URGENT NEED FOR AN ALTERNATIVE

1. URGENT NEED FOR AN ALTERNATIVE “the drug effect on behavior was exquisitely related to the schedule (of reinforcement, i.e. the behavior and its context/consequences)… the schedule is,as it were, the score of the symphony… These changes are sufficient to change themusic profoundly, making slow themes intofast and soft interludes into loud, even thoughthe drugs do not affect the symphony or thequality of the instruments. (Peter Dews, 1964)

2. Behavior is a sequence of doings that occur, of necessity, in time. The schedule (of reinforcement) establishes the temporal sequencing of events and largely determines the temporal patterning of the dependent behavior. The schedule and the behavior are dynamically related. Drugs affect the equilibrium points of various transient steady states. The schedule is, as it were, the score of the symphony. Drugs given to the orchestral organism affect the tempi of the themes and the relative predominance of different sections of the orchestra. These changes are sufficient to change the music profoundly, making slow themes into fast and soft interludes into loud, even though the drugs do not affect the symphony or the quality of the instruments. (Peter Dews, Humors, Proc Am Philosophical Society 1964)

3. FUNCTIONAL CONTEXTUAL PHARMACOLOGY Functional contextual pharmacology uses methods and concepts from behavior analysis to explore and explain the behavioral effects of drugs. Behavior analysis is a unique natural science approach to the study of behavior developed by B. F. Skinner, but since then refined and clarified philosophically (Steven Hayes, Aaron Brownstein, Linda Hayes, Dermot Barnes-Holmes, Kelly Wilson, etc) Because functional contextualism forms the theoretical and methodological foundation of FC pharmacology, it deserves careful attention. Because contextual behavioral science is our foundation, likewise attention The following review may clarify possibilities, and some of the reasons for the assumptions of functional contextualism, the position taken, why our flag is planted just here. In contrast to the dead ends of reductive mechanistic biologism.

4. Assumptions, coherence, effectiveness Behavioral Pharmacology Mentalistic/Cognitivistic Psychopharmacology

5. Kelly Wilson 2001- Functional Contextualism The following are some key points and underlying assumptions of our case: 1. Formulated constructs ought to be continuous with the events within the field of purported interest. 2. The ultimate validity of constructs is reducible to the extent of improvement in orientation to the field of interest they provide (i.e., enhanced prediction and control [with precision, scope and depth]). 3. Constructs ought not be confused with the crude events with which the scientist interacts.

7. 4. Constructs are never attributed ontological validity as result of any operational successes, rather they are maintained as operationally valid. The extent of this validity may be assessed according to the metric described in proposition 2 (improvement in orientation to the field of interest – prediction and control…). 5. Divergence from the above will at best be superfluous and at worst will draw the investigator’s efforts in directions unfruitful to the advancement of a given field. Some Notes on Theoretical Constructs. Kelly Wilson 2001 International Journal of Psychology and Psychological Therapy Kelly Wilson 2001 - FC made simple - 2

9. i.e. but… the “realness” of drugs, neurotransmitters etc ??? Scientific laws (and statements about observed phenomena including drugs, fMRI’s, neurones) ... specify or imply responses and consequences. They are not ... obeyed by nature but… … by men that deal effectively with nature. The formula s = 1/2 gt2 does not govern the behavior of falling bodies… … it governs those who correctly predict the position of falling bodies at given times. (BF Skinner, 1969, p. 141)

11. Can we talk ontologically workably, and not slip into ontological mechanism? Languaging “depression” / “SSRI” / “fMRI finding of enhanced dorsolateral medial cortex activity” can becontinuous with observed client / client-clinician behavior/ verbal response / scientist response to instrument output Saying “SSRI” etc may enhance precision, scope and depth of analysing contextually client verbal response/ effective scientist behavior to instrument output andapplicability to other client behavior/experiments/aspects of experiment and other fields of interest – i.e. success in workability

