This article, prepared with the assistance of 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. In addition, 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.
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 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 aware that Turkey came with its own unique challenges, although we believed that these were not unsurmountable in developing a program.
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 (EMCDDA, 2017).
For several years, “bonzai”—a type of bootleg, synthetic cannabis—had been ravaging its way across the lower echelons of Turkish society, leaving little but destroyed lives, addicted youth, and shattered dreams in its wake (Leverink, 2015). There are currently 1.5 million drug addicts in Turkey and one-third of them are bonzai users. Moreover, deaths related to bonzai abuse are increasing day by day (“Bonzai,” 2017).
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. Baker writes,
According to the office of the US 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 is 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 [four to ten years of jail time] and imprisonment will be increased by one-sixth” (2015).
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 affected by nicotine addiction. Smoking and alcohol abuse among medical students and physicians should be taken more seriously, as their own attitudes towards substances may influence their professional behavior. There is a need for better education about substances (Baumann et al., 2007).
A Gallup poll in May 2007 revealed that over half of Turks aged fifteen to forty-nine had smoked on the day before the survey (Ray, 2008).
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,” 2016).
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, inpatient, adolescent 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 outpatient 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” (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, 2013). In other words, a model consisting of clinicians and recovery advocates with a focus on abstinence supported by the Twelve 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 of the door, our static capacity with two clinicians, two peer counselors, and one secretary was less than thirty 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 of the 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: falling for the misconception that if a practice has some validity in the counseling world, it could easily be thrust upon addicts under the guise of evidence-based care. This is not true, so 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, and assured 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. The municipality experienced serious financial issues and they were no longer able to fund their share of the employees, leaving only two C4-funded employees.
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 addicts would not come to the center and we wanted to reach large numbers, we would go to the addicts 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; in other ways, it was 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 or EMDR. What does sustain recovery are real-life services such as employment, housing, transportation, childcare, and others that meet clients’ needs as they understand them.
In this program, clients are not merely the individuals in treatment, but also families and communities. Rather than a rigid level of care, the program represents a continuum driven by the needs of these clients.
The following is what we proposed should be the revised focus of the center:
Services within the center include the following:
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, and creating multiple layers of recovery support while the center has a very large impact on the community.
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, and health care services that could provide withdrawal management and appropriate medication, therapists, psychologists, and 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. We were meeting with those 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.
In this phase, we began to invite individual stakeholders to the center and, in turn, 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.
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.
Based on the inclusion of stakeholders in the system on a reciprocal level, the program has expanded exponentially in the following areas.
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 clients’ permission, the program communicates with employers and provides counseling to clients regarding real-time events on the job and continuing drug screens to assure employers that the clients are not using drugs. As a result, employers gain a better understanding of recovery and the barriers created by stigma while often gaining grateful and enthusiastic employees.
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.
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 addicts, and direct them to the center. This is the prearrest component of the program. The same addicts 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. 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.
The Turkish Ministry of Health provides national treatment for drug use through twenty-two existing governmentally funded Research, Treatment, and Training Centers for Alcohol and Substance Dependence (called “AMATEMs” or “AMATEM centers”) that are in thirteen of the eighty-one 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 (EMCDDA, 2012).
These primarily inpatient programs are based on a system titled “SAMBA,” which is based on CBT (Ögel et al., 2011). In some sessions, interventions are based on mindfulness, acceptance, and often include techniques of DBT and emotion regulation.
The structure of SAMBA is composed of seven modules and thirteen sessions. The modules of SAMBA are:
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 Twelve Step programs. 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, including one on the Asian side. These agreements include medical care for patients, inpatient treatment when needed, and other support services. In turn, the center provides seminars to patients and their families, care coordination, and access to community resources. With some patients, the center provides conjoint treatment: 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, the Turkish arm of the Green Crescent Society. The Turkish Green Crescent Society was founded by patriotic people and intellectuals—Distinguished Professor Mazhar Osman and his friends—from a diverse set of backgrounds in 1920 (Green Crescent, n.d.). It was a 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,” or “Hilal-i Ahdar,” in Istanbul in order to warn Turkish society. The official name of the association is “Türkiye Yeşilay Cemiyeti,” or the “Turkish Green Crescent Society” (Green Crescent, n.d.).
The significance of this relationship is that the program is working with this leading agency responsible for addressing issues related to addiction in Turkey.
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 hardcore 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.
Family sessions, education, and participation in the care plan is an underpinning of the community-based program. Families receive ongoing psychoeducation, engage in individual and multifamily groups, and most importantly are in involved in facilitating access to essential services needed for long-term recovery.
Our survey of stakeholders revealed that although there were many services in the community clients 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 is an ongoing activity that provides support and advocacy for clients 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, case managers are advocates for clients and their communities.
The program continues to involve religious leaders in the system. The majority of Turkish people are Muslim (Pew Research Center, 2015) and as a result, it has been important to assure that not only was the program culturally infused, it had 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 (Giridharadas, 2012). Critics argue that Turkish public institutions, once staunchly secular, are shifting in favor of Islamists.
The significance for the program is that religion is often a large part of people’s daily lives and politics and must be considered when establishing client-driven treatment goals and program protocols.
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 patients are 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.
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 has ever had the privilege of supporting. Moving from a clinical model to a community model has already produced significant outcomes for clients, programs, and communities. 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, where we rarely know the impact of the session, this center is working with real-time 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 fewer 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. At the end of the day, the program clearly reflects the values of this community and is uniquely their own.
Acknowledgements: I would be remiss if I did not acknowledge the contributions of Jill Lynn, who has spent a great deal of time contributing to the veracity of this article.