Transcript ACT on Drugs Functional Contextual Behavioral Pharmacology Dr

ACT on Drugs
Functional Contextual Behavioral Pharmacology
Dr Robert Purssey MBBS FRANZCP
Psychiatrist and ACT therapist
Clinical Senior Lecturer, Uni of Qld
www.mindfulpsychiatry.com.au
ACT on Drugs
Functional Contextual Behavioral Pharmacology:
•Transform understanding of psychiatric drugs
•Empower rational and truly informed consent
•Enable the workable use of medications
The things that you’re liable
To read in the (psychiatric ) bible
It ain’t necessarily so…
Introduction – Rob Purssey’s background
Formal training in medicine, conventional psychiatry 1982 – 2004
Clinical psychiatry work in all fields and settings 1992 – 2010
Since 2005 trained in ACT, from 2007/8 – a Functional Contextualist
Member ACBS, Healthy Skepticism, and Auspsyc email Listserves
eTOC’s of all major psychiatric / psychopharmacology journals
University of Qld and American Psychiatric Assoc library access
Sees 3-8 new patients weekly, 1:1 private rooms, and detox and
rehab setting, previously acute, perinatal, forensic, etc etc
Prescribes psychiatric medication every day in clinical practice
TAKE HOME MESSAGE
1. Change and improve your clients use of & response
to medications - Workability, Values, Acceptance
TAKE HOME MESSAGE
2. Grow the FC behavioral pharmacology evidence to
better help your clients and others taking meds
TAKE HOME MESSAGE
3. Stand with science in your own and clients’ meds
understanding and use – and access this science.
 www.mindfulpsychiatry.com.au
TAKE HOME MESSAGES
1. Change and improve your clients use of & response
to medications - Workability, Values, Acceptance
2. Grow the FC behavioral pharmacology evidence to
better help your clients and others taking meds
3. Stand with science in your own and clients’ meds
understanding and use – and access this science.
 www.mindfulpsychiatry.com.au
Change and improve your clients
use of and response to medications
1.
Psychiatric medications change neurochemistry
2.
Nothing wrong with neurochemistry to start with
3.
Real concern about longterm change in neurochemistry
NO evidence of chemical imbalance in anxiety, depression,
schizophrenia, bipolar, ADHD, PTSD, etc
Medications change neurotransmitters NO evidence that drug
induced imbalances are how they help, when they do.
Medication effectiveness exaggerated , hazards minimised.
Long-term outcomes steadily worsened in 40 years medications
widely used depression, anxiety, schizophrenia, and esp.
bipolar disorder and all behavioral disorders in children.
Change and improve your clients
use of and response to medications

Hazardous to rapidly stop any psychiatric medication

Significant hazards of long term use – outcomes / side-effects

New knowledge will contradict usual received wisdoms

Short term - may struggle more with feelings and thoughts

Guidelines carefully manipulated regarding medications

General Practitioners can’t know/access the real evidence base

Psychiatrists can’t know/access the real evidence base without
hard work, forgoing peer acceptance, refusing perks and luxuries

You / your clients should hold lightly, and tread softly, in this area
OUTLINE OF TALK

History of behavioral pharmacology – very briefly

Philosophical foundations of conventional psychopharmacology

Outcomes of conv’l psychopharmacology - scientific and clinical

Philosophical foundations of behavioral pharmacology (and
implications for a functional contextual neuroscience)

Outcomes of behavioral pharmacology - scientific and clinical

Verbal behavior - ACBS Research (Clinical Practice Collaborative)

Clinician responsibilities: clients and others – ethical, scientific

Clinical talk - hexaflex oriented middle level and other terms

Take home messages – and further research items if time… 
Hexaflex processes, useful drug effects?
Beta blockers ?less
“palpit’n, shakiness”
Contact with the
Present Moment
Heart’s desires vs
Head’s discomfort
Benzodiazepines
“relaxing warmth”
Acceptance
“sort of peek
over the wall”
Serotonin - SSRI
“serene/sanguine”
“takes edge off”
SNRI ?also
“energy/drive”
“a little more
distance”
Hazardous
Vs necessary
Values
Essential
Components
of ACT
Defusion
Antipsychotics
“who cares”
“detachment”
Lithium, “mood”
“stabilisers”???
Bodily health
Gradual wean
Committed
Action
Self as
Context
Increase adherence
In service of values
Stimulants
“focus, calming”
“tired, buzzing”
Behavioral Pharmacology
Two fundamental principles unite the field:
1. effects of drugs are lawful and subject to scientific analysis.
2. behavioral effects of drugs merit attention in and of themselves.
Behavioral pharmacologists assume that:

