Recovery-Focused Addiction Treatment: An Interview with Arthur C. Evans Jr., PhD

Dr. Arthur C. Evans Jr., currently serves as commissioner of the Philadelphia Department of Behavioral Health and Intellectual Disability Services, where he has guided the recovery-focused transformation of Philadelphia’s behavioral healthcare system. Through that process, the emerging “Philadelphia Model” has become a leading landmark in national and international efforts to transform addiction treatment into a recovery-oriented system of care. Dr. Evans brings to this role a distinct blend of vision, passion, intelligence, competence and joy. In this wide-ranging interview, Dr. Evans reflects on his career, his pioneering work in Connecticut and Philadelphia, and his thoughts about the future of addiction treatment and recovery in America. The full interview is posted at online (click Leadership Interviews).

Entry into the Field  

Bill White: When did you decide to specialize in the treatment of psychiatric and addictive illnesses?

Dr. Arthur Evans: I went to Florida Atlantic University as an undergraduate and master’s degree student with a focus on experimental psychology and then went to the University of Maryland for my PhD. At that time, Maryland had a combined clinical and community psychology program and it was there that I first started to understand how I, as a psychologist, could have the greatest impact on helping people. A lot of how we have approached recovery management in Philadelphia has been informed by an ecological perspective, a systems perspective and a strengths/challenges perspective—all of which are rooted in my community psychology training. My experimental psychology training has greatly influenced my emphasis on empiricism and research to inform our decision making.

Bill White: How did your early work after Maryland influence your later efforts to transform behavioral health care in the United States?

Dr. Evans: When I left Maryland, I went to Yale University’s School of Medicine for my internship. At the time, there were only a few APA-accredited internship programs where you could get community psychology experience as well as clinical experience. Yale was one of those programs, and my experience there was very important to my career. My internship included traditional clinical work with children, families and persons with serious mental illness, as well as community-level work such as prevention projects in schools and evaluating community-based mental health programs. That mix conveyed to me the importance of working at multiple levels simultaneously—providing both good clinical services, while also maintaining a broader focus on promoting population health through prevention and early intervention programs. If you look at how we have implemented recovery management in Philadelphia, you will see this mixed emphasis on excellent clinical care and broad interventions aimed at enhancing community health.

Bill White: In 1998, you worked with Dr. Tom Kirk in Connecticut to launch the first state-level, recovery-focused systems transformation process in the country.

Dr. Evans: I give Tom Kirk a tremendous amount of credit for his vision. A lot of things that we take for granted now about recovery-oriented care within behavioral health care simply did not exist ten years ago. When Tom said, “We’re going to move our service system,” which was both a mental health and addiction treatment system, “to a recovery orientation,” this was a radically different approach than prevailing practices in both systems at that time. It took a lot of courage to initiate that kind of systems transformation process. There was not a lot to guide our work, with the exception of your writings and those of a few other people. When it came to translating the emerging concepts into policy and operations at the system level, we had to make it up as we went along. We relied heavily on the voice of the recovery community and other stakeholders. You cannot overstate the importance of Tom’s vision to move Connecticut toward a recovery framework. It has had a profound impact on the field.

Bill White: Were you immediately drawn to this new approach?

Dr. Evans: For me, it just made sense and was so consistent with my philosophy and my training. What I didn’t anticipate at the time, when Tom and I had those first conversations, is how much of a challenge it was going to be to change the paradigm on which the treatment system was built to one that really embraced recovery as the organizing framework. While we still have a long way to go, I feel good about how, over time, even people who pushed back pretty hard initially have come to embrace the philosophy and move forward with many service innovations.

Bill White: Much of your writing during this period was focused on the implementation of evidence-based practices and developing cultural competence in the treatment of behavioral health disorders.

Dr. Evans: My belief is that if we’re going to give people the best chance for recovery, we have to utilize state-of-the-art practices. Integrating evidence-based practices is a fundamental part of the Philadelphia Model of recovery-oriented care. And I should say that, in the early days, that was not the typical way that people thought about recovery-oriented care. In fact, there was a camp that said evidence-based practices are antithetical to a recovery orientation because they limited peoples’ choices.

