A Community Empowerment Approach to Addiction in Turkey
By Dr. Bob Lynn Ed.D
This article, prepared with the assistance of the program staff at the Avcilar Community Center in Istanbul Turkey, chronicles the developmental process that we underwent while designing and implementing community-based addiction services on behalf of C4 Recovery Solutions and the Levenson Foundation. C4 Recovery Solutions has a long history of providing support services and developing programs while addressing the challenges presented by drug and alcohol addiction around the globe. C4 Recovery Solutions has experience in helping regions more clearly define services, creating systems for better resource utilization as well as sustainable growth.
We have developed culturally relevant instruments that are user friendly and pave the way for the support of a comprehensive treatment continuum. The focus of C4 and the Levenson Foundation has always been to develop a culturally relevant treatment experience that was client driven as well as being couched in real time data that was replicable and sustainable all seen through a lens of cultural humility and empowerment.
Why Turkey? Having worked in the US and other countries for many years we were keen to find a place that was not bogged down in regulations and dogma. Since there are very little standards of care in the US, few verifiable outcomes, unclear benchmarks and baselines all entrenched in hordes of regulations, we needed a fresh start to demonstrate a new lens for providing care. We also knew that we needed to be in a place where we were not influenced by the pseudo-science that so many programs are based upon.
In addition, Turkey did not have a comparable outpatient alternative and there was a strong belief by the local treatment community that one was needed. We were sensitive to the fact that Turkey came with its own unique challenges although we believed that these were not unsurmountable in developing a program.
Drug Use in Turkey Data from the few specialized Government treatment centers, locally known as Amatems, indicated that heroin was the most commonly reported primary substance for first-time clients entering treatment in 2015. (1)
For several years, “bonzai” — a type of bootleg synthetic cannabis — has been ravaging its way across the lower echelons of Turkish society, leaving little but destroyed lives, addicted youths and shattered dreams in its wake. (2)
There are currently 1.5 million drug addicts in the country and one third of them are bonzai users. Moreover, deaths related to bonzai abuse are increasing day by day according to the Bureau for International Narcotics and Law Enforcement Affairs US .
Historically Turkey has relied on the criminal justice system to deal with drug use. This has been slowly changing based on the realization that drug use is undermining the strength of Turkish society. As reported to the office of the U.S. Ambassador in Ankara, “Penalties for violating Turkish laws, even unknowingly, can be severe. Penalties for possession, use, or trafficking in illegal drugs in Turkey are particularly strict and convicted offenders should expect jail sentences with heavy fines.” And it’s not just growing, possessing or selling that can land you in hot water or a Turkish prison: According to Section #404 of the Turkish code cited by the embassy, “Whoever facilitates a person's use of drugs by providing a special place or in another way ... shall be punished under items 5 and 6 of Article 403 [4-10 years of jail time] and imprisonment will be increased by one-sixth.“
One cannot speak of drug use in Turkey without mentioning the most prevalent killer of Turkish people – nicotine. Even those in the medical profession are impacted by nicotine addiction. Smoking and alcohol abuse amongst medical students and physicians should be taken more seriously because their own attitudes towards substances may influence their professional behavior. There is a need for better education about substances. (3)
A Gallup poll in May 2007 revealed that over half of Turks aged 15 to 49 had smoked on the day before the survey. This was the highest rate among the 100 countries surveyed, along with Lebanon (41%), Greece (40%), and Cuba (40%) in descending order. The figure went down to 12% in females and 40% in males in 2015, according to World Bank.
It is interesting that the Turkish government has now become aware of the challenges related to smoking. Smoking in Turkey is now banned in government offices, workplaces, bars, restaurants, cafés, shopping malls, schools, hospitals, and all forms of public transport including trains, taxis and ferries. Turkey's smoking ban includes provisions for violators, where anyone caught smoking in a designated smoke-free area faces a fine of 69 Turkish lira (~€15/$18/£13) and bar owners who fail to enforce the ban could be fined from 560 liras for a first offence up to 5,600 liras. The laws are enforced by the Tobacco and Alcohol Market Regulatory Authority. (4) This approach alone is not without skeptics as in the past the attempt to criminalize an addiction has failed miserably.
The Program
Our goal in opening a program in Turkey was to develop a culturally relevant replicable and sustainable model of care that was couched in credible data. Much of our early work in Turkey was based on the writing of the late Dr. David Powell who had spent a considerable amount of time in Turkey opening a groundbreaking adolescent inpatient treatment program for addiction. The decision to choose the municipality for the demonstration project was in part driven by an enthusiastic and supportive Mayor in addition to the community building a center dedicated to this project. The municipality may be described as having a great deal of industrial development around a port and a rather high crime rate.