drugs are environmental events (stimuli -response relations),

drugs and their effects, like those of other stimuli -response relations, can
be understood (i.e., predicted and controlled with precision, scope, depth)

without recourse to reductionistic, biologistic or mentalistic explanations.
From this perspective, the study of drug effects should focus upon:
(1)
determination of behavioral loci of drug action,
(2)
determination of behavioral mechanisms of drug action,
(3)
determination of variables that modulate a drug’s behavioral effects
Behavioral Pharmacology – a history
J. R. Pappenheimer, B. F. Skinner, and P. B. Dews.
The historical context
The foundation and initial directions
of behavioral pharmacology
 1950s - the Psychobiology Laboratory at Harvard began
 behavioral context found to be a very significant influence
indeed on the behavioral effects of drug action.
The 1950’s - “Golden Age of Psychopharmacology”
 In ten years, drugs discovered, clinically introduced and
helped with schizophrenia, depression, and anxiety.
Chlorpromazine, imipramine, and diazepam influence on
treatment was tremendous
Effects of drugs on emotional states
versus the influence of context… 
1950s research effects of drugs on emotional states, the theoretical
reduction of drive states – i.e. mentalism, or cognitivism

how drugs affect presumed underlying emotional states
1955 Peter Dews - 1st major finding of Psychobiology Lab published in
The Journal of Pharmacology and Experimental Therapeutics
“hungry pigeons” – same underlying emotional state… and …
Pentobarbital affected behavior under a fixed-interval (FI) schedule
differently from behavior controlled by a fixed-ratio (FR) schedule

pentobarbital increased pecking rates under FR schedule

same dose decreased or eliminated responding under FI schedule.
Dews, P.B. Studies on behavior. I.
Differential sensitivity to pentobarbital of
pecking performance in pigeons depending
on the schedule of reward.
1955
Effects depend not only on drug, dose, and behavior, but also
on the circumstances under which the behavior is occurring:
Hungry pigeons pecking disc “to earn food”
1.
Fixed Ratio of pecks – i.e. 50 pecks – to earn food.
2.
Fixed Interval of time - i.e. 10 minutes – to earn food (lots of pecks)
Effects of Pentobarbital tested – and with intermediate doses
1.
Fixed Ratio subjects  enormous increase in pecking
2.
Fixed Interval subjects  almost complete elimination of pecking
In FR a stimulant, in FI a depressant, depending on behavioral history
NOT just drug, dose, kind of subject, and “why” doing it, but b/h history
B. F. Skinner and P. B. Dews
Implications and extensions of Dews’s work
Evaluation and interpretation of drug effects on behavior shifted
from speculation about ephemeral emotional states to quantitative
and observable aspects of behavior
 manipulable directly and testable experimentally
These effects are demonstrated quite graphically in individual pigeons,
with the effects of pentobarbital shifting rapidly dependent on context
Effects of Amphetamine also differed under FR, as opposed to FI,
schedules in a direction opposite that of pentobarbital.
Schedule-controlled behavioral research in pharmacological studies
provided insight into behavioral and pharmacological principles
Implications and extensions of Dews’s work profound – guided nature /
direction of research in behavioral pharmacology over four decades.
Classic Harvard Psychobiology Lab
demonstration – the influence of context
2 pigeons trained under Fixed Ratio 30
1 in apparatus other in holding cage
Peck peck peck in apparatus, other just sitting there
Inject each with pentobarbital dose nearly enough to cause sleep
1 in apparatus pecks even more quickly than normal, 1 in holding
cage almost asleep. Switch pigeons, and behaviors switch.
Shows effect of drugs depends not only on drug, dose, behavior, but the
environment and history IN that environment of that behavior
This visually shown dramatically with contexts so apparently close
Techniques for the Study of the Behavioral Effects of Drugs
New York Academy of Sciences
Chaired by Skinner and Dews (Annals, 1956)
EAB methods for analyzing the behavioral effects of drugs.
Impetus for a science of behavioral pharmacology resulted from:
1.
treatment of behavioral problems (i.e., psychotropic drugs) and
2.
the ubiquity and seriousness of drug abuse problems.
3.
Concern re: effects of environmental chemical contamination.
Experiential / contextual factors have a
huge influence on drug effects on behavior
Effects HIGHLY INFLUENCED by historical and present context
NO GREAT ADVANCES in exactly what about historical / present
contexts make drug effects so very different in individuals.
A few general rules, which drugs do follow, but not much…
(Marc Branch podcast, www.behaviortherapist.com )
Behavioral pharmacology in many areas synonymous with
psychopharmacology  mechanism and biologism
Biological differences exist, but… although individual neuron
function understood somewhat clearly, but…
1 Voxel in each fMRI comprise at least ½ million neurons… ?
Rule-Governed Behavior and
Human Behavioral Pharmacology
Alan Poling’s plea, 1992  RGB, help us! Verbal behavior and the
theoretical and experimental analysis of drug-related human behaviors.
Behavior analysts in 1980’s began exploring variables controlling rule
generation and rule following (e.g., Hayes, 1989). Noticing that rulegoverned behavior is operant behavior, and hence…
… varies within / across people as function of historical + current variables,
which are in the environment, hence measurable and manipulable
 Role of ACBS / RFT / ACT in furthering Behavioral Pharmacology
Assumptions, coherence, effectiveness
Behavioral
Pharmacology
Mentalistic/Cognitivistic
Psychopharmacology
Philosophy of science – why bother?
Pre-analytic assumptions explicit  owning them
Attempting to eliminate incoherence in assumptions
Rules of evidence (or criteria for truth)

