CONTEXTUAL MEDICINE SIG INAUGURAL SYMPOSIUM ACBS World Conference 11 Sydney Australia 2011 Rob Purssey Functional Contextual Psychiatrist Kelly Wilson Contextual Behavioral Scientist Julian McNally Psychologist, ACT Therapist Tony Biglan Contextual Behavioral Scientist - discussant (FUNCTIONAL) CONTEXTUAL
MEDICINE - strategy, history, purpose, progress Dr Robert Purssey MBBS FRANZCP Functional Contextual Psychiatrist Clinical Senior Lecturer, Uni of Qld Brisbane ACT Centre, Queensland (FUNCTIONAL) CONTEXTUAL MEDICINE - strategy, history, purpose, progress An approach that satisfies scientists and practitioners
David Hume Peter Dews Steven Hayes Ernst Mach BF Skinner Stephen Pepper Linda Parrot Hayes Kelly Wilson Dermot Barnes-Holmes Unites biological,
cognitive and behavioral along with evolutionary science Opens exciting avenues in our ability to understand how people work, & help them. JR Pappenheimer, BF Skinner, PB Dews (FUNCTIONAL) CONTEXTUAL MEDICINE - strategy, history, purpose, progress Simon Dymond
David Healy Robert Whelan JR Pappenheimer, BF Skinner, PB Dews Michael Schlund Alan Poling CM SIG Topics of Interest - ACBS Human physiology, neuroscience, medicine, and their relations within the broader field of
evolutionary science. Developing CBS-based case conceptualization integrated with models and language familiar to medical practitioners. Functional contextual study of the effect of drugs on human behavior - conceptual, research, and clinical. Public health, socio-cultural, and economic issues relevant to practices of medicine incl. prescribing practices, health systems. I take Contextual Medicine to be an exploration of the (FUNCTIONAL) CONTEXTUAL MEDICINE 1.
Winds of change in strategy in Medicine and Psychiatry 2. What does it mean to be a doctor, a healer? 3. Strategic (philosophical) foundations, (not) including history 4. Contextual Medicine = consistent behavior / biology science
5. Progress in Contextual Behavioral Neuroscience to mid 2013 6. Contextual Medicine Organisational Practices 7. Clinical to follow: Kelly Wilson on CM medication / societal level, and Julian McNally 1.Winds
of change in strategy in Medicine and Psychiatry Winds of change in the mainstream? PLoS MEDICINE Podcast 2009 Prof Bruce Lanphear - new editorial vision New focus on the social, environmental and political determinants of health. Over focussed on drug trials, journals reliant on Pharma, Academics focused on grant dollars. Lost focus on the underlying determinants of health and disease. Prevalent diseases particularly in developed/ing societies can be linked to industrial pollutants, to environmental chemicals (? particularly medications, see Anatomy, Pharmageddon) We have a stone in our shoeWe have a stone in our shoe Heart disease, asthma, diabetes, We have a stone in our shoecholesterol, psychopathology, chronicity... The Second Coming of the Sanitarians, heroes of the 1800s, early 1900s
Florence Nightingale, John Snow dramatic public health improvements occurred before vaccinations and antibiotics: see Pharmageddon !!! 2009 PLoS MEDICINE Podcast Bruce Lanphear Does the prevailing, dominant model of medicine get us where we want to go? No it wont. Not until we address the social, environmental and political determinants of health will we have the impact that we really want. We need respectful irreverence. To question the existing models. Are they doing what we want them to do? Are they serving the public? Clearly they are not! Journals, editors, are clearly beholden to the pharmaceutical industry. Science must be more accessible to people, and serve them, globally. Via blogs, interactive sites, within the developed and developing world.
Protect children from environmental influences accelerate this process by public engagement. Public pay for the science, they should have access. 2013 RIAT Restoring Invisible and Abandoned Trials: A Anatomy, RxISK, alltrials, RIAT,DSM Anatomy of an Epidemic madinamerica.com ; 82 US writers, 26 foreign correspondents, incl. Moncrieff, Healy, Drs, patients, SWs, Lawyers, Sociologists, parents.
