But my patients are already taking these medications… What am I then to do?

1. 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…

2. Hexaflex processes, useful drug effects? Beta blockers ?less “palpit’n, shakiness” Heart’s desires vs Head’s discomfort Benzodiazepines “relaxing warmth” Hazardous Vs necessary Serotonin - SSRI “serene/sanguine” “takes edge off” “sort of peek over the wall” Bodily health Gradual wean “a little more distance” SNRI ?also “energy/drive” Increase adherence In service of values Antipsychotics “who cares” “detachment” Stimulants “focus, calming” “tired, buzzing” Lithium, “mood” “stabilisers”???

3. 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.

4. CLINICIAN - 3 intervention provisions • The goals of treatment are clear and in the treated individual's best interests. • 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. • Drug therapy is flexible and integrated with nonpharmacological interventions, including applied behavior analysis – i.e. ACT/BA/FAP

5. 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

6. Hexaflex processes, useful drug effects? Beta blockers ?less “palpit’n, shakiness” Heart’s desires vs Head’s discomfort Benzodiazepines “relaxing warmth” Hazardous Vs necessary Serotonin - SSRI “serene/sanguine” “takes edge off” “sort of peek over the wall” Bodily health Gradual wean “a little more distance” SNRI ?also “energy/drive” Increase adherence In service of values Antipsychotics “who cares” “detachment” Stimulants “focus, calming” “tired, buzzing” Lithium, “mood” “stabilisers”???

7. 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?

8. 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…

9. 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.

10. 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

11. Change and improve your clients use of and response to medications Psychiatric medications change neurochemistry Nothing wrong with neurochemistry to start with 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.

12. 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 manipulatedregarding medications • General Practitionerscan’t know/accessthe real evidence base • Psychiatrists can’t know/accessthe 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

13. 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

14. 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. Empower and support clinicians in utilizing research methods Develop procedures and routines to give session-by-session feedback to track both client progress and our own progress as therapists. Identify a list of questions that clinicians would like answers to so that treatment development and training prioritize these solutions. Develop strategies to collect and utilize effectiveness data to inform treatment development, protocol modification (examining mediators, moderators),increase efficiency, promote dissemination and training. Develop a set of practical tools.

15. 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

16. Essential features of EAB research Behavior is important in its own right Intensive study of a few subjects is generally fruitful Visual (graphic) analysis of data is desirable Direct and repeated measures of behavior are invaluable Variable data are best dealt with by isolating and controlling the responsible extraneous variables Study of nonhuman subjects under controlled experimental conditions can be of great value

17. 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”

18. 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 agenciesviaiterative 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.

19. 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.