used to create, assess, and evaluate knowledge
claims and theories

how otherwise to proceed effectively in science?
Coherence, less misunderstanding & pointless debate,
productive comparisons / theory evaluations
PROGRESSIVITY OF SCIENCE, BUILDING THE WORK
DIFFERENT MOUNTAINS- assumptions
FUNCTIONAL CONTEXTUALISM
MECHANISM / BIOLOGISM
Destructive Normality
Healthy Normality
Pragmatism / Aontology
Realism / Ontology
Monism
Dualism / Pluralism
(aontological)
Contextual analysis
Isolated analysis
SCIENTIST – part of process
SCIENTIST – exempt from process
What’s true is what works, and
what works is in relation to a
specified direction or goal.
What’s true is what corresponds
most closely to a measurable
reality. Direction irrelevant.
DIFFERENT MOUNTAINS – strategies
BEHAVIORAL PHARMACOLOGY
MENTALISTIC/ COGNITIVISTIC
PSYCHOPHARMACOLOGY
RELATIONAL CONDITIONING AND
RULE GOVERNANCE
HYPOTHETICAL CONSTRUCTS
RESPONDENT AND OPERANT
CONDITIONING
PHYSIOLOGICAL “actual reality” /
CORRESPONDENCE to this reality
FUNCTIONAL CONTEXTUALISM –
Aontological, monistic, pragmatic
truth (prediction and influence),
requires science values – as it is a
chosen direction
MECHANISM/BIOLOGISM –
Ontological, dualistic/pluralistic , truth
the real nature of things/universe, no
need for values – as it is simply
discovering “reality”
“How songbirds learn to sing” – choose Biologism’s Assumption - song learning
level of analysis, for chosen purposes
must take place in the brain.
Pragmatism or “Realism” – a choice
Monistic/holistic
Dualistic/pluralistic
Contextualistic
Mechanistic, non-contextualistic
Humility of only ever considering the work
as something of use for a chosen purpose
Nobility of discovery of the reality of the
way the universe is truly constructed
i.e. truth is specifically defined as the
usefulness regarding prediction and
influence, with precision, scope and depth
i.e. truth being assumed to be what things
are really like, an ever more accurate
correspondence to the reality of things
Treatment / intervention utility of the
strategy is built in to every aspect of the
work; philosophy / basic science / clinical
Treatment / intervention utility of the
strategy is a separate matter entirely
requiring a subsequent research program
Values must guide the scientific approach
Values not needed – this IS how things ARE