Emotional breakthrough and psychedelics: validation of the emotional breakthrough inventory

This non-controlled, naturalistic, observational study (n=379) collected self-reported user data one day after a preregistered psychedelic experience, for the purpose of validating a questionnaire that can assess ’emotional breakthrough’. This new scale was sufficiently different from previous tools, such as the Mystical Experience Questionnaire (MEQ), while sensitive enough to detect dose-dependent differences in the experience and predict post-psychedelic changes in well-being.

Abstract

“Background: Psychedelic therapy is gaining recognition and the nature of the psychedelic experience itself has been found to mediate subsequent long-term psychological changes. Much emphasis has been placed on the occurrence of mystical-type experiences in determining long-term responses to psychedelics yet here we demonstrate the importance of another component, namely: emotional breakthrough.

Methods: Three hundred and seventy-nine participants completed online surveys before and after a planned psychedelic experience. Items pertaining to emotional breakthrough were completed one day after the psychedelic experience, as were items comprising the already validated Mystical Experience Questionnaire and the Challenging Experience Questionnaire. Emotional breakthrough, Mystical Experience Questionnaire and Challenging Experience Questionnaire scores were used to predict changes in well-being (Warwick-Edinburgh Mental Wellbeing Scale) in a subsample of 75 participants with low well-being baseline scores (⩽45).

Results: Factor analyses revealed six emotional breakthrough items with high internal consistency (Cronbach’s alpha=0.932) and supported our prior hypothesis that emotional breakthrough is a distinct component of the psychedelic experience. Emotional breakthrough scores behaved dose-dependently, and were higher if the psychedelic was taken with therapeutic planning and intent. Emotional breakthrough, Mystical Experience Questionnaire and Challenging Experience Questionnaire scores combined, significantly predicted subsequent changes in well-being (r=0.45, p=0.0005, n=75), with each scale contributing significant predictive value. Emotional breakthrough and Mystical Experience Questionnaire scores predicted increases in well-being and Challenging Experience Questionnaire scores predicted less increases.

Conclusions: Here we validate a six-item ‘Emotional Breakthrough Inventory’. Emotional breakthrough is an important and distinct component of the acute psychedelic experience that appears to be a key mediator of subsequent longer-term psychological changes. Implications for psychedelic therapy are discussed.”

Authors: Leor Roseman, Eline Haijen, Kelvin Idialu-Ikato, Mendel Kaelen, Rosalind Watts & Robin L. Carhart-Harris

Summary

Introduction

Psychedelic therapy is a re-emerging paradigm within mental health research, and the mystical-type experience is a key determinant of long-term responses to psychedelics. However, the mystical-type experience is not well-defined, and it is not the sole or indeed the primary determinant of long-term psychological outcomes.

The Challenging Experience Questionnaire (CEQ) is a tool for measuring challenging emotions such as grief, fear, paranoia, etc., and has been found to be influential in determining long-term responses. However, the CEQ does not measure the potential clinical value of accepting and/or overcoming the relevant challenges.

Psychedelic therapy is gaining recognition, and emotional breakthrough is an important component of the psychedelic experience. This component was found to predict changes in well-being in a subsample of 75 participants.

Here, we constructed and validated the Emotional Breakthrough Inventory, a third potential mediator of longer-term responses to psychedelics, based on the assumption that the MEQ and CEQ do not fully or clearly capture the phenomenon of overcoming challenging emotions/memories and thereby experiencing emotional release or breakthrough.

The psychedelic model of psychedelic therapy uses high doses of a psychedelic to promote the attainment of a powerful self-transcendent state, while the psycholytic model uses lower doses in concert with psychoanalytically oriented psychotherapy.

LSD breaks emotional or memory blocks and causes the patient to experience an exhilarating feeling of liberation. This feeling is often accompanied by personal and interpersonal insights, and is therefore not necessarily transpersonal in the same way mystical-type or peak experiences appear to be.

The present study sought to develop and validate a brief EBI that is focused and concise in nature. It used an online prospective survey and a well-validated measure of psychological well-being.

EBI scores increase in a dose-dependent manner, are associated with a therapeutic context, and discriminate from MEQ and CEQ scores. EBI predicts changes in well-being.

Method

The study was approved by Imperial College Research Ethics Committee and the Joint Research Compliance Office and was carried out with written informed consent.

Design

The data presented in this article was collected as part of a larger prospective study (Haijen et al., 2018). 379 participants completed a survey on-line before and after a psychedelic experience, and two weeks after the experience was collected to determine long-term outcomes.

Item selection and face validity

Eight initial items were devised based on interviews with patients in our previous psilocybin for treatment-resistant depression trial, and five experts assessed and revised the items if needed. The quotes below are from the qualitative analysis of Watts et al. (2017).

I felt a relief, I could feel it all coming out, and the weight and anxiety and overwhelming depression have been lifted.

The dosing session was uncomfortable, but I got angry with it and challenged it, and it went away. I was weeping and crying, and I could feel the grief, but I let it go because holding onto it was hurting me, holding me back.

Other measures

The MEQ was developed by Walter Pahnke and Bill Richards based on the anthropological research and theoretical writings of philosopher Walter Stace (1960). It includes 30 questions rated according to a five-point Likert scale and is divided into four subscales: Mystical, Positive-mood, Transcendence of time and space, and Ineffability.

