Episode 3: Fighting Stigma Around Recovery in Turkey
In this episode we hear from Cigdem Sonmez who used her lived experience as a recovered addict to help C4 create a tailor-made treatment program in Avcilar, Turkey. She is joined by Dr Bob Lynn for a panel discussion on the intricacies of setting up such a program in Turkey.
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Jack O’Donnell Welcome to the third episode of the C4 Recovery Solutions podcast. I am your host, Jack O’Donnell. Some of you might know me as the CEO of C4 Recovery Foundation. As many of you know, C4 is dedicated to improving access to high-quality, ethical treatment services for behavioral health and social wellness. We are fierce advocates for the often overlooked individuals and underserved populations within our society. Through innovation and forward-thinking, C4 has developed service delivery systems for addiction and recovery programmes throughout the US and throughout the world in some of the most challenging environments.
Each week on this podcast, we will hear stories from people who have benefited directly from programmes C4 developed, those who assisted C4 in the process, and especially those still involved in the implementation of the programmes today.
On today’s episode, we’re discussing the issue of recovery and rehabilitation in Turkey, a country where the recovery and treatment field was dormant in the face of a growing addiction problem. This is where Çiğdem Sonmez comes in. Çiğdem created one of the few community-based programmes with a local focus. And now, here is her story.
Çiğdem Sonmez Merhaba. Benim adım Çiğdem. [Hello. My name is Çiğdem.] I am forty-five years old and have been clean for eighteen years and five months. When I stopped using, I started educating. Education has always been a passion of mine through my own lived experience of being an addict in Turkey. I realised the need for addiction treatment programmes in Turkey. My company, Life Academy, in Istanbul, where I work as a social worker, family services, a liaison, and addiction consultant. I met C4 in 2014 when Rick Ohrstrom, the chairman of C4 Recovery Foundation, came to Turkey. They wanted to assess what treatment and rehabilitation programmes were available to addicts in Turkey. They held a conference attended by almost everyone working in the field of addiction and recovery. They chose me to lead their Turkish programme.
This is where it got tricky. While Rick believed in me, I face more challenges as a woman in leadership position. Much like domestic violence, addiction is a huge issues in Turkey that the country has been working on finding solutions for. In terms of addiction, treatment, and recovery, things are improving in Turkey. This is partially due to C4’s involvement. C4 and I started one recovery and stabilisation programme in Avcilar. After a year, we were able to show that not only was it possible to make sound business within the addiction treatment sector. In doing so, we were able to inspire people to create more addiction treatment programmes.
Our program fought against so much stigma. In Turkey, addicts were not employable and are seen as a nuisance. Our programme showed that people can be rehabilitated. Too many people of Turkish descent are addicted to bonzai, a chemically altered from the THC that was introduced in 2002 to replace marijuana. It is far more toxic than cannabis. And in just 2018 alone, five hundred sixty-four people died from bonzai overdose. The other major problem, like the rest of the world, is methamphetamines.
This is why we started small in Avcilar. We wanted to perfect our model to ensure we had the best chance of successfully helping people recover and rehabilitate. We knew we were doing something great when members of Green Crescent came to visit our rehab centre. They were impressed with our focus on the aftereffects and rehabilitation side of addiction treatment instead of the usual focus on prevention.
Before C4, they were a few twelve-steps programmes and hospitals with detox programmes. But people had to wait a while to get in. On top of that, there wasn’t much guidance for people after finishing these programmes. There was no continuum of care. The rich were always able to go to expensive centres. The poor had no options.
After C4, we have one of the most important things: momentum in the field. We showed people that it works. And recurring support has blossomed. C4 showed that there didn’t need to be stigma in working in this field and that these programmes could be viable businesses.
Fifteen years ago, it was impossible for people to understand what an ex-user was. They didn’t see the lived experience I had as a valuable tool for education. The only respectable people in the field were those who graduate from university with psychiatry and psychology degrees. They told me I wasn’t enough. C4 changed the conversation.
Today, Turkey still needs a lot of help in the rehabilitation area. I am currently working on a project that combines cycling with recovery. I’m a professional cyclist and actually ride on a team in Istanbul. We were preparing for a big ride against addiction to raise awareness, so it’s covered by the media.
