If you ask people with psychosis about their inner life, a recurring theme emerges: they are often extremely hard on themselves. Voices say cruel things. Memories of behaviour during episodes haunt them. The diagnosis itself can feel like proof of being broken. Compassion-Focused Therapy (CFT), developed by clinical psychologist Paul Gilbert, was built precisely for people whose primary emotional landscape is shame and self-criticism — and a growing body of research suggests it has real promise for psychosis.
Compassion-Focused Therapy uses imagery, breathing, and behavioural practices to strengthen the brain's soothing system, soften self-criticism, and change a person's relationship with hostile voices.
The three-systems model
CFT rests on a simple model of three emotion-regulation systems in the brain:
- The threat system — anxiety, anger, disgust; activated when something feels dangerous
- The drive system — wanting, achieving, pursuing
- The soothing system — calm, contentment, safe connection
For many people with psychosis, the threat system is chronically dominant and the soothing system is underdeveloped — partly through trauma, partly through years of stigma and isolation. CFT works to rebalance the three.
Why this matters in psychosis
Voices in schizophrenia are very often critical, hostile, or shaming. Research by Birchwood and colleagues has shown that the relationship between the person and the voice mirrors interpersonal patterns from earlier life — particularly experiences of being subordinated, bullied, or abused. CFT treats voices not just as cognitive events but as relational ones, and it builds the inner capacity to respond to a hostile voice the way one might respond to a hostile but real person — with steadiness, kindness, and boundaries.
Core CFT practices for psychosis
Soothing rhythm breathing
A slightly slower, slightly deeper breath rhythm — usually 5 to 6 breaths per minute — that activates the parasympathetic nervous system. Practised daily, often eyes open, with a steady, grounded posture.
The compassionate self
An imagery exercise in which the person evokes their own wisest, kindest, strongest self and inhabits it. From this place, they then turn attention to their suffering — including their voices.
The compassionate other
Imagining a warm, wise being (a person, an animal, an imagined figure) who feels deep compassion for the person and offers steady acceptance. For trauma survivors, this can be a powerful corrective.
Compassionate letter writing
Writing a letter from the compassionate self to the suffering self, often about specific painful situations — a recent voice attack, a flashback, a lost relationship.
Working with the voice as a relationship
Therapist and client explore who the voice resembles, what it wants, and how to respond from a place of compassion rather than fear or appeasement. This intersects with avatar therapy and CBTp for voices.
The evidence
Charles Heriot-Maitland and others at King's College London have run several studies of CFT for psychosis. A pilot trial published in the British Journal of Clinical Psychology showed reductions in distress and depression in people with persistent psychotic symptoms. The COMPASS trial, a multi-site UK study, examined CFT for distressing voices and found improvements in voice-related distress and in compassion. The evidence base is smaller than for CBTp but consistently positive across studies.
Who tends to benefit most
- People with prominent shame and self-criticism
- People with histories of trauma, bullying, or invalidating environments
- People whose voices are mostly critical or persecutory
- People who have made gains in CBTp but still feel stuck in self-attack
What it does not do
CFT is not "positive thinking" or self-affirmation. It does not pretend pain away. It does not work overnight. People with very high shame sometimes experience early CFT exercises as paradoxically activating the threat system — an experience Gilbert calls fear of compassion — and the therapy explicitly addresses this rather than pushing past it.
What a session looks like
Sessions are usually weekly, 50 minutes, for 12 to 24 sessions. They blend education about the three systems, experiential imagery exercises, mindfulness practices, behavioural homework, and reflection on what came up. Audio recordings of practices are common between sessions.
Compassion exercises are activating overwhelming grief, voices are spiking in distressing ways, or you feel destabilised. CFT explicitly slows down for these reactions rather than pushing through. Tell your therapist.
Self-help options
Paul Gilbert's books, including The Compassionate Mind and Mindful Compassion, are widely used. The Compassionate Mind Foundation hosts resources and a clinician directory.
The bigger picture
CFT addresses something that medication cannot: the inner relationship a person has with themselves and with the parts of their experience that feel most unbearable. It does not replace antipsychotics or CBTp. It complements them by softening the soil — making it more possible to take in any therapeutic work, more possible to ask for help, more possible to live with what cannot yet be fixed. For many people whose psychosis is intertwined with shame, that soil-softening turns out to matter as much as the more visible interventions.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.