April Ask the Expert
04 Building Public Awareness and Community Support
Ask the Expert:
Arthur C. Evans Jr, Ph.D. is the Commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), a $1 billion healthcare agency. In this capacity, he is leading a major initiative to transform how behavioral health care and intellectual disability services are delivered in the city. Since Dr. Evans’ appointment in November 2004, Philadelphia has begun a transformation of its system to one that focuses on recovery for adults, resilience for children and self-determination for all people with intellectual disabilities.
Dr. Evans is a clinical and community psychologist. He holds a faculty appointment at the University of Pennsylvania School of Medicine. He has also held faculty appointments at the Yale University School of Medicine and Quinnipiac University. Dr. Evans has extensive experience in transforming systems of care while serving in several national leadership roles.
Prior to coming to Philadelphia, Dr. Evans was the Deputy Commissioner for the Connecticut Department of Mental Health & Addiction Services (DMHAS). In this capacity, he led several major strategic initiatives for the Connecticut behavioral healthcare system. He was instrumental in implementing a recovery-oriented policy framework, addressing health care disparities and increasing the use of evidence-based practices.
Dr. Evans has served or is currently serving in several national leadership roles that include: Chair of Substance Abuse and Mental Health Services Administration, Partners for Recovery Initiative Steering Committee, Co-Chair of National Action Group on Fostering System Reform for Adults with Serious Mental Illness, and Member of the Federal Center for Substance Abuse Treatment Advisory Committee, Chair of the National Advisory Committee for the Robert Wood Johnson’s Path To Recovery Project; President of the Board of Directors of the New England Institute of Addiction Studies Inc. (NEIAS).
Dr. Evans is highly committed to serving people who are underserved and ensuring that all people have access to effective, quality services.
1) Question: I am interested in learning more about how drugs damage the brain, and have several specific questions:
a) Is it true that hallucinogens cause the most damage to the brain, as evidenced by PET Scans?
Answer: Hallucinogens are particularly harmful to the brain. Small quantities can cause lasting damage to the brain. University of Florida researchers engaged in animal studies showing the negative effects of Ecstasy on the brain. In their study on the effects of Ecstasy on rats, they demonstrated that the use of Ecstasy and other similar hallucinogens on the brain is similar to that of a traumatic brain injury. The use of these substances caused change reactions that caused damage to certain proteins in the brain, leading to fluctuating protein levels. This caused both brain cells to die and inflammation to the brain. For Ecstasy, low levels of doses can be dangerous. Three tablets can be toxic to different areas of the brain. The effects of brain injury caused by Ecstasy and other hallucinogens may or may not be permanent. The researchers believed that damage to the brain may not be reversible, but recognized future research was needed to determine if damage is reversible. (Warren, Kobeissy, Liu, Wang 2006)
b) Is there evidence to suggest that the brain damage caused by Ecstasy, LSD and other hallucinogens is irreversible?
Answer: The use of these substances caused change reactions that caused damage to certain proteins in the brain, leading to fluctuating protein levels. This caused both brain cells to die and inflammation to the brain. For Ecstasy, low levels of doses can be dangerous. Three tablets can be toxic to different areas of the brain. The effects of brain injury caused by Ecstasy and other hallucinogens may or may not be permanent. The researchers believed that damage to the brain may not be reversible, but recognized future research was needed to determine if damage is reversible. (Warren, Kobeissy, Liu, Wang 2006)
c) Other than depleting dopamine and other neurotransmitters (which cause mood imbalance), how do Opiates and/or Opioids damage the brain? Do Opioids and/or Opiates impair a person's intellectual ability? Is there a permanent memory loss due to years of Opioid Dependency?
Answer: Most studies of the effect of substances on the brain gather information through either animal studies or scans of the brain, such CT or PET scans. These studies examine two areas. First area of study is searching for physical evidence that substances diminish the capacities of the brain, such as cognitive, emotional, and motor capacities. The second area deals with the brain’s ability to recover from the damaging effects caused by substance abuse. Recovery specifically focuses on the brain’s ability to rebound and produce proper dopamine levels. Dopamine plays a major part in regulating both cognitive and emotional processing. (Ansorge, Zhou, Lira, 2004) The restoration of dopamine levels is essential to stop injuries to the brain and help bring it to a state of healing. The good news is that PET scans show that, after several months of abstinence, dopamine levels are able to be restored to healthy levels.
d) I am aware of the new research which provides evidence that the brain can heal, despite years of drug use. I am assuming memory loss, diminished intellectual ability, and possibly mood instability, such as depression, plus an inability to control anger, are examples of how the brain is affected/damaged. When we say that drugs damage the brain, it is so vague a statement, can you please define exactly what kind of damage is caused by drug use? If possible, please provide references for further reading.
Answer: Brain damage is a term that we attempt not to use. It is stigmatizing and brings a sense of permanency. The brain has cognitive, emotion, and motor capacities and corresponding brain areas of the cortex, limbic system, and brainstem to these capacities. We prefer to focus on how substances can diminish certain brain capacities, at least temporarily. At this point of the research, we are not able to say whether diminished capacities are temporary or permanent.