12. Can we talk ontologically workably, and not slip into ontological mechanism? Naming “SSRI”ought not be confused with the crude constructs with which the clinician/ scientist is interacting i.e. client, clinician or scientist behavior in a context “depression” / “SSRI” / “fMRI finding” need not be given ontological validity, rather only effectiveness validity, i.e. improving prediction and influence of client / clinician / scientist behavior with precision, scope and depth Divergence from the above will be superfluous or harmfully distracting….  SEE ANATOMY OF AN EPIDEMIC… the failureof DSM… of neurochemical theories… the mainstream psychiatric field

14. Hank Robb – Listserve 25 Sept 2010 “Life is between the trapeze bars” The problem is a non-unitary assumption. You can't really "prove" the non-dualistic approach except to point out all the messes and dead ends you end up with nottaking it - "Maybe so," agree the dualists… "But that is just how things are! The problems that flow from dualism are just too bad and it's just HOW THINGS ARE!” From a functional contextualist view, in the end, there's nothing ontologically that you can "hang on to." Life (and science) is an "act of faith up in the air” how it works for a chosen purpose

15. Pragmatism or “Realism” – a choice

16. IntegratingPsychological / NeurobiologicalLevels in Contextual Behavioral Science The Psychological Level The study of whole organisms acting in and with a context considered historically and situationally The Neurobiological Level The study of the nervous system of organisms in reaction to external and internal events and in relation to behavior

17. Integrating psychological and neurobiological in CBS  in ACT / BA / FAP clinical practice The dangers of moving across levels without care: Hiding ignorance in concrete knowledge at other levels of analysis – “we ‘know’ what this scan / chemical etc does” The appeal of reductionism – “that’s ‘why’ it changes behavior” The possibilities of research / clinical behavior across levels of analysis: Seeing / acting clinically on consistent processes An integrated fabric of science and clinician practice

18. The Vision of Contextual Neuroscience= the vision of behavioral pharmacology Place neurobiological evidence inside a larger effort understanding situated actions of whole organisms, focusing on the depth of psychological processes known to be important Including especially transformative human verbal processes, i.e. arbitrarily applicable derived relational responding  RFT = leaving the animal lab for behav pharma ???

19. Assumptions, coherence, effectiveness Behavioral Pharmacology Mentalistic/Cognitivistic Psychopharmacology

21. Environmental influence on lethality of heroin in rats – and humans Lethality of large dose of heroin in 3 groups of rats: 2 groups made dependent/tolerant over 30 days, and 1 control group 2 different environments – animal’s colony, and “white noise” room. 15mg/kg then given to all 3 groups and results as follows: 96% lethality - Control group 64% lethality - Novel environment to that of tolerance 32% lethality - Same environment as that of tolerance

22. Environmental influence on lethality of heroin in rats – and humans Siegel et al. 1982 “Heroin ‘overdose’ death: Contribution of drug-associated Environmental cues.” Science.

23. The situational specificity of tolerance Implicated in unexpected overdose deaths due to: • Opioids • Alcohol • Pentobarbital Relevant to understanding and preventing enigmatic overdoses in clinical practice. Eg - In the present study, all three overdose deaths could reflect this mechanism, as it is unlikely that these patients normally injected on staircases or public house toilets. Deaths of heroin users in a general practice population. Bucknall and Robertson, J R Coll Gen Pract. 1986

24. Animal model antipsychotic screening Pole climbing procedure - rats placed in a chamber with metal grid floor that can be electrified. A wooden pole protrudes upward from the floor. Occasionally, a tone sounds for a brief period, after which a shock is delivered to the grid.The rat can… escape from the shock by climbing the pole after the shock starts, or avoid it by climbing during the tone. Neuroleptics interfere with avoidance responding at doses that do not affect escape responding;  other drug classes fail to do so.