RxISK S/Es are being elucidated, useful lessons learnt. Alltrials extraordinary support across organisations RIAT Restoration of Incomplete and Abandoned Trials supported by BMJ, PLoS, wide coverage in the media
Epigenetic Mechanisms in Psychiatry Akbarian and Nestler, Neuropsychopharmacology Reviews 2013 6th issue of Neuropsychopharmacology Reviews `neuroepigenetics' A `molecular bridge' context shapes genetics over the lifespan Epigenetics center stage in medicine, incl. neurology and psychiatry. For basic and clinical neuroscience, important insights fuel interest (i) many epigenetic markings are `plastic' throughout brain development, (ii) some chromatin-modifying drugsexert profound behavioral effects
NIMH's new stance and CBS research Steve Hayes- RFT List post reply June 2013 Epigenetic regulation of the glucocorticoid receptor in human brain associated with childhood abuse. Nature Neuroscience (2009) Biological system impacted over years by a psychosocial event, plus evidence of epigenetic regulation by psychosocial methods. psychological and biological function in glucocorticoid receptors. Examine functions in multiple evolutionary time frames. Link functions to things like experiential avoidance. Voila. Genetics can be our ally. It is not "genes made me do it".
What does it mean to be a doctor, to Declaration of Geneva (WMA, 2006) - modern version of Hippocratic Oath As a member of the medical profession: I pledge to the service of humanity; I will give my teachers the respect that is their due; I will practise with conscience; The health of my patient will be my first consideration; I will maintain the honour and the noble traditions of the medical profession;
I will not permit age, disease, creed, etc or any other factor to intervene between my PRIMUM NON NOCERE FIRST DO NO HARM Yet Anatomy of an Epidemic Robert Whitaker Pharmageddon David Healy And locally, here in Australia, a similar picture Trends in psychotropic meds in Australia: 2000 - 2011
Stephenson et al, Aust N Z J Psychiatry 2012 ANTIDEPRESSANTS DOUBLED ATYPICAL ANTIPSYCHOTICS TRIPLED ADHD MEDS DOUBLED XANAX DOUBLED LAMOTRIGINE DOUBLED AND AUSTRALIANS MENTAL HEALTH? NO IMPROVEMENT Changes in psychological distress in Australian adults 1995 - 2011.
Jorm and Reavley, Aust N Z J Psychiatry 2012 Strategic (philosophi cal) foundation Philosophy, ethics, medicine and health care: the urgent need for critical practice Michael Loughlin et al, Journal of Evaluation in Clinical Practice 2010 First philosophy issue of the Journal of Evaluation in Clinical Practice What is philosophy? Should health practitioners take it seriously? From nature of clinical evidence to management, many answer no, refusing even to think about what it
means. It is acceptable to write about the nature of clinical knowledge and the proper relationship between scientific research and medical practice, while having no interest in epistemology and the philosophy of science As though underlying questions about the nature, limitations and role of science in clinical practice were just too obvious to merit serious consideration. Evidence: philosophy of science meets medicine John Warrell Ph D Journal of Evaluation in Clinical Practice 2010 A wise man proportions his belief to the evidence. (David Hume) Any belief that the controlled trial is the only way
would mean not that the pendulum had swung too far, but that it had come right off the hook. (Austin Bradford Hill, Reflections on the Controlled Trial) Following Hume, medicine, like any rational pursuit, should be based on evidence. What else should it be based on? Myth? Superstition? It isn't a question of if medicine is or should be evidence-based. The issues lie in the details: what exactly counts as evidence? Do certain kinds of evidence carry more weight than others? (And if so why?) And how exactly should medicine be based on evidence? When it comes to these details, the evidence-based medicine (EBM) movement has got itself into a mess or so it will be argued.
