Day trip to hell: A mixed methods study of challenging psychedelic experiences

Psychedelics produce powerful alterations in perception, emotion and cognition and have attracted renewed research interest for therapeutic effects in conditions such as depression, anxiety and substance dependence. Earlier work has emphasised certain recurring features of challenging psychedelic experiences, most notably fear associated with ego dissolution; scales such as Dread of Ego Dissolution (DED) and a seven-factor questionnaire of difficult psilocybin experiences have been proposed to capture these phenomena. However, some commentators have argued that these instruments and the prevailing ‘‘set and setting’’ framework may underspecify the variety of adverse or challenging experiences and their causes. Petter and colleagues set out to broaden understanding of so-called ‘‘bad trips’’ by exploring their phenomenology, antecedents and self-assessed consequences using a mixed methods design. The study combined asynchronous, Internet-mediated interviews with 38 current or past psychedelic users and a larger anonymous online survey of 319 participants, with hypotheses that challenging experiences have a wider thematic range than previously reported, that set and setting are important but not decisive, and that long-term consequences tend to be rated positively by respondents.

The qualitative component comprised two phases of asynchronous, Internet-mediated interviews. In phase one 26 users with experience of psychedelics in spiritual contexts were interviewed about a broad range of issues; in phase two 12 additional participants were recruited specifically because they had posted accounts of challenging experiences online. Participants provided informed consent, anonymity was emphasised, and thematic analysis combined with meaning condensation was used to generate exploratory, data-driven themes. Some publicly posted ‘‘bad trip’’ reports informed the study but were not quoted to preserve privacy. The quantitative component used the Cannabis and Psychedelics User Survey, developed from themes emerging in the interviews and piloted with 18 volunteers. The survey was available April–September 2019 and recruited self-selected adults (18+) proficient in English from seven online communities and groups. Inclusion required prior experience with a commonly used psychedelic; women were especially invited. The final analytic sample comprised 319 participants after exclusion of empty or inconsistent responses. Survey measures captured demographics, religious/spiritual background and practice, drug use history for a specified psychedelic (participants selected one from a list including psilocybin, LSD, DMT, ayahuasca, mescaline, MDMA and others), motivations for use, and emotional, cognitive and relational characteristics of a typical and of the respondent’s worst psychedelic experience. Personality was measured with a five-point Ten-Item Personality Inventory (TIPI). Risk propensity was assessed using a modified five-item Risk Taking Index (RTI) with the substance-use health-risk item removed. For inferential analyses, the investigators constructed an additive ‘‘absolute difficulty’’ indicator by summing eight negatively worded characteristics (anger/hate; confusion; disgust; fear; feeling isolated from others; regrettable behaviour towards others; sadness; violent behaviour), yielding a 0–8 range. Ordinal regression models tested predictors of absolute difficulty and of relative difficulty (worst psychedelic experience ranked against other difficult life events). A linear regression tested predictors of respondent-assessed long-term consequences (five-level Likert). Independent variables included demographics, the Big Five traits, meditation/prayer/energy-work practice (dichotomous), years of cannabis experience, lifetime occasions of the chosen psychedelic, typical social environment for use, session planning horizon, and escapist motivation. Ordinal variables were treated as continuous and analyses used IBM SPSS Statistics 25. Nagelkerke R2 was reported to indicate explained variance in the ordinal models.

