awareness, acceptance of one's experiences, defusion from the vels of neurotransmitters, and neuroreceptors. In this model, the patient
literal belief in one's thoughts, values clarification, the identification of is positioned as a passive recipient or consumer of such treatments,
specific behaviors in the service of those values (committed action), and tasked only with adhering to the treatment regimen and reporting their
contact with a flexible experience of the self (self-as-context) (Hayes response. Additionally, conventional pharmacological approaches to

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J. Sloshower, et al. Journal of Contextual Behavioral Science 15 (2020) 12–19

depression primarily target signs and symptoms of depression, but do alteration of self-perception towards an experience of unity, or at its
not address underlying psychological, emotional, social, and spiritual extreme, ego dissolution (MacLean et al., 2012). This may allow the
causes of depressive suffering. experience of self-transcendence; an experience of the self that is larger
ACT, like most psychotherapies, differs from pharmacologic ap- than a familiar depressive identity, and thus, not as strongly identified
proaches in several important ways. First, it actively engages the par- with depressive cognition and self-critical, pessimistic, ruminative
ticipant in the process of recovery. For instance, patients engage in narratives. From this spacious vantage point, the participant may have
mindfulness practices, values clarification exercises, as well as beha- an intensely felt experience of self-as-context in which the self is per-
vioral activation. Second, ACT does not explicitly set as its goal the ceived as distinct from the thoughts that arise in the mind. Finally, it is
amelioration of symptoms of depression or any other specific condition. possible for psychedelic therapy to assist people in gaining clarity of
Rather, ACT targets the more complex construct of psychological flex- their values and priorities in life (Swift et al., 2017). The experience
ibility as discussed above. Part of increasing psychological flexibility may reveal areas of life that have been neglected, aspects of self-care
involves acceptance of internal and external discomfort, which perhaps that need to be addressed, or how interpersonal relationships might be
paradoxically for some patients, involves decreased avoidance of un- improved. Thus, there are many potential areas of synergism between
pleasant thoughts and emotions, and instead, fully experiencing them ACT and psychedelic experience.
with openness and acceptance. The desired outcome is to live a full, Of course, not all of these processes and experiences will emerge
meaningful life. Doing so may indirectly lead to a reduction of de- clearly in every psychedelic experience for every individual, and study
pressive symptoms. participants with long standing depressive disorders may have parti-
Similarly, we conceive of psilocybin-assisted therapy as also re- cularly entrenched problems of psychological inflexibility. This sug-
quiring the active engagement of participants in their own healing. We gests that ultimately, we may find that multiple psilocybin sessions are
question the view of psychedelic therapy as a “magic bullet” inter- optimal for the treatment of major depressive disorder. It also speaks to
vention, requiring only the safely contained dosing of the medicine by the important role of preparatory and follow-up psychotherapy sessions
the suffering participant. Certainly, psychedelic substances may have to support the effects of the psilocybin dosing sessions. Integration
beneficial pharmacological effects that are independent of set and set- sessions are almost universally recommended in psychedelic therapy
ting or therapeutic approach. For instance, recent studies suggest that protocols as a means of both making sense and creating new meaning
psychedelics can alter functional connectivity in a manner that disrupts out of the experience, and helping positive changes and insights carry
stable spatiotemporal patterns of brain activity and increases commu- forth into day to day life. While psychedelic integration is widely dis-
nication between brain regions that are usually isolated (Carhart-Harris cussed as part of psychedelic therapy, it remains vaguely conceived,
et al., 2014; 2012; 2017). Additionally, the research study of which the undertheorized, and may lack an operational relationship to the pro-
ACT protocol described here is a part3 is further investigating the hy- blem being treated. It is often a non-specific mixture of supportive lis-