Similarly, I thought it was important to incorporate the idea of cultural competency and the reduction of health disparities. My rationale was that if a system is going to be effective in helping people recover, then it has to work for everyone. In the early days, these were seen as disparate concepts. We were very intentional in affirming that cultural competence was not just complimentary, but an essential quality of recovery-oriented systems of care. It was the same with trauma and other important clinical issues. Integrating what were thought to be disparate initiatives under the framework of recovery was very intentional and helped people to see that addressing these various issues was important in order to help people recover.

I was also concerned that the recovery movement in Connecticut would be seen as a fringe issue and that it could become marginalized, so it was important to show how the key issues in the field tied in to the concept. I wanted people who saw recovery-oriented care as fluff and not real clinical work to understand that in actuality, it required a greater level of clinical sophistication and skill.

Systems Transformation in Philadelphia  

Bill White: In 2004, you assumed leadership of the city of Philadelphia’s behavioral health services. How did that opportunity arise?

Dr. Evans: I was in Connecticut minding my own business in what I considered the best behavioral health job in one of the best behavioral health systems in the country. I received a call inquiring about my potential interest in heading Philadelphia’s behavioral healthcare system. Philadelphia, which was doing some really interesting and important work around the financing and administration of behavioral health care, was looking for someone to head their system and elevate the quality of clinical care within the service system. Over a period of several months of discussion, I was offered the position and made the decision that this would be an interesting place to apply the lessons I had learned in Connecticut to a larger system. So, I made the jump, and now I still think I have the best behavioral health job in the country.

Bill White: How did the systems transformation process begin during your early tenure in Philadelphia during 2004 and 2005?

Dr. Evans: The first thing I did was to acknowledge the great work that was already under way in Philadelphia and engage people at all levels in how we could further elevate the quality of treatment and recovery support services. There were great resources in Philadelphia, but everyone acknowledged that there was not enough focus on clinical outcomes in general and recovery-orientated practices in particular. One of the key strategies that we used early on was to bring in national leaders like yourself and Mike Hogan, to articulate why a recovery orientation was important and how clinical practices changed within this orientation. I personally spent a lot of time talking to treatment providers, advocacy groups and other community groups informally and through a series of community-wide focus groups. Through this process, we developed a shared sense of urgency about the need to heighten the recovery orientation of the existing service system, and we established a recovery advisory committee to guide that process.

Bill White: By 2007 and 2008, people were beginning to refer to the Philadelphia Model of recovery management and building recovery-oriented systems of care. What do you see as the most important elements of such a model?

Dr. Evans: There are three or four things that, in my mind, are really central to the approach that we’ve taken that are different from the approach taken in other places. First, we have tried to create a transformation process that is both a science and an art. On the one hand, you’ll hear us talk about the importance of research, data and rigor in evaluating performance outcomes. On the other hand, you’ll hear us talk about the importance of faith, hope and the relational aspects of service delivery—at all levels of the system. To me, both of these dimensions are important.

I think another important issue is to distinguish the various approaches that people take when implementing recovery-oriented systems of care (ROSC). In our writings about ROSC, we have described the additive, selective and transformative approaches to developing a ROSC. In Philadelphia, we think that ROSC requires a transformative approach in which the core governing concepts, core service practices and the contexts (policies, funding mechanisms, regulatory guidelines, etc.) are all aligned to support long-term recovery for individuals and families, as well as neighborhoods and the community as a whole. We also place emphasis on working in a social and community context. For example, we believe that it is counterproductive to help people initiate recovery and then have them go back into communities that fail to support their recovery. It doesn’t make sense to me to have a system of excellent care and not attend to the context in which people actually live and will need to be supported. Both have to be addressed.

Part of what we are trying to do in Philadelphia is create a supportive community in which recovery can flourish. That includes but goes beyond breaking down barriers that people may have about wanting to come into treatment. It involves challenging stereotypes about people in recovery by building relationships between people in recovery and the larger community. We envision a world in which recovering people are warmly welcomed into the neighborhoods, schools, workplaces, churches and other social venues. One of the ways we facilitate this process of community inclusion is through mini-grants to community coalitions for projects that will help recovering people and their families experience a full life in the community. It’s important to have treatment resources, but it is also important to have these broader and more enduring supports in the community.

Bill White: You have placed special emphasis on the mobilization of the recovery community and on peer leadership development.