Philosophy of science why bother? or perhaps? Strategy of science 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 FUNCTIONAL CONTEXTUALISM A philosophy of science and variant of contextualism that has as its primary goal The prediction and influence of events with precision, scope, and depth using Empirically based concepts and rules. It seeks the construction of knowledge that is General, abstract, and spatiotemporally unrestricted, like a scientific principle Yet also specific in particular circumstances
MEDICAL SCIENCE including diagnosis, treatment, health systems A human activity that has as its primary goal The prediction and influence of health and illness with precision, scope, and depth using Empirically based concepts and rules. It seeks the construction of knowledge and associated interventions / systems that are General, abstract, and spatiotemporally unrestricted, like a scientific principle Yet also specific in particular circumstances CBS truth = successful working
Science rules for effective action, true if yielding the most effective action possible BF Skinner, About Behaviorism, 1974 A theory is true to the extent that it organises the behavior of scientists (or clinicians) reach the goals of their science. Parts, relations and forces may be described, but parts are a useful fiction functionally describing aspects of the whole. CBS = interested in pragmatic truth linked to stated goals, and nothing else. Principled disinterest in common sense ontological
truth and great interest in pragmatic truth is consistent across all levels of CBS RFT to ACT to CM. NOT anti-ontological, NOR anti-realist, RATHER CBS is realist as MONISTS were interested in the one real world, but theres just one. FC in Five Easy Pieces. Kelly G Wilson ? D.o.b.... 195x Some notes on theoretical constructs. 2001 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 influence FC by phil science geek Kelly Wilson 3. Constructs ought not be confused with the crude events with which the scientist interacts 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
(i.e. improvement in orientation to the field of interest prediction and control with precision, scope and depth). 5. Divergence from the above will at best be superfluous and at worst will draw the investigators efforts in directions unfruitful to the advancement of a given field BF Skinner About Behaviorism Cumulative Record... It would be absurd for the behaviorist to contend that he is in any way exempt from his analysis. He
cannot step outside of the causal stream and observe behavior from some special point of vantage, perched on the epicycle of Mercury. In the very act of analyzing human behavior he is behaving. (1974) For the functional contextualist, biological events are not biological Physiological events may be incorporated into a science of behaviour not as physiological offence per se, but as behavioural
events. Dermot Barnes Holmes 2003 i.e., the behaviour of physiologists in identifying physiological relations with behavioral measures may also be analysed as behaviour. Assumptions, coherence, effectiveness Structure and Function relations = FC Neuroscience / CM / RFT Emotions, Motivation Memory, Hallucinations
Brain circuits Elemental realist neuroscience i.e. but the realness of drugs, neurotransmitters etc ??? Scientific laws... specify or imply responses and consequences. They are not ... obeyed by nature but by men that deal effectively with nature. Laws of gravity do not govern the behavior of falling bodies they govern those who correctly predict the position of falling bodies at given times.
(BF Skinner, 1969, p. 141) Can we talk ontologically workably, and not slip into ontological mechanism? 1. Languaging depression / SSRI / fMRI finding can be continuous with observed response to instrument output 2. Saying SSRI etc may enhance precision, scope and depth of analysing contextually the behavior we see in relation to observed output and increase applicability to other
aspects and other fields of interest i.e. success in workability Can we talk ontologically workably, and not slip into ontological mechanism? 3. Naming SSRI ought not be confused with the crude constructs i.e. client, clinician or scientist behavior in a context 4. 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 5. Divergence from the above will be superfluous or harmfully distracting. SEE ANATOMY OF AN EPIDEMIC the failure of 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 Treatment / intervention utility of the strategy is built in to every aspect of the work;
philosophy / basic science / clinical 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 a separate matter entirely requiring a subsequent research program Values not needed this IS how Contextual Medicine =
consistent behavior / biology science Contextual Behavioral Neuroscience Contextual Behavioral Science: Creating a science more adequate to the challenge of the human condition. Hayes, Barnes-Holmes, Wilson JCBS 2012 The material state of the brain is never by itself a scientifically adequate cause of psychological action; instead neurobiological evidence relative to psychology examines the depth of psychological accounts and provides a larger scientific context for them. If a behavioral event is understood in terms of history, context, and function, nothing should appear at the neurobiological level that contradicts that understanding. If it does, then the analysis fails because it has no depth. If, conversely, relations between precisely defined situated
actions and neurobiology are obtained then we have increased our understanding of neurobiology and of behavior, because all of the factors of history, context, and function known to be important at the behavioral level can now inform our understanding of how the brain develops and functions. As neurobiological evidence grows based on more adequate behavioral and contextual knowledge, the implications for behavioral science of neurobiological knowledge grow as well. For example, knowledge of contextual effects on brain functioning can later allow neurobiologists to provide additional PROGRESS IN BASIC CONTEXTUAL BEHAVIORAL NEUROSCIENC E?