pothesis that psilocybin induces a transient neuroplastic brain state (Ly tening and encouragement to engage in introspective practices, such as
et al., 2018). While these pharmacological effects may inherently confer journaling, meditation, and spending time in nature. In the context of
some degree of symptom relief or benefit, we suggest that the full po- our study, ACT offers a framework for integration sessions (as well as
tential of psychedelic therapy is more likely to be unlocked when the preparatory sessions), which we will describe in the following section.
participant is actively engaged in a multifaceted therapeutic process of We believe that having such a template allows therapists to mean-
interrupting deep-seated pathological patterns of thought and behavior ingfully engage with familiar depressive negativism, pessimism, self-
through integrated neurobiological and psychosocial intervention. This criticism and despair as they may arise during the integration period.
biopsychosocial approach (Engel, 1980) is especially important when In summary, we propose that ACT and psilocybin therapy create a
working with chronic depressive pathology characterized by deeply synergism as both foster the core principles of psychological flexibility.
ingrained rigid self-criticism, hopelessness, experiential avoidance of It is our hypothesis that embedding psilocybin therapy within an ACT
pain, and abandonment of valued actions. Thus, it is our hypothesis that framework may amplify the response and lengthen duration of im-
psilocybin-assisted therapy of depressive disorders can confer more provement from depression by actively engaging the participant in
meaningful and longer lasting benefits by thoughtfully infusing ACT making changes to his or her patterns of thinking and behavior. We
principles into the course of psilocybin therapy. believe these changes may be enhanced through the combined neuro-
In order to achieve this, we constructed our therapy protocol ac- biological effects and psychological experiences during psilocybin ses-
cording to the theory that the experience of moderate to high doses of sions, followed by active reinforcement by the therapists.
psilocybin, with preparatory priming and psychoeducation, can provide
direct experiential contact with the ACT processes known to increase 5. Constructing the therapy manual: how ACT is incorporated into
psychological flexibility (McCracken & Gutiérrez-Martínez, 2011) and the structure of psychedelic therapy
that these deeply felt experiences may in turn be reinforced during
ACT-informed therapy sessions. For example, the intensity of the psy- In constructing our therapy manual, we maintained the familiar
chedelic experience may bring the participant directly and forcefully structure of preparation, support, and integration sessions used in other
into contact with the present moment via all the thoughts, sensations, psychedelic therapy protocols, but infused ACT perspectives, principles,
emotions, and memories that arise. These experiences are generally and interventions into the sessions in a variety of ways.
perceived as occurring beyond conscious control, often as a stream or
flood of consciousness.4 Participants are encouraged to surrender to 5.1. ACT-based clinical formulation
their experience during drug sessions, or to “trust, let go, and be open”
(W. A. Richards, 2015). The release of tension that may be experienced While depressive and psychedelic narratives can be understood
when this is done can serve as a deeply felt experience of the ACT through a variety of different discourses, in our protocol, ACT provides
principle of acceptance. Another aspect of psychedelic experience is the a primary mode of understanding the nature of depressive thoughts,
feelings, and behaviors, as well as participants' responses to psychedelic
experiences. During preparatory sessions, therapists are instructed to
3
Please see National Institute of Health (2018) for more information on listen to participants' histories of depression through an ACT lens, no-
clinical trial NCT03554174. ticing examples of cognitive fusion, experiential avoidance, loss of va-
4
The organization of this emergent experience occurs at a level of con- lues or other examples of psychological inflexibility. In this way, they
sciousness that is outside awareness, and is a source of many speculative dis- begin to understand the participant's narrative along these ACT di-
courses. mensions and identify which ACT processes on the hexaflex model are

