Primary prevention involves efforts to protect individuals from disease agents before diseases emerge. In the context of addiction, primary prevention focuses on activities aimed at preventing individuals who have not yet been exposed to substances or are at risk of exposure from developing substance use disorders.

Primary prevention programs are designed to be implemented before individuals start using substances. Therefore, preventive interventions are typically applied during primary and middle school years (early adolescence).

In this context, efforts have been accelerated by National Green Crescent Organizations to develop and disseminate prevention-focused educational programs. Some examples of educational programs include:

Green Crescent Addiction Prevention Education Program:

Developed and implemented by the Turkish Green Crescent, a member of the International Federation of Green Crescent, the Green Crescent Addiction Prevention Training Program is a school-based primary prevention program initiated in 2014.

The aim of the program is to prevent alcohol, tobacco, substance, gambling, and technology addictions across the entire community, with a primary focus on children and youth, and to promote a healthy lifestyle awareness. The program's objectives include:

• Increasing societal awareness in preventing addictions,

• Contribution to the community's safe and healthy living,

• Enhancing knowledge about alcohol, tobacco, substance, gambling, and technology addictions within the community,

• Supporting protective and preventive factors,

• Strengthening advocacy activities against addictions.

The target audience of the Green Crescent Addiction Prevention Education Program includes children, youth, and adults, starting from the age of 4, covering preschool, primary school, middle school, high school, and adult modules.

The content of the educational program has been developed by the Green Crescent Scientific Board and experts, aligning with the levels of education defined by the Ministry of National Education and considering educational achievements. In order to build the scientific and academic foundation of the created content, Addiction Resource Books have been prepared. These books are authored by experts and academics who stand out with their academic studies and clinical experiences in the relevant field. This ensures that all educational content is based on solid and reliable scientific principles. Additionally, based on needs analysis studies conducted by the Green Crescent and feedback from the field, all educational content prepared within the program was reviewed in 2020. Rewriting and production work were carried out in identified areas. In this context, presentations, workbooks, 10 storybooks, 5 children's songs, 21 animations, 76 activities, 5 board games, and 21 posters and brochures were prepared. Furthermore, a gambling addiction module has been added to the program as a new module at the middle school, high school, and adult levels.

The Addiction Prevention Education Program consists of 34 modules under 6 main topics. These topics include healthy living, alcohol addiction, tobacco addiction, substance addiction, gambling addiction, and technology addiction. Modules have been developed for all age groups from preschool to adulthood, taking into account developmental characteristics and average ages of substance initiation.

The program is designed with a student-centered educational philosophy, emphasizing scientific accuracy, relevance, and experiential learning. A spiral programming approach was used in the design, allowing the program to start in preschool and repeat and expand its scope in primary, middle, and high school. Repetition is incorporated into the program to ensure the permanence of learning, and support activities strengthen the program.

The program follows a strategy of widespread dissemination by training specialized educators first, who then train practitioners in the role of instructors. As part of the dissemination strategy, trainers with the role of expert educators are initially trained, and these trainers then train practitioners in the role of instructors. With the knowledge and skills acquired through their training, these instructors transfer educational content to students and adults from different layers of society, contributing to the widespread implementation of the program.

Through the Distance Education Platform, content related to alcohol, tobacco, substance, gambling, and technology addiction, as well as content related to healthy living, can be accessed both synchronously and asynchronously. The content is also supported in Arabic, French, English, and Russian languages, making it accessible to a global audience.

Reaching millions of students and adults each year, this program is implemented nationwide in collaboration with the Ministry of National Education, covering all schools in the country. In addition, it is being expanded through training sessions for private sector organizations and non-governmental organizations that request it. The Addiction Prevention Education Program, aiming to be a global model as a scientifically based and evidence-based education program, has been adapted and translated by various Green Crescent Organizations worldwide through collaborations and training.

Green Crescent Life Skills Education Program:

The Green Crescent Addiction Prevention Training Program, developed by the Turkish Green Crescent, a member of the International Federation of Green Crescent, has been implemented since 2014. This program falls under the category of school-based primary prevention education.

The main goal of the Addiction Prevention Training Program is to prevent alcohol, tobacco, substance, gambling and technology addictions, and to promote a consciousness of healthy living throughout society, with a focus on children and youth. The program's objectives include:

• Increasing social awareness in preventing addictions.
• Contributing to the overall safety and health of the community.
• Enhancing the community's knowledge about alcohol, tobacco, substance, gambling, and technology addictions.
• Supporting protective and preventive factors.
• Strengthening advocacy activities against addictions.

The target audience of the Green Crescent Addiction Prevention Education Program includes children, youth, and adults, starting from the age of 4, covering preschool, primary school, middle school, high school, and adult modules.

The content of the education program has been prepared by the Green Crescent Scientific Board and experts, considering the levels of the Ministry of National Education and the achievements. Addiction Resource Books have been created to establish the scientific and academic infrastructure of the content. These books are authored by experts and academicians who stand out with their academic studies and clinical experiences in the relevant field.

In addition to the scientific foundation, the content has undergone reviews and revisions based on needs analysis studies and feedback obtained from the field by the Green Crescent. In this context, presentations, workbooks, 10 storybooks, 5 children's songs, 21 animations, 76 activities, 5 board games, and 21 posters and brochures have been prepared. Furthermore, a gambling addiction module has been added to the program content for middle school, high school, and adult levels.

The Addiction Prevention Education Program consists of 34 modules under 6 main topics: healthy living, alcohol addiction, tobacco addiction, substance addiction, gambling addiction, and technology addiction. These modules, designed for all age groups from preschool to adulthood, consider developmental characteristics and average starting ages for substance use.