My focus is on addict and their families. I run my company, Life Academy, and I am soon graduating from university with a degree in sociology. I can’t stop learning and know my work will never be finished, because I have so much knowledge to share. My passion is coaching people. I do a little bit of life coaching, too. But addiction therapy will always have a special place in my heart.
Jack O’Donnell As Çiğdem touched on, Turkey, and Istanbul, in particular, has a drug and alcohol problem that is having a far-reaching impact on society as a whole. Like most countries, people with substance use disorders in Turkey face high incarceration rates. There is treatment provided in jails, but the aim of programmes like Çiğdem’s and that of the Green Crescent is to make sure addicts get the help they need before encountering the criminal justice system. Also like most countries, there is a lot of stigma and denial regarding the issue of addiction. This is because for those on the outside, it is hard to understand.
There was a wide range of drug types that individuals suffering from substance use disorders use—from street inhalants, cannabis, ecstasy, benzodiazepines to injectables, such as heroin and cocaine. Many drug users began abusing drugs at a very early age. A national survey in 2003 saw many begin using street inhalants as early as eight to eleven years old. As Istanbul has a population of over fifteen million people, there is bound to be higher demand there than in the rest of Turkey. It is hard to meet such high demand and provide quality drug treatment programmes to all who need it. The centres that did treat drug use focus mainly on detox as this is one of the most immediate solutions they can offer. Unfortunately, this means a high rate of relapse.
This is why C4 got involved to help provide continuing care, so that individuals could stay clean and reintegrate into society. After detox, C4 started to convene meetings between professionals, twelve-step fellowships, and anyone else interested in developing the current treatment field. As a result of those conversations, C4 started partnerships with two local municipalities. This local community approach was a great fit for the community treatment system C4 wanted to implement. The community treatment system has four main components. One: local government, which in this case was the municipalities of Avcilar and Beylikduzu. Two: primary care, clinical, medical, detox, acute care, and stabilisation. Three: community recovery, peer support, job training, childcare, housing, and education. And four: spiritual or clergy. C4 helped fund the centres, hired and trained the employees, convened meetings between different stakeholders, launched online platforms, and provided clinical supervision.
Instead of creating a boilerplate treatment template, C4 conducted research and iterated the treatment programme continuously in order to address the local needs from a socio-cultural standpoint. In addition to developing a unique programme for the local community, C4 also provided training to many individuals, whom then became the qualified workforce for the treatment field in Turkey today.
For today’s panel, we are joined by Çiğdem and internationally-recognised lecturer, researcher, and clinician in the field of counseling, psychology, and addiction, Dr. Bob Lynn.
So, Dr. Bob, thanks for being with us today. I want to begin our panel discussion with an obvious subject. That is in regard to the cultural differences in a country such as Turkey. Compared to other places C4 has designed treatment systems, tell me a little bit about the big differences between Istanbul and, say, designing a system in the United States.
Bob Lynn Originally, when we came to Turkey, we thought we would export some of the clinical and theoretical experiences we had in other countries. And – and we want it to be totally inculturated and we wanted to come in with cultural humility. So, we worked with a lot of the local expertise, including people in the universities to develop instruments, et cetera, and we spent a great deal of time making sure that the theoretical and the practical instruments and – and all of the clinical processes reflected the needs of the community in Turkey.
That was our tension from the beginning, Jack. However, we found out very quickly that—and just as you pointed out—the differences were even greater than we expected. In fact, by trying to import anything that looked like a clinical process from another even evidence-based model just didn’t float in Turkey. Just didn’t make sense at some point. So, what we did was we changed our direction and moved to what is called the community-based system. And the way that we overcame just the issue that you brought up, Jack, the diff- – the cultural challenges, we were able to develop a system and a treatment model that clearly reflected the community itself, empowered community stakeholders, and privileged – and privileged local expertise.
So, the – the system itself became a unique – a uniquely Turkish system as opposed to an inputted system from another region. And that was – that was one of the most exciting parts about being in Turkey, is that we were able to approach it from a one-down informed position rather than a one-up position where we were looking down or bringing something in. And that’s what made it so exciting, because it became a Turkish system as opposed to an imported Italian, American, French system.
Jack O’Donnell Yeah. You know, that makes perfect sense, ‘cause I guess if you get the professionals on board, then you go to the municipalities, and they know that you’ve already taken this into consideration. It’s a lot easier for them to accept.