Our initial attempt to develop an out-patient treatment center was based on a typical American clinical system as described by the American Society of Addiction Medicine (ASAM) manual as Level 2 Intensive Outpatient /Partial Hospitalization Services. (5) In other words, a model consisting of clinicians and recovery advocates with a focus on abstinence supported by the 12 steps of NA and AA. Having hired well trained staff and a dynamic Director we opened our doors believing that if we built it they would come. Our experience in the next several years was just the opposite. The census remained low despite serious community advertising and very few clients were referred to the program or came on their own. What also became obvious was that even if we had a line out the door our static capacity with 2 clinicians, 2 peer counselors and a secretary was less than 30 clients. Further our scope of services was fairly limited beyond the typical counseling and group work such as CBT, EMDR, etc. all with little evidence that they impact on long term recovery.
Our intuitive reaction to this seemingly failed attempt was to find a new director, hire better staff and enhance our so-called evidence driven clinical model with extensive training and the writing of a highly comprehensive manual. We once again fell down the same slippery slope that many programs do laboring under the misconception that if a practice had some validity in the counseling world it could easily be thrust upon addicts under the guise of evidence driven care – which it is not! The outcome was the same: very few clients and little community impact despite several well trained staff members and local political support.
We were baffled as we believed we did everything correctly - hired local talented staff, had strong local political support, provided high level training and clinical supervision, assured that the protocols were highly enculturated even to the extent of reviewing our forms and clinical protocols with Turkish scholars from the medical and social service communities.
Since we had a history of successful endeavors in other countries we decided to step back and dissect our successful projects to find the holy grail missing from our Turkish program. At the same time events on the ground hastened the process as the Municipality experienced serious financial issues and they were no longer able to fund their share of the employees, leaving only two C4/Levenson Foundation funded employees.
The New System
Once again, we respectfully dismissed our staff and rehired all new folks based on revised theoretical and practice guidelines. The overreaching thought was that if the addict would not come to the center, and we wanted to reach large numbers, we would go to the addict and leverage resources already in place in the community. Our next step was to revisit the relevant literature and engage local scholars who were familiar with the direction in which we were now taking the program. In some ways this was our “Hail Mary” pass and in others a logical extension of our work over many years. A real challenge was presented by the lack of credible outcome studies related to the treatment of addiction. This was in fact one of the drivers that fueled our enthusiasm as we were married to the idea that outcomes need to be measured and that treatment should be couched in science.
Most important is the recognition that recovery is more closely related to life skills and community than clinical theory and practice. Few addicts report staying sober due to clinical counseling and methods such as CBT, EMDR etc. What does sustain recovery are real life services such as employment, housing, transportation, childcare etc. that meet the clients’ needs as they understand them.
In this program the client is not merely the individual but is also the family and community. Rather than a rigid level of care the program represents a continuum driven by the needs of these clients.
Program Design: The following is what we proposed should be the revised focus of the center:
Identify all relevant stakeholders in the community i.e. those who represent services that will impact and support recovery - these should be both clinical/medical, social/legal and spiritual
Have an introductory meeting of all community stakeholders at the center
Identify a representative in each stakeholder group who will perform an advisory role and be willing to participate in meetings at the center
Center participation in community meetings and events
Meet with stakeholders individually both in the community and beyond for networking purposes
Provide literature and information regarding treatment and recovery to combat stigma
Have an open-door policy where community members can drop in to discuss addiction issues
Be the subject matter experts who people will contact when they need information about addiction and recovery
Services within the center:
· Comprehensive ongoing assessment based on individual client goals
· Referral to social, clinical and spiritual supports
· Group Meetings from the onset of engagement
· Multi-family sessions
· Psycho-social educational meetings
· Gender specific groups
· Early engagement utilizing motivational interviewing, which typically means meeting with the client no more than three times individually (if they remain ambivalent regarding participation, let them know that the door is open when they feel ready)
· Crisis meetings when indicated with individuals and families
· NA meetings and other support groups to include the establishment of new support groups in the community
· Stakeholder meetings are ongoing at the center
These are not one-time encounters as they are designed to create a supportive community by leveraging local resources and engaging in ongoing relationships. We believe that this system has the potential to go far in reaching more addicts through early engagement activities and by creating new local pathways to treatment, addressing stigma, creating multiple layers of recovery support while the center has a very large impact on the community.
