Download Functional Contextual Pharmacology #4

But my patients are already
taking these medications…
What am I then to do?
How may I best serve them?
When might these possible
effects be of benefit to them?
Can the hexaflex help me here?
Hmmm, help me speculate a little…
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”
ROLE OF THERAPIST / CLINICIAN
Arguing for or against psychotropic drugs is as silly as
arguing for or against rain.
Psychotropic drugs, like rain, can be helpful, harmful,
or inconsequential, depending on the specific
circumstances – i.e. behavior and context
Everyday drug evaluations may ensure that treated
individuals actually benefit from their medications.
Maximizing the likelihood that they do so requires
that caregivers meet three provisions.
CLINICIAN - 3 intervention provisions
1.
The goals of treatment are clear and in the
treated individual's best interests.
2.
Drug effects are adequately monitored and
treatment decisions are made on the basis of
real drug effects – i.e. behavioral mechanisms,
not unrelated neurochemical mechanisms.
3.
Drug therapy is flexible and integrated with
nonpharmacological interventions, including
applied behavior analysis – i.e. ACT/BA/FAP
Behavioral effects of drugs – Usefulness
for patients? Useful ways of speaking?
Neurochemical effects of a drug predict of some, but by no
means all, of the behavioral effects of these drugs.
Behavioral mechanisms of explaining drug actions offer a
viable alternative – one with more scientific support
? Potential, in the absence of any clear empirical guidance,
of analysing behavioral drugs in language of core hexaflex
processes – which are middle terms, behaviorally.
In due course, clearer guidance with re-emergence of
Functional Contextual Pharmacology informed by
RFT, and further EAB – eg ACBS Practice Research Network
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”
SSRI and SNRI
“…these medications can allow you to sort of peek over the wall
and tell you a little bit about what it might be like if you
weren’t drawn into a struggle with these private experiences”
... Interview with Steve Hayes in Common Ground magazine
When SSRI’s work … more mellow, more docile, and more
serene or sanguine. In some … complaints of emotional (or
sexual) blunting or numbness…
(Nor)adrenergic system, when appreciated, a useful sense of
increase in energy and drive. All these effects were visible
within 48hours. Tranter, Healy et al Psychol Med 2002
Hence SSRI’s in mild depression and anxiety,
And SNRI in more severe depression?
Antipsychotics – a “who cares” feeling
Antipsychotics - a feeling of detachment, of being less
bothered - benefit on focus, concentration, less distracted by
internal dialogues, strange thoughts or intrusive imagery.
Voices, thoughts or obsessions may well still be present, but
appear to have receded from centre stage.
Broadly, more antipsychotic gives more of a “who cares”
feeling up to a certain level, just as more coffee gives more
of a stimulating effect – up to a certain level…
Just as aspirin may help a range of conditions, so may
antipsychotics if used carefully help psychosis, anxiety,
impulse control, etc and vomiting, itching, coughing…
Benzodiazepines & Anxiety
Benzodiazepines give a relaxing warm glow, very much like
alcohol. There is a sense of muscular release and a soothing
feeling that most people describe as pleasant. After 2000
years of trying to improve on alcohol, in some ways, success!
Benzodiazepines best in anxiety states that have a significant
muscle tension or dissociative component.
Antipsychotics best if distraught and agitated anxiety
Beta Blockers best if tachycardia, palpitations, shaky anxiety.
The above is quite approximate – and given the
number of these drugs prescribed, is a major
indictment of the way we develop drugs at present.
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
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
Research in Clinical Practice - ACBS
The Research in Clinical Practice Collaborative is designed to bridge the
gap between clinical practice and applied science.
Our mission is to help members gather data that informs clinical decision
making and that contributes to research.
1.
Empower and support clinicians in utilizing research methods
2.
Develop procedures and routines to give session-by-session feedback to
track both client progress and our own progress as therapists.
3.
Identify a list of questions that clinicians would like answers to so that
treatment development and training prioritize these solutions.
4.
Develop strategies to collect and utilize effectiveness data to inform
treatment development, protocol modification (examining mediators,
moderators),increase efficiency, promote dissemination and training.
5.
Develop a set of practical tools.
Behavior-Analytic Drug Studies
1). Studying, intensively, a few (usually fewer than five)
participants with well defined characteristics.
2). Using within-subject (e.g., multiple-baseline across
participants, withdrawal) experimental designs.
3). Defining target behaviors carefully and using direct and
repeated measures to quantify them.
4). Analyzing data through visual inspection of figures
depicting each participant's responding, not through
inferential statistics comparing group performance.
5). Socially validating acceptability of goals, procedures, and
results of intervention for clients and care providers.
Social validation implies emphasis on clinical, not experimental
or statistical, significance of obtained effects
Essential features of EAB research
1.
Behavior is important in its own right
2.
Intensive study of a few subjects is generally fruitful
3.
Visual (graphic) analysis of data is desirable
4.
Direct and repeated measures of behavior are invaluable
5.
Variable data are best dealt with by isolating and
controlling the responsible extraneous variables
6.
Study of nonhuman subjects under controlled
experimental conditions can be of great value
Drugs as Stimuli (same as any other)
Drugs as Interoceptive Stimuli - “no fundamental difference in
behavioral functions of interoceptive & exteroceptive stimuli”
“interoceptive stimuli can belong to the same functional class
as exteroceptive stimuli”
“drug effects are fundamentally (behaviorally) lawful, although
they also are a function of many interrelated variables”
“therefore, one should be cautious in interpreting
experimental results, and in making or accepting…
… simple statements about any drug’s behavioral effects”
Healthy Skepticism proposals
Pharmaceutical companies currently have four main functions:
manufacturing, research, promotion, and education.
Performance of those functions is currently distorted by incentive
systems that reward only activities that increase sales of more
expensive drugs regardless of the impact on health care.
We recommend that these functions be paid for separately by govt
agencies via iterative open competitive public tender.
Relevant divisions and subcontractors of pharmaceutical
companies to compete with universities and other non-profit
organisations for funding to provide each function separately.
Healthy Skepticism proposals
Incentives can then to be aligned to reward quality
performance at each function separately.
If a company performed poorly, e.g., committed research fraud
or provided misleading promotion, then it would not get
funding for that function in the next tender round.
Drug prices would no longer include a premium for research,
promotion, and education.
Consequently, drug companies would no longer fund those
functions from drug sales.
Lower prices would make drugs more cost-effective for
larger numbers of people.