Bob Lynn And – and that’s when it – and that’s when it really took off. And it was really interesting, Jack, that we found out that in terms of recovery in Turkey, more important than, you know, CBT or EMDR or any other clinical model that you might import, most important was the connection to real – real life on the ground. Quality of life on the ground, which included things like transportation, jobs, childcare, medical care. All of the things that were available in the community, but they were disparate. They were not connected. They were… There was not a real system. So, what we were able to do was to put together a system on the ground that really supported sustained recovery as opposed to a counseling session, which – which might appear to be making sense, but really did not support sustain recovery as we knew it.
Jack O’Donnell You know, how important were the traditional recovery support groups to the systems, such as, you know, AA and NA? Did Istanbul have a good twelve-step network when C4 arrived?
Bob Lynn Well, there were challenges in that area as well, Jack. The AA was highly problematic and it was very difficult to make any inroads with AA. We – we had several meetings. However, the – the paradigm, the AA paradigm, as we know it in the United States and other places, really, was very different in Turkey. What did have a greater root was NA. And we were able to make significant inroads into NA as a result of meeting some of the significant people being a leader in – in the NA community. And as a… And then, we were able to bring some of the long-term NAA folks into the system. The – the interesting thing was that we realised that, although the NA community was very powerful for some people, that we really could not put all our eggs in that basket. That we really needed to have NA as – as an option, but we needed other alternatives as well.
Jack O’Donnell So, you have the, you know, the local AA community. You’ve got the treatment providers. You’ve got the social services lined up. What about law enforcement? That’s a key component here. And that’s difficult in any country. How difficult was it to get law enforcement buy-in in an environment like Istanbul?
Bob Lynn Brilliant question for Istanbul and for Turkey, in general. As you probably… As you may know, that historically, politically, and through law enforcement, addiction was seen through a punitive lens. Law enforcement, it was seen as part of the political system. What was really interesting for us once we were able to develop a community based-model—and I think this is really important to understand, because, you know, at least contextually—we were able to get law enforcement involved in the programme to the extent police were bringing folks to the centre for treatment and that we were able to partner with – with law enforcement in the Istanbul community, particularly where the centre was located. Now, that might not sound like a monumental accomplishment, but in Turkey, it was, Jack. And it was one of the more exciting things about the programme.
Jack O’Donnell Listen, it’s a tough challenge everywhere to get law enforcement buy-in. And it’s really a shame, you know, that you have to kind of drag them along. But once they get there, you know, they really see the benefit, because it, you know, it, A, it gets people healthy again, but it also cuts down on a lot of work and costs for the criminal justice system.
So, Çiğdem, did you see early resistance? Or did the local governments get on board quickly?
Çiğdem Sonmez When we started, two local governments wanted to start right away. And they did. When we tried to reach out to other municipalities, we faced challenges. Most of them had a hard time understanding what we wanted to do. They were hesitant, because the topic was addiction. It was not resistance, but hesitancy. In addition, most of them didn’t think that funding a project like this will be meaningful, because they didn’t have enough knowledge about long-term recovery from addiction.
Jack O’Donnell So, how was the communication between different stakeholders in the field? Do the public programmes, community, and private practitioners come together or do they tend to work separately?
Çiğdem Sonmez The stakeholders were somewhat in communication, but it was mostly conversational. They met with some hospitals as long-term recovery from addiction was a relatively new concept. Our country needed some clarification before getting involved. It was a bit difficult to provide treatment services in organisations due to some regulations at the time. But in 2019, the regulations were published in the Official Gazette, which proved to be a pivotal move.
Jack O’Donnell Does the field, both the public and private sector, now recognise that better treatment is necessary to defeat the issue? Or are they still slow to respond and admit the seriousness of the issue?
Çiğdem Sonmez Our country was already aware of this situation, and they knew it was serious. But like in other countries, one of the biggest challenges was raising awareness. Fortunately, our government supported this cause greatly. None of the previous governments were attentive to the issue like the current one. In 2014 or 2015, the president of Turkey had a large conference on this topic and ordered that action must be taken to address this issue. He gave this job to organizations like Green Crescent and all municipalities.