Dr. Charles Raison, CNN Mental Health Expert, Psychiatrist, Emory University Medical School
How long does it take for a once-addicted brain to heal? http://www.cnn.com/2009/HEALTH/expert.q.a/08/25/pregnant.addict.raison/
NIDA: National Institute on Drug Abuse. Bringing the Full Power of Science to Bear on Drug Abuse and Addiction [Powerpoint] http://www.drugabuse.gov/publications/teaching-packets/power-science
Adamse, M. , Gawin, FH. , Heaton, RK., O'Malley, S. Neuropsychological impairment in chronic cocaine abusers. American Journal of Drug and Alcohol Abuse. 18.2 (June 1992): p131-144.
Ansorge MS, Zhou M, Lira A, Hen R, Gingrich JA. Early-life blockade of the 5-HT transporter alters emotional behavior in adult mice. Science. 2004 Oct 29;306(5697):879-81.
Lyoo IK, Pollack MH, Silveri MM, Ahn KH, Diaz CI, Hwang J, Kim SJ, Yurgelun-Todd DA, Kaufman MJ, Renshaw PF. Prefrontal and temporal gray matter density decreases in opiate dependence. Psychopharmacology. 2006 Jan;184(2):139-44.
Volkow ND, Chang L, Wang GJ, Fowler JS, Leonido-Yee M, Franceschi D, Sedler MJ, Gatley SJ, Hitzemann R, Ding YS, Logan J, Wong C, Miller EN. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry. 2001 March ;158(3):377-82.
Volkow, ND., Fowler, JS., Addiction, a Disease of Compulsion and Drive: Involvement of the Orbitofrontal Cortex, Cerebral Cortex, 1992,Volume 10, Issue 3Pp. 318-325
Warren MW, Kobeissy FH, Liu MC, Hayes RL, Gold MS, Wang KK. Ecstasy toxicity: a comparison to methamphetamine and traumatic brain injury. J Addict Dis. 2006;25(4):115-23. (University of Florida Study)
2) Question: How important do you think years/ages 0-3 and 3-5 are to a child learning empathy and impulse control, and if you do think this is important, is prevention/intervention (in the form of family and mental health support) in these years crucial to this child's future ability to live a motivated and meaningful life?
- These years are absolutely and fundamentally critical in laying the foundation for social and emotional development, the beginnings of empathy, the control of impulsive behavior and the initiation of positive, loving relationships with parents, siblings and friends.
- Studies have shown that a child's empathy toward the pain and suffering of other children can be observed as early as the toddler period.
- The first three years of life are a period of incredible growth. A newborn's brain is 25 percent of the adult brain's weight; by age three it has grown dramatically, producing billions of cells and functions which relate not only to motor development, but to memory, emotional regulation, social interaction and impulse control.
- From ages 3-5, children become more independent, form friendships, become more curious about their environment, and learn more about how to get along with others during their preschool experience.
- During the first 5 years – and of course in later years – the role of the parent is paramount. The parent is the giver, and the teacher, of love. The parent is the model of positive social and emotional behavior. The parent sets the limits, and inculcates in the child a sense of order, discipline and respect for others
- If parents are, for whatever reason, unable to provide the nurturing and stimulating environment which the child needs to foster social and emotional development, then mental health intervention and support for the family is essential. We know that children raised in adverse circumstances are at risk for not only psychological disorders which impair their relationships, their achievement, and their life, but are at risk for physical illness as well.
- The parent is truly the child's first "therapist." If a mental health intervention is necessary, the parents must become allies with the mental health provider and work together to ensure a positive outcome for the child, now and in the future.
3) Question: A few questions from North Carolina's recovery initiative:
Can we get a complete “list’ or diagram or link to things that make up a continuum of care?
How do we build an advocacy presence in the midst of so much change in government? How do we ensure that large contracted private managed care orgs keep recovery and quality as objectives in their programming? How do we ensure the prize is recovery and not perpetuation of health care needs so that companies can profit?
What are some key points to transforming the system into a recovery oriented system of care while still preserving the unique qualities of all disabilities (MH, SA, and IDD) - such as focusing on the end goal?
Answer: A comprehensive continuum of care includes prevention, early intervention and continuing care support services. Additionally, it is important for behavioral health systems to connect to a wide range of community indigenous support resources. In terms of a list of services, I can share with you the range of services that we provide within the Philadelphia Behavioral Health System.
- Complete list of continuum of care from most acute services to least restrictive:
- Acute Inpatient Psychiatric Services for adults, children and adolescents
- Acute Partial Hospitalization Services
- Detoxification programs
- Hospital-Based substance abuse programs
- Non-hospital substance abuse residential programs
- Residential Treatment Facilities (RTF) and Residential Treatment Facilities for Adults (RTFA)
- Community Residential Rehabilitation Host Home (CRRHH) programs
- Behavioral Health Rehabilitation Services (BHRS)
- School Therapeutic Services (STS)
- Family-Based Services (FBS)
- Functional Family Therapy
- Parent Child Interaction Therapy (PCIT)
- Family-Focused Behavioral Health Services (FFBH)
- Philadelphia Intensive in-home Child and Adolescents Psychiatric Services (PHIICAPS)
- Multi-systemic Treatment for Problem Sexual Behaviors (MST-PSB)
- Day Partial Programming for children and adolescents
- Community Intensive Recovery Center (CIRC)
- Targeted Case Management/Blended Case Management/ACT/CTT
- Mobile Psychiatric Rehabilitation Services.