Phase One
The first step was to identify all stakeholders in the community that may be directly or indirectly related to the treatment of addiction and support of long-term recovery. Our first line stakeholders included families, physicians/health care services that could provide withdrawal management and appropriate medication, therapists and psychologists as well as social workers. Our second line stakeholders, equally important, included housing authority, potential employers, religious leaders, school systems, police, child care support, transportation and political systems. In other words, we were meeting with those folks who, as a group, could be defined as the community in which we were working. Meetings were convened and social mixers were conducted to create a system of community activists and to introduce the program.
Phase Two
In this phase we began to invite individual stakeholders to the center and in turn we visited them at their locations throughout the city. We began to develop reciprocal agreements where they would refer addicts to the center and in their specialty be willing to provide services to those in recovery.
Phase Three
This was our time to take to the streets and meet the addicts where they used drugs. By setting up booths, distributing literature and speaking one on one to those in need of services we were able to engage many folks who otherwise would have never reached the center. This was accomplished with strong local political support and in partnership with law enforcement.
OUTCOMES
Based on the inclusion of stakeholders in the system on a reciprocal level, the program has expanded exponentially in the following areas:
Employment: By meeting with potential employers the program has been able to create a pathway for recovering addicts to gain employment which is essential to sustained recovery. It was important to provide education regarding recovery combined with program support to all potential employers. With the client’s permission the program communicates with the employer and provides counseling to the client regarding real time events on the job and continuing drug screens to assure the employer that the client is not using drugs. As a result, the employer gains a better understanding of recovery and the barriers created by stigma while often gaining a grateful and enthusiastic employee.
Education: By working with the school system the program creates another two-way street. The program provides education to staff and students while accepting referrals for at risk students. Rather than a narrow focus on prevention which has not been able to produce significant outcomes in the US, this is a demonstration of early engagement while combating stigma and is woven into all center activities.
Law Enforcement: Historically drug use and treatment has been viewed through a rather punitive legal lens in Turkey. The program has gone far in breaking this mold by developing a strong relationship with local police. Police feel comfortable bringing clients to the center and in turn the center provides support to the police in dealing with drug addicts on the street. This is a monumental culture shift for this community.
The Police Project has grown following a meeting with the Police Chief and is now called the Park Team. In summary the police will go to places like parks where addicts are known to frequent, speak with the addict and direct them to the center. This is the pre-arrest component of the program. The same addict may be referred on several occasions with no legal consequences unless they are actively selling drugs. This arrangement with the police department has resulted in the police referring drug users and their families to the center. Once they participate satisfactorily they are considered "free" of legal issues and are able to pursue a life of recovery. Needless to say, this would be significant anywhere in the world and takes on special meaning in Turkey.
The police do not require any reporting and in fact there is an effort to remove the legal issues from the center so as not to create the idea that the center is working as an agent for the police department. This would be considered innovative almost anywhere and speaks volumes as to the strength of a community-based program.
Existing Programs: The Turkish Ministry of Health provides national treatment for drug use through 22 existing governmentally funded Research, Treatment and Training Centers for Alcohol and Substance Addiction (AMATEMS centers) that are in 13 of the 81 provinces of Turkey. With so few facilities, inconsistencies and limitations in obtaining addiction treatment are widespread. Moreover, the extensive ties between addiction, society, and environment are often not reflected in current treatment models. Turkish citizens are covered by its general health insurance, which in accordance with Turkey’s Law on Social Security and General Health Insurance, covers all services and costs provided at AMATEMs (6).
These primarily inpatient programs are based on a system titled SAMBA which is based on Cognitive Behavioral Theory. In some sessions interventions are based on Mindfulness, Acceptance and often include techniques of Dialectical Behavior Therapy and Emotion Regulation .
The Structure of SAMBA is composed of 7 modules and 13 sessions. Modules of SAMBA are:
1. The Effects of Drugs, Alcohol, and Tobacco 2. Motivation 3. Mindfulness 4. Anger and Stress Management 5. Relapse Prevention 6. Communication Skills 7. Thinking Errors (7)
These programs also provide medication assisted treatment (MAT) primarily through the application of Suboxone, a buprenorphine/naloxone combination oral medication.