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J. Sloshower, et al. Journal of Contextual Behavioral Science 15 (2020) 12–19

Table 1
Sequence of therapy sessions contained in treatment protocol and ways ACT was employed in each session.
Session Information Session Goals and How ACT is Employed

Preparatory Psychoeducation Session #1 (2 hours) Establishment of therapeutic alliance.

Therapist listening to participant's narrative of depression and treatment history to understand patterns of
psychological inflexibility that are most prominent.
Psychoeducation regarding the psilocybin experience, grounding techniques including diaphragmatic breathing,
therapeutic boundaries (e.g, touch) and safety measures.
Intention setting for medication session #1.

Medication session #1 (at 1 week) ACT-based clinical formulation continues as therapist listens to emergent narratives and notes instances of
psychological flexibility and inflexibility, especially present moment awareness, self-as-context, and experiential
avoidance.
In line with supportive stance during medication sessions, no significant ACT interventions or feedback provided.

Debriefing session #1 (1–2 hours, day after medication Elicit complete narrative of participant's experience during medication session.
session) Identify and explore aspects of the participant's narrative that engage with core ACT principles, as well as
instances when they moved toward or away from psychological flexibility.

Debriefing session #2 (1–2 hours, 1 week after medication Further review and reflection of participant's medication experience and what changes have taken place since.
session) Begin the process of values clarification by discussing the participant's completed Valued Living Questionnaire.
Discuss relative importance of valued domains of living and how they are or are not living in accordance with
their values.

Preparatory Psychoeducation session #2 (2 hours, at 4 weeks) Psychoeducation regarding the cognitive processes and behaviors that are problematic in depression from ACT
perspective (i.e. cognitive fusion, experiential avoidance, reason-giving etc.).
Induce “creative hopelessness” an and suggest depressive patterns can be changed through an interactive process
between the principles of ACT and the experience with psilocybin.
Teach mindfulness practice.
Intention setting for medication session #2.

Medication session #2 (at 5 weeks) Same as medication session #1

Debriefing session #3 (1–2 hours, day after medication Elicit complete narrative of participant's experience during medication session.
session) Explore aspects of the experience in relation to ACT principles discussed previously.
Consider use of metaphors derived from psilocybin experience or from ACT (i.e. house and furniture metaphor)
to aid in understanding of the principles, such as self-as-context.

Debriefing session #4 (1–2 hours, 1 week after medication Further review and reflections of participant's medication experience and changes that have taken place.
session) Continue values clarification with focus on putting values into action; Consider use of the ACT Matrix, and
shifting towards a more directive behavioral approach helping the participant define exactly what actions they
can take to start living in accordance with their values.

Follow-up sessions #1 and #2 (2 and 4 weeks after medication Continue to explore insights gained from the psilocybin experience and assess for changes in psychological
session #2) flexibility. Consider introducing the ACT hexaflex and explore how the dosing and therapy sessions brought each
ACT process to light.
Reinforce relevant ACT concepts and encourage successful behavioral changes and committed actions taken.
Review mindfulness practices and other concrete ways the study experience can be translated into lasting
changes.
Termination discussions and planning for post-study follow up care.

sites of potential change for the individual. The participant also com- interventions to target particular areas of the ACT hexaflex that need
pletes the Valued Living Questionnaire (Wilson, Sandoz, Kitchens, & more attention, such as values-based goal setting, defusion from un-
Roberts, 2017) at baseline, which is reviewed by the therapist for later workable negative thought constructs, and overcoming experiential
discussion. During dosing and debriefing sessions, therapists pay at- avoidance. For example, several of our depressed participants expressed
tention to instances when the participant's experience either moved deeply held negative beliefs regarding their self-worth. In this case, the
them toward or away from psychological flexibility. Cases of the former therapist may examine the ways that the participant is conflating a
can serve as deeply felt reference points for more flexible and “work- depressive thought with an absolute truth (fusion) and the resulting
able” ways of thinking and behaving, which can guide the therapeutic impacts on their behavior. During debriefing and follow-up sessions,
approach during the integration period. Conversely, instances in which therapists may evoke moments from the psilocybin sessions to reinforce
the participant avoided experiences of the present moment, or specific lived experiences of increased psychological flexibility. For example,
emotional states or self-concepts, can point to particular areas of the the therapist might say, “remember how you told me about how you
ACT hexaflex that would benefit from increased attention during were calmly watching a stream of shapes, colors, and images move
follow-up sessions. Thus, ACT-based clinical formulation occurs through your mind for several minutes during your dosing session?
throughout all therapeutic encounters with the participant, guiding That is the kind of mindful attention we hope to cultivate through ev-
therapeutic approach and assessment of progress in an iterative eryday mindfulness practices.” One participant in our study presented
manner. with an obsessive tendency to try to articulate himself perfectly during
social interactions, often resulting in avoidance and social isolation.
5.2. ACT-based clinician intervention During his dosing session, however, he became very playful with his
language and body movements. The therapist was able to remind him of
Holding an ACT formulation of the participant's difficulties and this openness and freedom from fear with the hope of decreasing his
values in mind, therapists can provide feedback and use other experiential avoidance of future social interactions.