Michael Schlund publications 2011-13 The spread of fear: Symbolic generalization mediates graded threat avoidance in specific phobia. Dymond S, Schlund MW, Roche B, Whelan R. Q J Exp Psychol (Hove). 2013 Safe from harm: learned, instructed, and symbolic generalization pathways of human threat-avoidance. Dymond S, Schlund MW, Roche B, De Houwer J, Freegard GP. PLoS One. 2012 Dynamic brain mapping of behavior change: tracking response initiation and inhibition to changes in reinforcement rate. Schlund MW, Magee S, Hudgins CD. Behav Brain Res. 2012
Generalized anxiety modulates frontal and limbic activation in major depression. Schlund MW, Verduzco G, Cataldo MF, Hoehn-Saric R. Behav Brain Funct. 2012 Human avoidance and approach learning: evidence for overlapping neural systems and experiential avoidance modulation of avoidance neurocircuitry. Schlund MW, Magee S, Hudgins CD. Behav Brain Res. 2011 Inferred threat and safety: symbolic generalization of human avoidance learning. Dymond S, Schlund MW, Roche B, Whelan R, Richards J, Davies C. Behav Res Ther. 2011 Michael Schlund publications 2008-10 Amygdala involvement in human avoidance, escape and approach behavior. Schlund MW, Cataldo MF. Neuroimage. 2010 Nothing to fear? Neural systems supporting avoidance behavior in healthy youths. Schlund MW, Siegle GJ, Ladouceur CD, Silk JS, Cataldo MF, Forbes EE, Dahl RE, Ryan ND. Neuroimage. 2010
Experience-dependent changes in human brain activation during contingency learning. Schlund MW, Ortu D. Neuroscience. 2010 Experience-dependent plasticity: differential changes in activation associated with repeated reinforcement. Schlund MW, Rosales-Ruiz J, Vaidya M, Glenn SS, StaffD. Neuroscience. 2008 Neural correlates of derived relational responding on tests of stimulus equivalence. Schlund MW, Cataldo MF, Hoehn-Saric R. Behav Brain Funct. 2008 Robert Whelan publications 2013 When optimism hurts: Inflated predictions in psychiatric neuroimaging. Biological Psychiatry. The Spread of Fear: Symbolic Generalization Mediates Graded Threat-Avoidance in Specific Phobia. The
Quarterly Journal of Experimental Psychology. The Neurobiology of Successful Abstinence. Current Opinion in Neurobiology. Symptom overlap in anxiety and multiple sclerosis. Multiple Sclerosis Journal. Commentary on Coming to Terms with Motivation in the Behavior-Analytic Literature by Al and Canado. (in press). The Psychological Record. Establishing arbitrarily applicable relations of same and opposite with the relational completion procedure: selection-based feedback. The Psychological Record, 63, 1 20 Fractionating the impulsivity concept in adolescence. Neuropsychopharmacology 38, 250251. Robert Whelan publications 2012
Adolescent impulsivity phenotypes characterized by distinct brain networks. Nature Neuroscience - Featured article in Nature Neuroscience. Only Low Frequency Event-Related EEG Activity is Compromised in Multiple Sclerosis: Insights From an Independent Component Clustering Analysis. PLoS ONE The orbitofrontal cortex, substance misuse and impulsivity: can teenage rebellion be predicted through neural correlates? Future Neurology. Very large fMRI study using the IMAGEN database: Sensitivityspecificity and population effect modeling in relation to the underlying anatomy. NeuroImage Neural correlates of oddball detection in self-motion heading: A high-density event-related potential study of vestibular integration (2012). Experimental Brain Research A test of the discrimination account in equivalence class
formation. Learning and Motivation Advances in RFT Chapter 4 Rob Whelan and Mike Schlund Next steps: neurobehavioural systems underlying indirect pathways of human avoidance Simon Dymond job advert! Two separable processes are thought to maintain pathological forms of fear and threat-avoidance: direct and indirect. For direct threat-avoidance, pathology has involved undergoing aversive experiences. By comparison, indirect threat-avoidance occurs because of knowledge of threats and adaptive avoidance responses acquired through description (e.g. instructions), social observation or cognitive