It appeared as reported by the AMATEMS that these programs desired education regarding addiction and recovery to include the role of 12 step programs and this is now provided to two AMATEMS by the center. In turn the AMATEMS provide detox services to the local program. As of late, additional AMATEMS outside of the community have asked to develop reciprocal agreements with the local program. At this time the Center has formal agreements with three local AMATEMS (one on the Asian side). These agreements include medical care for patients, inpatient treatment when needed and other support services. In turn the Center is providing seminars to patients and their families, care coordination and access to community resources. With some patients the center provides conjoint treatment where the clinical services are at the AMATEMS while the Center provides the essential services for long term recovery.
In addition, the local hospital has agreed to offer medical support to the center’s clients based on a strong reciprocal relationship established by the center.
The program has developed another strategic partner called Yesilay which is the Turkish arm of the Green Crescent Society. The Turkish Green Crescent Society was founded by patriotic people and intellectuals (Dist. Prof. Mazhar Osman and his friends) from a diverse set of backgrounds in 1920, response to the British attempts to distribute booze and drugs free of charge in Istanbul in an effort to undermine the resistance against the occupation. The founders sensed the upcoming dangers of alcohol and drug addiction that resulted in decline of the resistance against the occupation. The patriotic intellectuals established the “Green Crescent”, “Hilal-i Ahdar” in Istanbul in order to warn Turkish society. The official name of the association is “Türkiye Yeşilay Cemiyeti”, “Turkish Green Crescent Society”. (8)
The significance of this relationship is that the program is working with this leading agency responsible for addressing issues related to addiction in Turkey.
Community Engagement: With the enthusiastic support of local government the program has taken to the streets. By erecting information stands in the most challenged neighborhoods where drug use is most prevalent, the center has been able to engage clients from those who have begun to experiment with drugs to hard core addicts.
Another program activity, community picnics, are sponsored by the center and include clients and their families along with many stakeholders and community members. This is another activity that engages clients in the program and helps to combat stigma with the theme "Days of Struggle Against Addiction".
Creative community activities are ongoing as the program develops its role as an essential link in the community service delivery system.
Families: Family sessions, education and participation in the care plan is an underpinning of the community-based program. Families receive ongoing psycho- education, engage in individual and multi family groups and most important are in involved in facilitating access to essential services needed for long term recovery.
Barriers: Our survey of stakeholders revealed that although there were many services in the community that the client could benefit from, they were disparate and access to these services were a serious challenge for the clients and their families. Providing pathways to services and a network among stakeholders has proven to be very powerful and an important ingredient in supporting sustained recovery.
Case Management: Case Management is an ongoing activity which provides support and advocacy for the client across the care continuum. The goal of Case Management is to assure that care plans are current and that clients are gaining real time access to essential services that support their recovery. Most of all the case manager is an advocate for the client and the community.
Religious Leaders: The program continues to involve religious leaders in the system. In a poll conducted by Sabancı University, 98.3% of Turks revealed they were Muslim. (9). As a result it has been important to assure that not only was the program culturally infused it had to have strong considerations for religious beliefs and practices. In addition, the inclusion of religious leaders as stakeholders has gone far in supporting a full integration into the community.
The New York Times published a report about Turkey in 2012, noting an increased polarization between secular and religious groups in Turkish society and politics. Critics argue that Turkish public institutions, once staunchly secular, are shifting in favor of Islamists (10).
The significance for the program is that religion is often a large part of one’s daily life, politics, etc. and must be considered when establishing client driven treatment goals and program protocols.
Stigma: Although stigma is viewed as a universal challenge it takes on special meaning in Turkish religion, culture, law enforcement and politics. As an example, every AMATEM doctor must report all patients, including the patient’s name, to a national registry; this lack of anonymity at public centers may be an important barrier to treatment access, particularly among Muslim women, who may avoid seeking help for drug use due to fear of negative community consequences.
Further, when admitted to an AMATEM center, the patient name and file can be accessed by any national body, including those that will determine whether a patient is able to pursue certain professions. Such policies can lead to stigmatization, fear of disclosure/lack of confidentiality, and issues with finding jobs.
The center has a strong commitment to activities that combat stigma such as education about the disease and publicizing the pathway to recovery and its benefits.
Summary
The leverage obtained through community relations and empowerment is very impressive. This remarkable team has been able to establish a significant community network that supports the center and the clients they serve. We feel confident that this program is on the road to becoming one of the most effective community focused programs that C4 and the Levenson Foundation have ever had the privilege of supporting. Moving from a clinical model to a community model has already produced signicant outcomes for the client, program and community. It is our impression that the success of this program has the potential to influence the field far beyond Turkey.