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5.2.1. Didactic explanations neurobiological actions of the medication (i.e. heightened neuroplas-
There are several points in the protocol in which the therapist di- ticity and altered functional connectivity) and the phenomenology of
rectly teaches and explains ACT principles to the participant. This oc- the drug experience in order to achieve more efficacious, long lasting
curs during preparatory sessions as a means of priming the participant effects. In so doing, we hoped to create a true medication-assisted
to register elements of the psilocybin sessions as reflecting ACT-defined psychotherapy in which the experience of the drug sessions represents
shifts in thinking, behavior, and awareness of values. It also may occur the pivot-point around which the rest of the therapy revolves. It is
during follow-up sessions, as a way to provide useful tools for the important to highlight that this is a different concept than conventional
participant to solidify understanding of ACT principles for self-directed, combination or sequential therapy, which combines an antidepressant
ongoing work toward psychological flexibility after their time in the medication with a course of evidence-based psychotherapy, such as
research study concludes. Cognitive Behavioral Therapy. In typical combination treatment
models, the drug treatment and psychotherapy occur independently of
5.2.2. Experiential exercises one another; the content and messaging of the two therapies are gen-
While didactic explanations of ACT principles provide a cognitive erally unrelated and each could be conducted separately, even with
understanding of problematic patterns and potential remedies, it is also different providers. This is not the case in psychedelic-assisted therapy,
critical that participants experience psychological flexibility on a deeper in which the two elements cannot be separated. The protocol we de-
level or derive their own understandings of the principles. We hy- signed would not make sense without the medication, as each session is
pothesize that the psilocybin experience can provide this to some de- specially designed to either prepare the participant for the drug ex-
gree, especially with priming, but we also implement ACT consistent perience, or to transform the content of the drug experience into longer
metaphors, mindfulness practices, and worksheets to deepen this ex- lasting changes in patterns of thoughts and behaviors. Clinically, we
perience. For instance, we use metaphors to help convey the concepts of know that combined treatments - psychotherapy and medication - are
fusion and self-as-context. We use worksheets to help participants generally more effective in treating depressive and anxiety disorders
clarify their values, as well as the “ACT Matrix” (Polk & Schoendorff, than medication alone (Cuijpers et al., 2014). We hope that our ap-
2014) to help participants discover how their internal experiences im- proach of rationally combining pharmacology and psychotherapy will
pact their ability to engage in values driven actions. For the purposes of be an important future direction for mental health treatment.
standardization in research, we selected a handful of metaphors,
worksheets, and exercises to include in our protocol, however these 7.1. Limitations
could be flexibly employed by ACT trained clinicians in other contexts.
Table 1 outlines the sequence of therapy sessions in our treatment While our limited experience using this treatment protocol with
protocol and some of the specific ways that ACT is employed in each research participants suggests it holds promise, there are a number of
session. important limitations to our approach. First, we are not currently
conducting a trial comparing our approach to psilocybin treatment with
6. Therapist training psychological support only. Thus, we cannot make any definitive claims
that the integration of ACT is actually more effective. We are however
Once the therapy manual was completed, we devised a training in the process of collecting qualitative data and self-report measures of
program for study therapists. All therapists recruited for the study are mindfulness, changes in values, cognitive flexibility, personality, and
licensed clinicians with extensive clinical experience treating patients quality of life, which we hope will shed light on which aspects of our
with depression. Most had significant experience or familiarity with therapy protocol are effective or helpful to participants. Another lim-
principles of both mindfulness and cognitive behavioral therapy, but itation is that our therapists are not highly experienced ACT practi-
limited experience with ACT specifically. The objective of the training tioners and received modified training in ACT, as described above. We
program was to introduce them to core principles of both psychedelic have now conducted two rounds of therapist training and have mod-
therapy and ACT, and to train them to implement our therapy protocol. ified the training program, yet the optimal approach in training
The training program consisted of pre-assigned didactic videos and therapists for this work remains an open question. Particularly in re-
readings, including ACT Made Simple (Harris, 2009) and the study search settings, utilizing tools to monitor adherence to the therapeutic
therapy manual, followed by four day-long sessions. These in-person model would be an important future step. Additionally, our protocol
sessions consisted of close reading and discussion of the therapy does not include the full range of possible ACT interventions. This
manual, didactic teaching, and role plays. Day 1 of the training focused limitation is inherent to this therapy protocol being designed for a
on essential elements of psychedelic therapy. Day 2 was spent re- small, placebo-controlled, within subject crossover clinical trial. For
viewing core principles and techniques of ACT and how these are used scientific reasons, we attempted to standardize the therapy protocol and
in the therapy manual. Days 3 and 4 focused on role plays and ex- provide a relatively consistent approach throughout the protocol and to
periential exercises, including a day long intensive retreat led by a peer- each participant. For reasons related to feasibility, the number of
reviewed ACT trainer. Role-play scenarios provided therapists an op- therapy sessions was constrained and we suspect that more preparatory
portunity to practice using ACT interventions and supporting partici- and follow-up sessions would be optimal. Similarly, therapy sessions in
pants through challenging psychedelic experiences. We consider the our study are conducted largely by a single therapist,5 as opposed to the
process of integrating the principles of ACT into psychedelic therapy to two-therapist model used in some other psychedelic therapy protocols.
be an iterative project requiring ongoing case supervision and refine- As a result of these limitations, we accept that we are providing a
ment of the protocol. Thus, regular peer case supervision sessions are limited form of ACT and that there are alternative, possibly superior
being conducted with a therapist who has extensive experience con- ways that ACT could be integrated with psychedelic therapy.
ducting psilocybin-assisted therapy in a research context.
7.2. Cultural considerations of ACT-facilitated psychedelic therapy
7. Discussion
Another important potential limitation of the approach outlined
The model presented here represents our best attempt to design a
here is its untested cultural relevance and acceptability among people
rational and effective therapy protocol to accompany a small clinical
trial of psilocybin-assisted treatment of depression. We sought to design
a bespoke therapy model that incorporates evidence-based treatment 5
A study physician is also present for all experimental drug sessions and takes
principles and intentionally builds upon both the presumed part in some preparatory and debriefing sessions.