This decision is very important organisation in Turkey. They launched their first programme YEDAM in 2015. Following that, they started many more addition treatment centres. Today, many people with substance use disorders and their families receive services for free through these centres. This is a very important step.
Jack O’Donnell So, Çiğdem, what was your most proud contribution to this project? What gave you the most satisfaction?
Çiğdem Sonmez I’m most proud of having ex-users take part in the field as recovery support specialists. This is what made me feel satisfied with our work. This is important, because it has never been done this way before. Today, ex-users guide and coach clients together with therapists. And this was a first for Turkey.
This is one of the most important contributions C4 made to Turkey. People like me, ex-users, and recovery community members, have tried this for many years. But it’s only happened once C4 became involved. Because of this, many more training programmes like ours have been able to come alive.
Jack O’Donnell So, Çiğdem, are you optimistic things will continue to improve regarding treatment in Turkey?
Çiğdem Sonmez I have always been optimistic and had hope for Turkey. These are problems that you can see everywhere else in the world. We have the same issues. We deal with the same drugs and challenges. The issue was this: We needed to raise awareness about who is an addict and what is recovery. This was critical.
Today, we have graduate programmes focused on addiction. There are many courses. More people than way before work in this field. Students from sociology or medical departments can take courses on addiction today. They can learn about addiction and rehabilitation. All of this happened in the last ten years.
Jack O’Donnell How has stigma and general attitudes toward the issue of addiction changed in Turkey since C4’s involvement?
Çiğdem Sonmez C4, as an international organisation, attracted a lot of attention here. An international organisation who has been working on the issue at the global level came to Turkey. They provided training, supervision, and funding for this field. This created awareness. We have been on the news. We had interviews in the newspaper. Me being the leader of the project as an ex-user and as a woman made people more interested. This public visibility has a lot more training programmes to serve the field.
Jack O’Donnell So, Bob, you’ve worked in a lot of environments, you know, from helping design systems in New Jersey to the UK, as we’ve discussed on other podcasts. What was it about Istanbul? I know you’ve – you’ve referenced how rewarding that work has been for you. What was really the most rewarding part of working in Istanbul for you?
Bob Lynn You know, I – I have to say without hesitation, Jack, that us working in Istanbul was really a highlight of my career. And what was really rewarding was that, you know, we talked the talk about community and being part of the community, developing serious community empowerment, being a – a serious part of the community in a way that we were able to see systems really developed that supported sustainable recovery. I mean, that – that was what was – was most important to me and is what… And I mean, to be honest, Jack, that’s what I’ve taken away from the experience, because I think that is what’s most replicable.
You know, just going back very quickly to your previous statement about culture and – and those challenges. When you develop a community programme such as this one, it transcends culture in a sense, because it’s normative and it reflects the community and its values. So, now, you have a system that not only it’s replicable and actually apply to almost any community, if not, you know, almost in the world, because what you’re doing is you’re coming in and working with and privileging local expertise. And the programme becomes uniquely theirs. And that’s what – that’s what was most exciting and what’s what – what I take back and what I take away from the Turkish experience, Jack.
Jack O’Donnell Instead of just copy-and-pasting the programme C4 had provided to be successful in New Jersey and in the United Kingdom, C4 spent time on the ground in Turkey, meeting with those already in the field, to help create a tailored programme that would bring the most benefit to the addiction treatment sector in Turkey. By working with Çiğdem on a pilot programme in [PLACE], C4 was able to provide the Turkish field with a blueprint for how to best create recovery programmes in the future. Without the dedication of Çiğdem, thousands, if not millions, of Turkish people would be without the care they need.
Well, listen, I want to thank you, Dr. Bob Lynn and Çiğdem, for – for joining me today. I am certainly proud of the work that you did. I’m proud that I was associated with this work as well. So, thanks very much. On behalf of all the people of Turkey and Istanbul, C4 is so grateful for the work that you do.
Jack O’Donnell Thank you for listening to this week’s episode of the C4 Recovery Solutions podcast, brought to you by C4 Recovery Foundation. For more information, please visit our website at c4recoveryfoundation.org or email us at email@example.com.
Be sure to rate, review, and subscribe on Apple Podcast, Spotify, Stitcher, or wherever you like to listen. I’ll see you the next time on the C4 Recovery Solutions podcast. Goodbye.