The CEQ was developed to measure the challenging experience of psychedelic use. It has 26 questions and is divided into seven dimensions: isolation, grief, physical distress, fear, insanity, paranoia, and death.

The WEMWBS was used to measure psychological well-being in a population. It was restricted to subjects with relatively low baseline well-being scores to examine potential changes in well-being two weeks after drug intake compared to baseline.

Drug dose was assessed using an LSD equivalent approach. Options were: a low dose, a moderate dose, a high dose, a very high dose, or an extremely high dose.

At pre-drug baseline, participants were asked to indicate what their motives were to undergo a psychedelic session/ceremony/experience. We looked at two intentions: therapeutic/personal growth and confronting difficult emotions.

Factor analysis and definition of EBI

The original eight EBI items were subject to an exploratory factor analysis using principal component analysis (PCA). Only factor 1 with six items was used in further analysis.

Discriminant validity

To test whether the EBI is significantly different from the MEQ and CEQ, the items of all three questionnaires were entered into one factor analysis (PCA), and a correlation matrix was calculated to explore similarities and differences between the three questionnaires and their components.

Predictive validity – changes in well-being

Pearson correlation and multiple regression were used to test whether the EBI could serve as a predictor of clinical changes. The EBI, MEQ and CEQ were found to have significant added value in explaining changes in the dependent variable.

Factor structure

We entered the eight original EBI items into a PCA and found that there were two factors that explained 57.1% of the variance and 18.3% of the variance. We decided not to use the two negative items in the final version of EBI.

Internal consistency

After discarding the two negative items, the resulting six-item EBI displayed a high internal consistency (Cronbach’s alpha=0.932) and a high correlation with factor 1 score (r=0.996, p0.0001). The mean of the six items was significantly higher than 0.

Predictive validity – dose, therapeutic intention and setting

EBI scores significantly correlated with estimated drug dose, baseline ratings of therapeutic intention, and willingness to confront difficult emotions, and participants who felt the setting for their experience was designed with a therapeutic objective in-mind.

Discriminant validity

To demonstrate that the EBI is a novel measure, all of the 62 items from MEQ, CEQ and EBI were entered into a single factor analysis (PCA). The results suggested that for some subjects, EB was accompanied by mystical-type phenomena, whilst for others, EB was distinct from either classical challenging and/or mystical-type phenomena.

The EBI correlates strongly with all MEQ dimensions and also with the grief dimension of CEQ. The EBI and MEQ are measuring sufficiently distinct phenomena.

Predictive validity – changes in well-being

The difference in WEMWBS from baseline to two weeks after the psychedelic experience was significant. Emotional breakthrough scores were significantly correlated with changes in well-being, and the EBI performed as well as the other measures. The difference in WEMWBS from baseline to two weeks after the experience was significant for the wider sample regardless of WEMWBS baseline scores, though with a smaller effect size. The correlations between the EBI, MEQ and CEQ and WEMWBS were marginally significant.

Results confirm that a prediction model containing measures of all three constructs will perform better than a model that neglects any one of them.

Discussion

Here, we sought to devise and carry out validation work on a new scale to describe an important component of the psychedelic experience, the emotional body. Results revealed that the emotional breakthrough index (EBI) is dose dependent and sufficiently different from the mystical-type and challenging experience as indexed by the MEQ and CEQ respectively. The EBI also significantly predicts post-psychedelic changes in well-being, and a multi-factorial predictor model that combines all three measures performs better than any alternative that neglects any one.

Modern phenomenological analyses and therapists’ accounts have tended to recognise the importance of the EB phenomenon within the context of psychedelic experiences and psychedelic therapy, but a validated quantitative measure of this phenomenon is arguably overdue and there is a significant contemporary need for it.

The present work has demonstrated that evaluating a state-based variable such as EB is an effective predictor of subsequent psychological outcomes after a psychedelic experience. However, other factors such as contextual factors and psychological insight may also be important determinants of longer-term responses to psychedelics.

Much more work is needed to understand the neurobiology of the entire psychedelic psychotherapy process, but increased brain entropy is a biomarker of the psychedelic state and is predictive of subsequent psychological changes.

We advocate looking at other dependent variables than just well-being, because certain psychiatric disorders may behave differently in their relation to predictor variables.

Our novel analysis of psychedelics focuses on the psychological mechanism of action and the context in which these drugs are taken.

Psychedelic therapy was once a widely practised intervention in Western psychiatry, but was curtailed by the pharmacological revolution and the thalidomide scandal. The demise of psychedelic psychotherapy was signalled by the 1970 Controlled Substances Act. The present study’s analyses confirm the findings of other analyses that context is an essential component of the psychedelic model, and that the use of music, empathic listening and purposefully designed supportive environments can promote positive therapeutic responses.

Practicing psychedelic therapy in a hospital has transformed the entire atmosphere, and this is essential for effective treatment.

Three limitations of the present study should be noted: the study was conducted in a healthy experienced psychedelic users population, and the results do not necessarily apply to clinical population.

The EBI should be used in clinical populations to assess its ability to predict changes in clinically recognised phenomena, such as depressive symptoms and anxiety. However, the current study relied on self-reports of drugs, doses and timing, which are not as accurate as in laboratory studies.

EBs are an essential component of psychedelic-assisted therapy, and should be measured in future experimental medicine studies and clinical trials with psychedelics. Furthermore, additional quantitative measures of psychological insight should be developed to better understand the psychological and neurobiological mechanism of psychedelic-assisted therapy.