25. Pole-jump procedure – “drive-reduction” i.e. cognitivist vs behavioral interpretations Usual interpretation waschlorpromazine selectively decreasedfear and anxiety without altering response to pain. Emphasis on functional control rather than hypothetical motivational constructs - Dews and Morse 1961 Differences in the stimulus control over the avoidance and escape behaviorsescape under a high stimulus control by shock (high probability in presence of shock) avoidance behavior under weaker discriminative control (relatively lower probability of occurrence compared to the escape) Behavioral mechanism of action of chlorpromazine was to decrease stimulus control

26. Pole-jump procedure – behavioral interpretations - implicatons Dews and Morse commented on early interpretations of clinical efficacy of psychotherapeutic drugs based on an alleviation of fear and anxiety: Researchers have done so due to impression that they are useful clinically, especially in reducing the reactions to aversive stimuli and situations. However, few people consult physicians because their work has too much fascination for them, or because they enjoy their play too much; the people to whom the drugs are given most frequently are by no means a representative sample of the general population. The drugs might be just as effective in alleviating fascination and enjoyment.  Dramatic effects of the drugs is in quieting manic psychotics in most of whom no reason to infer aversive stimulation as a cause of hyperactivity

27. Pole-jump procedure – behavioral interpretations – clinical implications Behavioral mechanism of action of chlorpromazine was to decrease stimulus control (= seroquel/zyprexa) Antipsychotics – a “who cares” feeling – David Healy “…detachment, less bothered, less distracted by internal dialogues, strange thoughts or intrusive imagery. Voices, thoughts or obsessions still present, but receded from centre stage..” “alleviating fascination and enjoyment”… negative symptoms? “neuropharmacological-neurotoxic factors” might be causing “cognitive deficits in bipolar disorder patients.” “As few as 1/3 of BPD patients achieve full social and occupational functional recovery to their own premorbid levels.” “depressive episodes” and “lower functional recovery”

28. Conditioned effects of drugs US + CS Lethality of heroin in rats – the situational specificity of tolerance Conditioned immunosuppression demonstrated in rats Conditioned nausea in patients receiving chemotherapy “Needle freaks” – extensive IV users find injection itself pleasurable DRUGS ACQUIRE STIMULUS PROPERTIES THROUGH CONDITIONING, AND AFFECT B/H IN ABSENCE OF CONDITIONING i.e. drugs are US and also CS – and effects will change over time. DRUGS ARE STIMULI AND THEREFORE PRODUCE EFFECTS WHICH DIFFER AS A FUNCTION OF THE CONDITIONS UNDER WHICH THEY ARE, AND HAVE BEEN, ADMINISTERED

29. Rate-dependent drug effects Amphetamines – at low to moderate doses: Increase low-rate operant responding Reduce high-rate operant responding ADHD – may be inattentive, others overactive. Dexamphetamine calms manic patients - temporarily Effects of stimulants depends on the baselinelevel of activity of person to whom they are given. Dews lab 1950’s showed these effects “Paradoxical effects of psychomotor stimulants” Robbins and Sahakian Neuropharmacology 1979

30. Verbal behavior and drug effects Experiment with instructions and nicotine altered behavioral responses to gum – Hughes et al 1985 & 1989  Rules can significantly influence both the quantitative effects and qualitative effects of active drugs and placebos Verbal mediation – learned behavior – often plays a role in determining the effects of abused and other substances However very few studies in this area – and transformation of stimulus functions not considered by any researchers… yet! Drug behavioral effects are rarely simple, but are lawful!

31. Verbal behavior and drug effects ACT &Substance Use Disorders Functional assessment / treatment – Kelly Wilson’s work, books Understanding Behavior Disorders chapter – Kathleen Palm Acceptance, defusion: altering context of aversive/strong appetitives Values: bring longer term valued consequences into present moment SAC / CPM empowering all of above, and “we’re all in this together” Also CRAFT, 12 Step, disulfiram, buprenorphine, naltrexone, etc. An RFT enhanced behavioral model provides a unifying and experimentally testable approach.

32. 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.

33. 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 inferential statistics comparing groups. 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

34. 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…