Is Insight the Ultimate Predictor of Therapeutic Outcomes?
A new psychometric tool called the Psychological Insight Questionnaire (PIQ) might be even more indicative of therapeutic improvements than the Mystical Experience Questionnaire.
The Mystical Experience Questionnaire (MEQ) might be the most famous indicators of positive therapeutic outcomes following psychedelic experience — a matter well illustrated in the work going on at Johns Hopkins for several years now. So much so that despite the scale’s shortcomings (some of which you can learn about in Alex Belser’s terrific talk, The Psychedelic Mystical Experience), Imperial College London finally conceded to using it in some cases after great initial resistance.
Yet positive outcomes following psychedelic-assisted psychotherapy were recently observed in the absence of mystical experience, Davis and colleagues point out, citing Roseman et al. (2018).[1]
Insight “as a general construct,” though, “keeps popping up,” Davis tells me — including “single item insight questions in our depression trial and other survey work.”
Others such as Garcia-Romeu et al. (2019),[2] Roseman et al. (2018, 2019),[1][3] and Studerus et al. (2010)[4] have also examined psychedelic insight. In particular, the Emotional Breakthrough Inventory (EBI)[5] was found to predict improved outcomes for alcohol use disorder and depression from psychedelic-assisted therapy.
The use of altered states of consciousness for gaining insight is nothing new, mind you. Take, for instance, Jacques Joseph Moreau, author of the first book written about a drug by a scientist, Du Haschish et de l’Alienation Mentale: études psychologiques (Hachisch and Mental Illness), published in 1845.[6] Moreau, known for his central role in Le Club Des Hashischins, wrote, based on controlled experiments with his patients, that oral doses of hashish (the concentrated form of cannabis) could help treat mental illness by revealing its origins through introspection and observation. But noticing chronic users becoming lethargic and anhedonic, he warned of the consequences of habitual use.
Yet unlike cannabis, research has found that classical psychedelics like psilocybin have a markedly lower abuse potential. Moreover, the kinds of psychedelic insights being investigated these days aren’t limited to the kind of psychotomimetic introspection suggested by Moreau in the 1800s.
In modern psychometric questionnaires designed to quantify specific facets of psychedelic experience (including the EBI,[5] the Altered States of Consciousness questionnaires (5D- and 11D-ASC),[7][4] and the Persisting Effects Questionnaire (PEQ)), items that relate to insight are few and generally capture trait insight, feelings of insightfulness, and emotional catharsis associated to insight about emotional capacity, but not what’s called discrete event-related insight, Davis et al. say; those tools don’t capture specific insights like realizations and awareness about relationships, past events, goals, values.
That’s why Davis and the team began discussions with their psilocybin session facilitators to find what kinds of insights patients described following their sessions. The kinds of insights reportedly experience by participants included realizations and discoveries about personality, about relationships, about memories, beliefs, behavioural patterns, and their emotions.
They ended up with 23 items (rated from “1 – Not at all,” to “5 – Extremely. More than ever in my life”) in two components: Avoidance and Maladaptive Patterns (AMP), including items like “discovered how aspects of my life are affecting my well-being,” and “realized how current feelings or perceptions are related to events from my past,” as well as Goals and Adaptive Patterns (GAP), including items like “awareness of beneficial patterns in my actions, thoughts and/or feelings,” and “discovered new actions that may help me achieve my goals.”
They then tested the PIQ on a sample of internet users and also measured life-satisfaction/well-being and psychological flexibility by co-administering the Satisfaction with Life Scale (SWLS) and the Acceptance and Action Questionnnaire II (AAQII). They simultaneously assessed acute psychedelic experience using the abbreviated Mystical Experience Questionnaire (MEQ-30), and the Challenging Experience Questionnaire (CEQ).
In this sample (n=1661), they found evidence for the PIQ’s psychometric reliability and validity in assessing psychedelic-induced psychological insight.
What’s really notable, though, is that scores on the PIQ were more strongly correlated with retrospective improvements in psychological flexibility and well-being/life satisfaction than those of the MEQ.
I asked Dr. Davis how surprised they were about this finding:
“I agree that it’s very interesting that the PIQ is outperforming the MEQ in predicting outcomes […] I think it was only surprising because the MEQ had been so widely studied; however, from a clinical standpoint I can see how insight could be very valuable for longterm outcomes. And when they co-occur perhaps even more so.”
Additionally, scores on the PIQ were not substantially correlated with those of the Challenging Experience Questionnaire (with factors for fear, grief, distress, isolation, paranoia, and sense of dying), suggesting “that, despite any difficulties associated with insight experiences, these experiences were not necessarily interpreted as being substantially challenging.”
Of course, there are several limitations. Future research in clinical and laboratory settings will be needed to strengthen the scale’s predictive validity. And “selection bias is always an issue,” Davis reminds me; the usual things that come with online survey takers, like the predominant young white male respondents, mean more data is needed to generalize the findings. But, he tells me, “we have now replicated the finding (manuscripts under review) in other populations using the PIQ.”
For the time being, the Psychological Insight Questionnaire looks promising. And as for Davis and the team,
“We are very excited about producing this measurement tool and the implications that may have for the field.”
The study, “Development of the Psychological Insight Questionnaire among a sample of people who have consumed psilocybin or LSD,”[8] was published in January 2021 in the Journal of Psychopharmacology, and was co-authored by Fred Barrett, Sara So, Natalie Gukasyan, Thomas Swift, and Roland Griffiths. It can be read in full on ResearchGate.