As the Director of the center reported, " When I see one patient I make an impact only on that family when I work in the community I reach many”. This underscores the essence of the work being accomplished at this center. Far beyond any clinical practice such as CBT etc., where one rarely knows the impact of the session, this center is working with real time living and the challenges of daily recovery. The overall outcome is to provide comprehensive support all through the recovery journey not simply focused on drug use alone. This is about capacity building by leveraging stakeholders in the community. The center can provide recovery support on many levels without the constraints of a designated clinical outpatient program or level of care.
Finally, we have developed a qualitative methodology to track the outcomes at the center. Since the program is only about one year old we plan to provide longitudinal data to document outcomes. What we can say at this time is that significant strides have been realized as clients are retained by the center, resources and capacity to support recovery have been widely expanded and stakeholders not traditionally involved in recovery efforts have enthusiastically joined in supporting clients and their families.
It is interesting to note that in building this system the budget decreased as we needed less clinical staff. The result is comprehensive real-life services far beyond what we were able to offer in the past. The program has been able to mobilize finite resources already in existence to create
a system of services that is sustainable and has great potential to support long term recovery.
What we find most relevant is that this program is the catalyst for community empowerment and at the end of the day the program clearly reflects the values of this community, is couched in cultural humility, and is uniquely their own.
Note: I would be remiss if I did not acknowledge the contributions of Rick Ohrstrom and Jill Lynn who have spent a great deal of time contributing to the veracity of this article.
References
1 Turkey Government Report 2017 http://www.emcdda.europa.eu/countries/drug-reports/2017/turkey/drug-use_en Turkish Monitoring Centre for Drugs and Drug Addiction
2. Levernick J. Bonzai Epidemic Hits Turkey: New Drug, Old Story Roar Magazine. 2016
3. Baumann, M., Spitz, E., Guillemin, F., Ravaud, J., Choquet, M., Falissard, B., & Chau, N. (2007). Associations of social and material deprivation with tobacco, alcohol, and psychotropic drug use, and gender: a population-based study. International Journal of Health Georgraphics, 6(50), 1—12. doi:10.1186/1476-072X-6-50.
4. SONGÜN, SEVİM (2010-01-01). "Turkey's smoking ban changes habits, inspires innovations". Hürriyet Daily News. 201
5. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.
6 http://www.emcdda.europa.eu/attachements.cfm/att_214108_EN_Turkey_NR2012.pdf
7. EFFECTIVENESS OF AN ADDICTION TREATMENT PROGRAM CALLED SAMBA: A PILOT SUDY Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S150-1
8 Official Website Green Crescent https://www.yesilay.org.tr/en 2018
9."Religion is very important"). Global Attitudes Project. Pew Research Center. Spring 2015.
10. Source: http://www.birgun.net/haber-detay/bonzai-olumle-yasam
Bio Dr. Bob Lynn:
Dr. Lynn is an internationally recognized lecturer, researcher, and clinician in the field of Counseling Psychology and Substance Use Disorders. During the past 45 years, he has held leading positions in many clinical settings, levels of addiction treatment, Employee Assistance Programs, State Government, and as a professor in several universities. He is a Board Certified Licensed Professional Counselor and Senior Fellow in Neurofeedback Practice. He is also a recognized expert in Family and Behavioral Therapy.
Dr. Lynn completed his doctoral studies at Rutgers University School of Graduate Education. His major research focuses on issues related to treatment outcomes.
Dr. Lynn has been recognized by NJ Assembly Resolution for his efforts in the fight against Drug Dependence. He is Chief Clinical Advisor for The Levenson Foundation, Affiliate Rutgers Center of Alcohol and Substance Use Studies, Director of Program Development-International for C4 Recovery Solutions, CEO/Founder Addiction and Behavioral Health Alliance LLC, as well as Clinical Director for the National Council on Alcohol and Drug Dependence NJ Juvenile Justice System Adolescent Evaluation and Treatment Project.
Dr. Lynn, although known for his many contributions to the Treatment Community, may be best known for his development of methods for the assessment and placement of clients and developing client centered care coordinated treatment systems focused on research and outcome data in the United States, Europe and the Middle East. His major focus being the development of systemic community-based systems that promote wellness.
Dr. Lynn’s most significant accomplishment may be his ability to help restore hope in communities overwhelmed with despair, finding strength when resources have been depleted and empowering local people to better utilize finite resources and create programs for growth and empowerment that promote family and community sustainability.