inferences. We believe that each pathway may be distinguished by different brain mechanisms, with each pathway potentially having a different optimal treatment for successful behaviour change. This research fMRI neuroscientific level extension of: Safe From Harm: Learned, Instructed, and Symbolic Generalization Pathways of Human Threat-Avoidance. Simon Dymond, Michael W. Schlund, Bryan Roche, Jan De HOW RESEARCH IN BEHAVIORAL PHARMACOLOGY INFORMS BEHAVIORAL SCIENCE MARC N. BRANCH UNIVERSITY OF FLORIDA JEAB 2006 Research in behavioral pharmacology assists the experimental analysis of behavior, especially conceptualizations and theory.
3 general strategies in behavioral pharmacology research to increase understanding of behavioral processes. Examples of the strategies and of implications of previous research for behavior theory. Behavior analysis will advance as its theories are challenged. CONTEXTUAL MEDICINE organisational practices CONTEXTUAL MEDICINE SYSTEMS LEVEL Corporate Externalities: A Challenge to the Further Success of Prevention Science - Anthony Biglan, Prevention Science 2011
The full benefit of prevention (medical) science will not be realized until we influence organizational practices. Marketing of tobacco, alcohol, and food (AND MEDICATIONS) and corporate policies that maintain poverty are examples of practices we must influence. (? also medical / psychiatric professional bodies and journals, the pharmaceutical industry / regulatory agencies, and University and government research funding agencies. Perhaps outside the CM SIG remit, but critical environmental practices) This paper analyzes the evolution of such practices in terms of their selection by economic consequences. CBS scaled up to social organisational PROSOCIAL CONTEXTUAL MEDICINE SYSTEMS LEVEL
Corporate Externalities: A Challenge to the Further Success of Prevention Science - Anthony Biglan, Prevention Science 2011 A strategy for addressing these critical risk factors should include: systematic research on the impact of corporate practices on each of the most common and costly psychological and behavior problems; (a) empirical analyses of the consequences that select harmful corporate practices; (b) assessment of the impact of policies that could
affect problematic corporate practices; and (c) research on advocacy organizations to understand the factors that influence their growth and to help them develop effective strategies for influencing corporate externalities. (d) SERVICES TO EVOLVE EFFECTIVE POLICIES Tony Biglan & Christine Cody Oregon Research Institute Journal of Economic Behavior and Organisation 2013 Special issue on of
Evolution as Policy a framework Evolution US Public makingfor overPublic Policy 30 years Advocacy for free markets selected by benefits those who advocate for such policies CF tobacco control movement advocacy success These principles applied to advocacy
for p0licies, programs, practices increasing prevalence of nurturing families and schools (and corporate practices, medical / psychiatric systems) CM SIG Topics of Interest - ACBS Human physiology, neuroscience, medicine, and their relations within the broader field of evolutionary science. Developing CBS-based case conceptualization integrated with models and language familiar to medical practitioners. Functional contextual study of the effect of drugs
on human behavior - conceptual, research, and clinical. Public health, socio-cultural, and economic issues relevant to practices of medicine incl. prescribing practices, health systems. I take Contextual Medicine to be an exploration of the role of biological processes and medical issues in human functioning from a functional, process-focussed,
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