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J. Sloshower, et al. Journal of Contextual Behavioral Science 15 (2020) 12–19

of color and other marginalized and oppressed groups. This issue per- 8. Conclusion and future directions
tains to psychedelic therapy and research in general (Michaels, Purdon,
Collins, & Williams, 2018) and to aspects of ACT in particular. The Two of the most intriguing aspects of psychedelic-assisted therapy
behavior analytic roots of ACT do not preclude a deep understanding of are imagining the ways it may be helpful across a range of psychiatric
cultural contexts and histories of clients belonging to oppressed or (and possibly medical) conditions and the impact it might have when
stigmatized groups (Hayes & Toarmino, 1995) and preliminary evi- integrated with existing psychosocial therapies. In general, pharma-
dence suggests that ACT may be effective with different ethnic groups cotherapy and psychosocial therapies have existed in separate dis-
(Woidneck, Pratt, Gundy, Nelson, & Twohig, 2012). Nonetheless, a courses from one another with mind treated as distinct from brain. As
number of core concepts and practices in ACT need to be utilized with discussed in the previous sections, psychedelic-assisted therapy weds
caution and thoughtfulness when working with oppressed and stigma- these into a single intervention with neuroscientific mechanis me-
tized groups. chanisms and lived experience informing and actually creating one
Due to a variety of cultural factors, people of color may not seek another. Intriguingly, this opens up the possibility of deepening the
treatment until problems are severe, and most communities of color effectiveness of numerous treatments, and rendering certain treatment
have taboos against sharing problems outside their community resistant conditions more responsive to intervention.
(Chapman, DeLapp, & Williams, 2018). Mental health literacy and self- As a field, psychiatry and psychology are at an early stage of ima-
stigma of help-seeking may also vary among cultural groups, and some gining how psychedelic states of consciousness may have ameliorative
people may not consider their difficulties as signs of a mental disorder effects on different types of therapies for various conditions. Many
as defined by Western psychiatry and psychology (Cheng, Wang, questions exist about how psychedelic therapies work and how to im-
McDermott, Kridel, & Rislin, 2018). To use ACT effectively with people plement them, for different individuals, with different conditions, in an
of color, therapists must be aware of these factors and account for them optimal way (i.e. dose and frequency of medication and therapy, use of
in order to build rapport with clients. At the onset of treatment, clients music, individual versus group administration etc.). Thus far, positive
of color may expect therapists to provide expert advice to help them outcomes in trials of psychedelic-assisted therapies have been corre-
resolve urgent problems. Therefore, a non-directive approach could be lated with “mystical-type” subjective effects, suggesting a mediating
experienced as frustrating, unhelpful, and invalidating. For this reason, role of mystical-type experiences in psychedelic-assisted treatment
a clear explanation of the mechanism of treatment is essential, espe- (Garcia-Romeu, Griffiths, & Johnson, 2014; R. R.; Griffiths, Richards,
cially when using a modality like ACT whose therapeutic concepts may McCann, & Jesse, 2006; Ross, 2018). However, it remains unclear ex-
seem foreign, mysterious, or counterintuitive. For instance, the idea of actly how such experiences convey a therapeutic effect. In this paper,
“acceptance” may be misinterpreted as a need to continually accept we link aspects of psychedelic experience with specific psychother-
inequitable and hurtful treatment from others, rather than noting and apeutic processes that lead to greater psychological flexibility. Thus, we
allowing whatever responses are experienced as a result of such treat- would suggest that increased psychological flexibility may mediate the