Interview participants numbered 38; 30 supplied minimal demographic data (28 male, 2 female), median age in the mid-30s and a range from early 20s to late 50s. Occupations and relationship statuses varied. Thematic analysis of interview narratives produced a wide array of challenging experience types rather than a single defining category. Major themes from the interviews included: ‘‘life issues’’ (unpleasant insights or confrontations with personal problems, sometimes leading to change); social paranoia (beliefs that others disapproved or that authorities would intervene); troubling visions or hallucinations (including menacing entities, especially reported by DMT users); mental and sensory overload (confusion and an inability to think straight); ego death or dissolution (experienced variably as terrifying during the process but sometimes ecstatic once complete); fears of lasting mental or physical damage (including panic about brain damage or death, sometimes following drug combinations/overdose); time distortions and ‘‘loops’’ producing sensations of endless repetition; and rare episodes involving violent or regrettable behaviour with real-world consequences. Interviewees also described strategies for ‘‘finding the way back’’ such as sharing accounts on peer forums, returning to ordinary routines, reassurance by trusted others, and use of breathing or meditation techniques to re-centre the experience. The survey sample comprised 319 included participants (213 completed the full survey). The typical respondent was male, aged 32, with some university education and working full time; most were located in North America. Psilocybin was selected as the focal drug by 49% of respondents, LSD by 22% and DMT by 12%. Median recent use of the chosen psychedelic was between 1 and 10 occasions in the past 12 months; 7% reported 11–50 occasions and 2% reported twice weekly or more. When comparing respondents’ worst psychedelic experience to a typical experience, 23 of 24 emotional/cognitive/relational characteristics differed significantly; ego dissolution was the single exception. The eight negatively worded items were endorsed at higher levels for the worst experience and formed the additive ‘‘absolute difficulty’’ score, which had a mean of 2.7 (SD 1.8). Fourteen per cent endorsed none of the negative characteristics for their worst experience, while 17% reported five or more negative characteristics. On a relative scale comparing the worst psychedelic episode to other life difficulties, 6% rated it the most difficult experience of their life and 17% placed it among their five most difficult experiences; at the other extreme 26% compared it to an everyday or not difficult experience. The ordinal regression for absolute difficulty produced a Nagelkerke R2 of 0.34. Older age and higher education were associated with lower difficulty. Female gender and the personality trait Emotional stability (i.e. lower neuroticism) also predicted fewer negative characteristics. Meditation practice was associated with increased difficulty, whereas energy-work practice marginally reduced difficulty. Greater lifetime occasions of the chosen psychedelic predicted higher difficulty; by contrast, more years of cannabis experience predicted lower difficulty. An escapist motivation for use also predicted greater difficulty. The relative-difficulty model had a Nagelkerke R2 of 0.24 and largely replicated these findings; it additionally identified the personality trait Openness as predicting relatively more difficult experiences. Neither model found the respondent’s typical social environment for use nor the typical planning horizon to be significant predictors, though these variables reflected usual practice rather than the specific setting for the worst session. Regarding long-term consequences, more than 67% of respondents judged the consequences of their worst psychedelic experience to be positive or mostly positive, while fewer than 4% judged them negative or mostly negative. There were no significant correlations between either absolute or relative difficulty and the assessment of long-term consequences. A multivariate linear regression predicting long-term consequences achieved an adjusted R2 of only 0.05; only Openness predicted more positive consequences, and escapist motivation predicted more negative consequences.

Petter and colleagues interpret their findings as supporting the hypothesis that challenging psychedelic experiences exhibit a broader thematic range than previously described. Fear emerged as a central and pervasive feature across types of difficulty, encompassing fear of ego dissolution, death, insanity, social rejection and other forms of existential dread. Confusion was also highlighted as a prominent characteristic, endorsed by 62% of survey respondents and strongly correlated with ego dissolution measures. The interviews added further nuance by identifying themes such as social paranoia, troubling entity encounters, mental/sensory overload, time-loop phenomena and occasional violent or regrettable behaviour. The authors argue that ego dissolution, while frequent, was not unique to worst experiences and may sometimes protect against other fears; thus it should not be treated as the sole defining feature of ‘‘bad trips’’. Similarly, they find partial correspondence with earlier seven-category taxonomies but suggest those categories may be under-defined and miss important dimensions such as confusion and behavioural outcomes. In terms of etiology, set and setting retained importance in narratives but did not emerge as decisive predictors in the quantitative models; typical social environment and session planning did not predict difficulty, although the authors note that these survey items captured usual practice rather than conditions for the specific worst episode. A paradoxical association between meditation practice and greater reported difficulty was observed and discussed: meditators may either penetrate more deeply into challenging material or be more attentive to and able to label difficult mental states, producing higher endorsements of negative characteristics. The authors suggest this is a promising area for further research. Other notable predictors included lower difficulty with increasing age and education, reduced difficulty among females and those high in Emotional stability, and increased difficulty associated with greater lifetime psychedelic occasions and an escapist motivation for use; years of cannabis experience were associated with reduced difficulty. With regard to outcomes, the majority of participants reported positive long-term consequences from their worst psychedelic experience, consistent with prior surveys; nevertheless a minority reported negative or mixed outcomes and the authors acknowledge that beneficial effects may depend on the capacity to integrate the experience. Limitations are acknowledged: recruitment via online psychedelic communities produced self-selected participants, the sample was male-dominated and relatively well educated, and the study emphasises current or recent users who may view psychedelics favourably. The authors therefore caution about generalisability and encourage further research using broader and more representative samples, as well as deeper investigation of meditation practices and integration supports.

These exploratory mixed methods studies expand the phenomenology of challenging psychedelic experiences beyond previously established categories, emphasising fear and confusion as central elements and drawing attention to occasional behavioural consequences. Most respondents judged long-term outcomes to be positive despite often intense acute difficulty. The authors highlight the unexpected association between meditation practice and increased reported difficulty as an area for future work, and underscore limits to generalisability stemming from online, self-selected recruitment.