Dr. Evans: I think that this has been the single most important thing that we’ve done in promoting system transformation in Philadelphia. When we started this work, there were very few people—probably less than 10 outside of the professional advocacy community—who were highly visible as people in recovery and felt comfortable sharing their experiences of recovery in public settings. It is not an exaggeration today to say that there are thousands of people in Philadelphia who are standing up to put a face and voice on recovery. PRO-ACT, our local addiction recovery advocacy organization has played a very important role in the mobilization of the addiction recovery community. We met early on with them to develop our strategy. We have also supported all kinds of leadership development activities and created opportunities for people to provide service in a variety of roles throughout the system. Their work has made a huge difference in people’s lives.

Bill White: What kind of early resistance did you encounter to the systems transformation process?

Dr. Evans: While from the beginning there has been a lot of support, we did encounter a phenomenon called the “We be’s and the You be’s.” It means: “We will be here when you will be gone.” There was a sense that, “You’re appointed and here now, but this is going to go away.” Some people thought that in a couple years, we’d be on to something else. There was an early period in which some people wanted to marginalize recovery as this soft, philosophical shift that had little relevance to clinical practices. There was pushback from some professional disciplines who felt they were losing status, and, of course, there were a tremendous number of turf issues. Systems transformation requires people to give up some control and to do things differently.

There was also a response from some of the provider community: “We’ve been doing this ‘recovery’ for decades. We know what we’re doing. Are you telling us that what we’ve been doing is wrong?!” Because of some of these perceptions, we went out of our way to say, “This is not about people doing something wrong. This is about the evolution and advancement of the field.”

Having said this, I think, to the system’s credit, we had much less resistance and active pushback than has occurred in many places. I attribute that to the partnership relationship we developed with our key constituencies and to the collective commitment to improve the scope and quality of treatment and recovery support.

Bill White: How do recovery-oriented systems transformations change the role of frontline addiction professionals and other service professionals?

Dr. Evans: I think these roles change in two or three fundamental ways. First is the underlying clinical philosophy, which shifts to a focus on long-term recovery, as opposed to episodic treatment within a particular level of care. In essence, frontline addiction professionals expand their focus from just helping people initiate their recovery within the context of their particular program to providing people with the services, supports and community connections that will help them sustain long-term recovery and build a full life in the community.

Second, it changes how one sees his or her own role. In a recovery management approach, rather than viewing themselves as the experts who are responsible for directing the treatment process, the service relationships change so that frontline professionals see themselves as partnering and collaborating with the people they serve. There is recognition that the person has expertise about his or her goals, needs, preferences and what has or has not worked in the past, while the professional has clinical expertise. Together, they engage in shared decision making. This requires a shift in power. Rather than the professional independently calling the shots, power is shared and professionals respect that the person being served has the right and the ability to participate in making critical decisions that affect his or her life.

Third, I think this move to recovery management requires more skill than a more traditional approach. You really have to bring–to use a colloquial phrase—your “A” game, and that means you need to be versed in the best evidence-based practices. You need to be skilled in addressing the issues that get in the way of people’s recovery, like trauma and co-occurring conditions. You need to understand the diverse cultural contexts in which recovery must be nested. You need to be willing to understand the role of spirituality and faith in people’s recovery process. You have to be knowledgeable about the growing diversity of recovery pathways and support groups. The needed skill level is much higher and more demanding in a recovery-oriented system of care.

Bill White: You’ve recently invested a lot of time and resources in Philadelphia developing practice guidelines. Was this your way of bringing systems transformation to that frontline relationship?

Dr. Evans: The practice guidelines provided us an opportunity to translate key concepts into practical things that people can do across various levels of care and across a variety of populations. They are based on the scientific literature, the voice of people in recovery and professional consensus around the best recovery-oriented practices. For example, one of the domains addresses the need for assertive outreach and engagement, which has been well-documented in the literature. The guidelines articulate both the principle—that is the need to have strategies to assertively bring people into treatment—and suggested strategies for accomplishing this goal. In this case, we point out the need to understand the community and the help-seeking behaviors of the people who use the program. We also suggest that—even if you are an inpatient provider—you need to leave the four walls of your program and develop relationships with your community so that people will understand and feel comfortable with seeking out help from your program when the need arises. The practice guidelines take recovery concepts and put them into action.

Bill White: More than 11,000 people marched in the city of Philadelphia in the National Recovery Hub event. Did you ever imagine you would see that many recovering people and their families marching in Philadelphia?