ment. Marginalized individuals must be validated in their intersectional relationship between mystical type experiences and therapeutic re-
realities before acceptance can take place. Further, among people of sponse. This would help account for the preliminary efficacy of psy-
color, the idea of “commitment” may be experienced as an extension of chedelic-assisted therapies across a range of mental health disorders, as
racist cultural assumptions about an unwillingness to be accountable. many demonstrate aspects of psychological inflexibility: the cognitive
“Committed action” could then be more neutrally described in terms of rigidity and behavioral restrictions so prevalent in obsessive compulsive
identifying small steps to live a fuller or more meaningful life in line disorder and autism spectrum disorder, as well as the constriction in
with participant-suggested values, eliminating any implied link with a thinking and emotion that are commonly observed in anorexia nervosa.
lack of commitment and retaining the meaning of this mechanism Compulsivity and behavioral rigidity are obvious in substance use dis-
within ACT. In sum, therapists should take care to use the language of orders, as well as behavioral addictions.
ACT flexibly; the concepts can be described in a number of ways, and As large scale efficacy trials for psilocybin treatment proceed with
ACT protocols for topics such as chronic pain routinely excise the use of the aim of rescheduling the substance for medicinal use, we believe it is
the word “acceptance” while retaining the principles in practice critical to engage in lively and thoughtful discussions about how these
(McCracken, 2005). substances can be combined creatively and effectively with psy-
Caution must also be used when introducing mindfulness exercises, chotherapeutic processes and other healing modalities to optimize
such as meditation, as this may be misconstrued as engaging in a outcomes for patients. We hope this paper offers a cogent starting place
competing religious practice, resulting in ambivalence or refusal to for this discussion and look forward to iteratively refining our model
engage in such activities. Fortunately, formal meditation is only one of based on expert and participant feedback and clinical experience.
many ways to establish contact with the present moment and is not a
necessary component of ACT. All faiths have some type of con- Declarations of interest
templative practice, and it may be best to first gain an understanding of
a participant's religious beliefs so that mindfulness exercises can be None.
made congruent with their existing religious practices and worldview.
Finally, the ACT therapeutic frame permits participants to make Funding
contact with difficult internalized experiences, like racism. However, if
this occurs prematurely or is encouraged in an inappropriate manner, This work was supported by the Heffter Research Institute.
they may feel alienated, invalidated, or drained, thereby decreasing
therapeutic rapport and opportunities to deepen psychological flex- Acknowledgment
ibility. This exemplifies the importance of diversity training when doing
this kind of therapeutic work. Therapists should be well practiced and The authors would like to thank the Heffter Research Institute and
comfortable discussing issues of racism and oppression with clients, and Carey and Claudia Turnbull for their support of this project. We also
they should have a ready response for how ACT can be useful in na- want to thank Dr. Deepak Cyril D’Souza (principal investigator of
vigating, resisting, and healing from the effects of discrimination. For NCT03554174) and the research team at the Schizophrenia
example, a therapist can highlight that a client could accept distressing Neuropharmacology Research Unit at Yale (SNRGY) for all their work
emotional responses to racism and still view their life circumstances as implementing this study. Finally, we want to thank our study partici-
unacceptable (Sobczak & West, 2013). pants for teaching us how ACT does and does not work with psilocybin
therapy.

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