- Intensive Outpatient services and MATP
- Outpatient services
In terms of advocacy for recovery, this is a very important question and a question that stakeholders in every behavioral system should ask. I think that there are three major points to keep in mind.
- Recovery Oriented Systems of Care (ROSC) are fundamentally about taking a public health approach to behavioral health conditions. That means moving beyond what I call the “treatment black box” to an approach that attends to the broader community’s behavioral health status. In doing so, ROSCs focus on prevention, strategies, intervening early with people who have behavioral health conditions, delivering excellent treatment services and facilitating the development of a strong network of community-based support services.
- ROSCs are systems that have strong cross-systems partnerships. Behavioral health issues are complex and require strong collaboration and coordination for effective intervention.
- Transformative change is based on the principles and values of recovery and resilience throughout the delivery system, as well as the broader community. Advocacy efforts need to ensure that a systems approach is taken and the philosophical basis of the system is consistent with a recovery and resilience framework.
4) Question: In your view, what role has Recovery Month played, if any, in the furtherance of the recovery field?
Answer: I think Recovery Month has been very important in galvanizing both the recovery community and the broader treatment field around the notion of putting a positive face on recovery. In Philadelphia, for example, the Recovery Walk lead by PRO-ACT initially started with about 100 participants; last year, the walk had 18,000 participants. This growth reflects changing attitudes about the importance of celebrating recovery and showing the world that recovery is possible. Without Recovery Month, these kinds of activities would probably not happen in the dynamic way in which they are happening around the country.
(a) Should the municipalities and states be engaged in supporting the Recovery Month observance?
Answer: Definitely. My agency, which is a part of the City of Philadelphia government, actively supports several events during Recovery Month including Recovery Idol, educational events, and the Recovery Walk that I mentioned above.
5) Question: Are there any residential facilities in the Upstate of South Carolina that cater to rehabilitation with an adequate quality of life program that aids in garnering employment?
Answer: To find a vocational program that fits your needs, it is best to contact South Carolina’s Vocational Rehabilitation Department at http://scvrd.net/offices/. You will be able to email specific local offices through this webpage.
6) Question: Please provide information on recovering from a trauma regarding children and adults. Is it possible to heal from tragedy when the tragedy happened to your adult child? How?
Answer: There are effective treatments for traumatic stress disorders and symptoms as well as other trauma- related disorders. Depending on the particular event/s and symptoms, the treatments can be tailored or staged to meet the particular needs of the individual. Child treatment always includes caregiver or family involvement. It is important to recognize, however, that people who have long histories of chronic traumatization (including maltreatment) typically have more severe symptomatology and have more difficulty recovering. Regarding a tragedy happening to an adult child, again, psychotherapy can be quite successful even when it involves the death of an adult child. Importantly, individuals who are available to, and receive emotional support from, friends and family are more likely to do better as research has shown social support to be a key protective factor after a traumatizing event.
7) Question: Dr. Evans, my perspective comes as an advocate and patient. I served individuals with mental illness in social work and am a person whose depression got worse because my doctors, who were practicing integrated medicine in a leading government university system and record-keeping in my electronic health records, ignored my physical symptoms for many years, including descriptions of increased depression caused by the layering of medications. I now have Stevens Johnson Syndrome. I am better, now that I am off all medications, than in any of the 20 years when I was on them. Over the years I saw social workers, psychologists, and psychiatrists and was never able to get well because I did not have what I needed...a "safe" place to get well. The way "medicine" is practiced today is dangerous for patients like me. For instance, if I tell my primary care physician that I'm depressed because I am afraid of my husband, the doctors give me a prescription for medication instead of listening to me about the danger I am in with my husband. What I really need is the police to enforce my protection/restraining order.
I got better from the DBT practices I learned, which I found on my own 13 years later. When mental health professionals say there is only so much they can do, they are wrong. There is a lot that can be done but it will take a mindset drastically different than what we see today. Many people need a safe home in which to recover from trauma, and this also requires more wrap-around services for people and willingness on the part of an advocate or case manager to go wherever the patient needs advocacy, like for increased relationship and advocacy skills, as well as enforcement of people’s rights under the Americans with Disability Act. Anything less will lead us back to where we are today.
My question is: What do you propose as other possible solutions for the multi-faceted problems our clients/patients/consumers deal with, instead of just prescribing medication?
Answer: I think embracing recovery and resilience as the framework for our treatment systems is the most important thing that we can do to address the concerns that you outline. At the heart of a recovery-oriented system is the notion that service delivery is person-driven and that professionals work along with individuals who are engaged in the recovery process. This reorientation, I believe, has had a tremendous impact on our ability to engage and effectively serve people within our treatment systems.