Emotional breakthrough and psychedelics : Validation of the Emotional Breakthrough Inventory
Leor Roseman, Eline Haijen, Kelvin Idialu-Ikato, Mendel Kaelen, Rosalind Watts and Robin Carhart-Harris
Journal of Psychopharmacology, 2019, 1–12
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 dosedependently, 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.
Keywords : Psychedelics, catharsis, emotion, therapy
Psychedelic therapy is a re-emerging paradigm within mental health research (Schenberg, 2018). It is hypothesised that both biological and psychological processes play a role in this treatment, potentially working synergistically to determine therapeutic outcomes (Carhart-Harris, 2018; Carhart-Harris et al., 2017b). From a purely psychological perspective, most studies to-date have focused on the involvement of the mystical-type experience in determining long-term responses to psychedelics (Bogenschutz et al., 2015; Dakwar et al., 2014; Erritzoe et al., 2018; Garcia- Romeu et al., 2014; Griffiths et al., 2016; Johnson et al., 2016; Klavetter and Mogar, 1967; Kurland et al., 1972; MacLean et al., 2011; O’Reilly and Funk, 1964; Pahnke et al., 1970; Richards et al., 1977; Roseman et al., 2017; Ross et al., 2016) and see
Stace (1960) for some classical texts relevant to the mystical experience. Influential measures used to operationally define the mystical experience include factors within the altered states of consciousness questionnaire (Dittrich, 1998; Studerus et al., 2010) and the more recently validated Mystical Experience Questionnaire (MEQ) (MacLean et al., 2012; Pahnke and Richards, 1966). It is now a well-replicated finding that the quality of the acute psychedelic experience is a key determinant of longer-term responses to psychedelics – and the mystical type experience seems to be relevant and important in this regard. However, this does not imply that the construct is well-defined, or that it is the sole, or indeed, primary determinant of long-term psychological outcomes.
Another key component of the acute psychedelic experience that has been found to be influential in determining long-term responses is the challenging experience (CE) (Barrett et al., 2016). Perhaps the best available tool for measuring CEs is the recently validated Challenging Experience Questionnaire (CEQ). This scale was developed with the intention of quantifying challenging emotions such as grief, fear, paranoia, etc. (Barrett et al., 2016). Recent studies have suggested that higher scores of the CEQ and other measures of CE can predict worse longer-term mental health outcomes, thus suggesting that CE might be counter-therapeutic and perhaps even iatrogenic (Barrett et al., 2016; Carbonaro et al., 2016; Haijen et al., 2018; Roseman et al., 2017), although there are some contradictory findings in this regard, suggesting a more complex relationship (Barrett et al., 2016; Carbonaro et al., 2016). A major limitation of the CEQ however, is that it measures different challenging emotions and/or memories without addressing their potential resolution, and consequently is not able to quantify the potential clinical value of accepting and/or overcoming the relevant challenges (Watts et al., 2017).
Here, we endeavoured to examine 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 phenomenon of emotional breakthrough (EB) overlaps to some extent with the psychoanalytic notion of catharsis (Breuer and Freud, 1895; Jackson, 1994). We call the questionnaire we have constructed and validated here, the Emotional Breakthrough Inventory (EBI). Unlike the CEQ, which appears to be a ‘negative’ predictor of clinical outcomes (i.e. higher CEQ scores predict worse mental health outcomes), we theorised that EBI would serve as a positive predictor of mental health, i.e. higher scores would predict better mental health outcomes such as increases in well-being. The development and use of the EBI in intended to supplement the use of the CEQ and MEQ and motivate further critique of all of three measures and the real-world phenomena they are intended to capture.
The most often-used approach in modern psychedelic therapy trials has its basis in work advanced by the collaboratory effort of Al Hubbard, Humphry Osmond and Abram Hoffer in the 1950s (Dyck, 2006; MacLean et al., 1961; Osmond, 1957). The focus of the so-called ‘psychedelic’ model is to use relatively high doses of a given psychedelic to promote the attainment of a powerful self-transcendent state that may be positively transformative in effect. The other major alternative therapeutic model, is the socalled ‘psycholytic’ (mind-loosening) model. This approach used lower doses of a psychedelic in concert with psychoanalytically oriented psychotherapy. Despite differences, mainly related to dose and number of sessions (i.e. higher doses but fewer sessions in psychedelic therapy), both of the psychedelic and psycholytic models emphasised the importance of emotional release. One early account of Lysergic Acid Diethylamide’s (LSD) therapeutic action stated that drug works to break emotional or memory blocks and ‘in almost every case… terminates in psycho- catharsis, [causing] the patient to experience an exhilarating feeling of liberation’ (Frederking, 1955: 263). Other psychedelic therapists, with allegiances to varying psychoanalytic schools, shared this appreciation of the importance of EB (Bonny and Pahnke, 1972; Cohen, 1959; Crocket et al., 1963; Eisner and Cohen, 1958; Fisher, 2015; Grof et al., 1980; Jensen, 1963; Katzenelbogen and Fang, 1953; Leuner, 1961; Martin, 1957; Richards, 2015; Sandison, 1955), and patients often make special reference to it in post-treatment reports (Belser et al., 2017; Gasser et al., 2014; Watts et al., 2017). EBs are often accompanied by and related to personal and interpersonal insights, and are therefore not necessarily transpersonal in the same way – or to the same extent – that mystical-type or peak experiences appear to be (Belser et al., 2017; Gasser et al., 2014; Grof, 1975;
Loizaga-Velder, 2013; Richards, 2015; Watts et al., 2017).
The present study sought to develop and validate a brief EBI that is focused and concise in nature. Specifically, we assessed its internal, convergent, divergent and predictive validity. This was done using an online prospective survey in which participants answered questionnaires before and after drug intake in their own environment rather than e.g. in a laboratory. The sample was self-selecting and comprised mostly of healthy individuals, thus, to combat the issue of floor effects, a well-validated measure of psychological well-being was used as the primary dependent variable and index of post-psychedelic change in psychological/emotional health. We hypothesised that :
○ H1: Scores on the EBI will increase in a dose-dependent
○ H2: A therapeutic context (therapeutic intention before
drug intake and a therapeutic setting) will be associated
with higher EBI scores.
○ H3: EBI scores will significantly discriminate from MEQ
and CEQ scores.
○ H4: EBI will predict changes in well-being.
○ H5: A model incorporating EBI, MEQ and CEQ will predict
changes in well-being, with EBI performing at least
as well as the MEQ and CEQ.