Dr. Evans: I could not have imagined that we would see that size crowd when we started the work here, particularly when you think that the first recovery walk here drew some 150 people. To go from that to 11,000 people in 2010 is quite remarkable, and I think it says a lot about the city of Philadelphia and how recovery transformation has been embraced.

Bill White: You’ve had visitors from across the country and around the world visit Philadelphia to study the transformation process. What do these visitors tell you they find most striking from their visits there?

Dr. Evans: I think they are most struck by the scope and breadth of the things we are doing that we believe are necessary for a ROSC. When visitors arrive, they see a system that is simultaneously addressing a wide range of issues, including changing the treatment philosophy, increasing the use of evidence-based practices, addressing various forms of trauma, looking at the integrated treatment of co-occurring disorders, working with faith organizations and other indigenous community helpers, improving services to the LGBT community and engaging various immigrant and minority communities, including the Asian and West African communities and a number of other initiatives that we believe are critical for a ROSC. What ties all of these initiatives together is that they are all focused on maximizing people’s ability to recover. The other thing visitors comment on is the emphasis that is placed on peer services and peer culture and the strong voice people in recovery have throughout the system, both within the treatment programs and within my department.

Bill White: There seems to be a larger vision emerging in Philadelphia around the question: how do we move beyond the focus on the care of individuals (adults, adolescents and children, each treated as a discrete unit of care) to the development of sophisticated family- and community-focused strategies aimed at breaking intergenerational cycles of alcohol- and drug-related problems?

Dr. Evans: Yes, this ecological perspective is emerging as a fundamental element of the Philadelphia Model. We stress that we can’t just work with the individual, but instead have to work with the family, extended family and broader community to create a kind of healing sanctuary that can break such cycles. We have to have intervention strategies for all three levels: the individual, the family system and the community and broader social system. As we move forward, we must design, evaluate and continually improve such interventions.

Bill White: Dr. Evans, you have also begun to talk about this notion of community recovery—the idea that we may need processes that help whole communities heal from the effects of addiction and other behavioral health problems.

Dr. Evans: When I think of community recovery, I think of the work we’re doing in partnership with the Mural Arts Program here in Philadelphia to create a series of recovery-themed murals. For each mural, we partner with the local community to develop a theme for the planned mural. The process of planning and creating each mural is designed to exert a positive and enduring influence on the neighborhood—an influence designed to elevate local recovery capital and reduce the stigma associated with behavioral health conditions. With local and national foundation support, we are able to make a multiyear commitment to the neighborhoods to sustain the local mobilization that occurs through the mural development process. Over time, our goal is to strengthen the health and fabric of the community itself.

Career Reflections  

Bill White: What do you feel best about as you look back over your career to date?

Dr. Evans: I think the models that have been created in Connecticut and Philadelphia. The first job I had in government was leading the implementation of managed behavioral health care in the public sector in Connecticut. That project really made a difference in the lives of the people we were serving. That led to leading the larger transformation effort in Connecticut with Tom Kirk, which continues to be viewed nationally and internationally as a model for recovery-oriented systems of care. And I certainly feel good about the work that we’ve done here in Philadelphia over the past six years. The level of engagement and the amount of change that has occurred in a relatively short period of time continues to amaze me.

Bill White: As a final question, how can addiction professionals around the country help lead and support the kind of change processes that have been under way in Philadelphia?

Dr. Evans: I think it’s important to go back to why we came into the field in the first place—and that is to help people. At its most basic level, the recovery movement is about how we best help people recover their lives and lead the kind of life that any of us would want. The recovery movement is really about making the changes that are necessary for that to happen. We have to acknowledge that our systems have a lot of room for continual improvement, and if we are committed to our mission of helping people, we have to exert the energy that it takes to make these improvements. By this standard, the status quo is unacceptable. As we make the necessary changes, I think we must recognize the difference between superficial changes in rhetoric and true systems transformation. Addiction professionals can embrace this recovery vision and become part of the movement to align clinical practices within their respective programs. They should read your monographs, which provide a tremendous amount of guidance to the field. They can also participate in some of the larger systems change efforts by volunteering to sit on various work groups and by actively participating in local recovery celebration events. Perhaps the most important thing addiction professionals can do is to listen to people who are in recovery, the people who are the true beneficiaries of this work. That stance of professional humility and that willingness to reframe our professional identity around the goal of long-term recovery for the people we serve will move us forward all over the country.

Bill White: Dr. Evans, thank you for spending this time with us.