The program, developed with a student-centered education philosophy, prioritizes scientific accuracy, relevance, and experiential learning. A spiral programming approach has been used, allowing program achievements to be repeated in primary, middle, and high schools while expanding the scope with new topics. To ensure the permanence of learning, the program includes periodic reviews and is reinforced with supporting activities.

The program adopts a strategy of raising awareness among influential professional groups directly connected to the target audience, enabling them to transfer this knowledge to the target audience through interactive content, presentations, and activities. As part of the dissemination strategy, expert trainers are initially trained, and upon completion, they train practitioners in the role of instructors. Equipped with the necessary knowledge and skills regarding addictions through their training, these trainers and practitioners ensure the dissemination of educational content to students and adults from different segments of society, contributing to the widespread implementation of the program.

Through the Distance Education Platform, access to the content related to alcohol, tobacco, substance, gambling, and technology addictions, as well as content on healthy living, is available both synchronously and asynchronously. The content is also supported in Arabic, French, English, and Russian languages, making it accessible to a global audience.

Implemented in collaboration with the Ministry of National Education, the program reaches millions of students and adults every year and is extended to cover all schools in all provinces. It is also expanded through training programs for private sector organizations and non-governmental organizations that request it. The Green Crescent Addiction Prevention Education Program, aiming to be a global model as a scientifically based and evidence-based education program, is implemented worldwide through collaborations and training with other member Green Crescents. It has served as an example for various Green Crescents in different countries, leading to translation and adaptation efforts.

Yeşilay Life Skills Education Program:

The Yeşilay Life Skills Education Program is a school-based preventive and empowering education program consisting of activities to help students lead a life free from addiction risks, acquire positive behavior changes and habits, and protect themselves from risky environments and situations. The program is developed with the aim of instilling life skills identified by an expert team based on the opinions of specialists, families, and young people to make individuals resilient against addiction during adolescence. The main objectives of the program in this context are:

• Preventing the use of addictive substances

• Reducing risk factors

• Increasing protective factors

The program aims to develop fundamental life skills in three main areas. Two important points were considered in selecting these life skills. Firstly, identifying the life skills that individuals especially need during adolescence, and secondly, considering the life skills required to prevent substance use. Therefore, in this program, students are targeted to:

• Cope with negative emotions

• Regulate peer relationships

• Have self-awareness and a healthy body image

The target audience of the program is 7th-grade students who have not tried or have tried but are not regular users of cigarettes, alcohol, or other substances. Additionally, supplementary activities have been developed for implementation when these students transition to 8th grade.

The program is implemented nationwide in collaboration with the Ministry of National Education. Psychological counselors/guidance teachers working in Ministry-affiliated middle schools are trained as trainers (master trainers). The trained trainers conduct training sessions in their regions, train practitioners who will implement the program, and continue to implement the program in their own schools. Trainers and practitioners implement the activities with 7th-grade students for 7 weeks. Additionally, supplementary activities are conducted for 3 weeks when the same students move on to 8th grade.

In addition to this education program, Country Green Crescents, serving in different parts of the world, carry out various prevention programs serving local needs. These include education and awareness programs, skill development workshops, various sports activities, social, artistic, and cultural events, and widespread social campaigns, all contributing to the primary prevention goal.

Secondary prevention involves efforts to intervene at a stage where a person has been exposed to the causative agent of a disease, but the symptoms have not yet manifested. Thus, the person may not be aware of being ill at this stage. Prevention efforts at this stage are referred to as secondary prevention. In the context of addiction, secondary prevention focuses on individuals who have been introduced to substances but have not yet developed an addiction.

One of the programs implemented at the secondary prevention level by the Country Green Crescents affiliated with the International Federation of Green Crescent is the School-Based Intervention Program for Addiction developed by the Turkish Green Crescent Society. This program has been developed and widely implemented nationwide.

School-Based Intervention Program for Addiction:

The School-Based Intervention Program for Addiction is a comprehensive school-based preventive intervention designed to discourage students at the "experimentation" or "user" level from harmful substances. As an early intervention program that progresses through individual counseling sessions conducted by psychological counselors/guidance teachers within the school, it is the first and only program in Türkiye for school-based intervention in addiction. Additionally, this program distinguishes itself from its global counterparts in terms of scope and quality.

The program is developed with a secondary prevention perspective targeting students at risk of smoking, alcohol consumption, substance addiction, gambling, and risky internet use. Furthermore, it enhances the professional competence of psychological counselors/guidance teachers, equips them with intervention skills, and organizes secondary prevention efforts systematically. The program aims to prevent many harmful behaviors from turning into addiction within the school environment, ensuring that students can be retained within the education system without being pushed out. Its primary goal is to prevent harmful habits and risky behaviors from turning into addiction through school-based preventive intervention activities. Additionally:

• Enhancing the professional competence of psychological counselors/guidance teachers in terms of numbers and qualifications.
• Strengthening primary prevention activities under the Green Crescent Addiction Combat Education Program and making preventive programs sustainable.
• Conducting analyses to assist decision-makers in determining strategies and policies in the field of addiction combat.

The program is designed for middle and high school students with tobacco, alcohol, substance, gambling, and intensive internet use. The program implementer teacher applies different intervention methods to the student based on their risk level. These interventions include various methods such as information, motivational interviews, monitoring, contacting families, psychosocial assessments, and referrals to healthcare institutions.

Intervention methods of the program include:

• Comprehensive and accurate evaluation of students using harmful substances.
• Application of short interventions using motivation-enhancing methods.
• Regular monitoring, referral when necessary, and subsequent follow-ups.

Moreover, continuous improvements are made on the software system designed for the School-Based Intervention Program to support and enhance the skills of implementers in case management. Educational video sets for implementers are also provided. Additionally, supervisory support is provided at specified intervals by field experts who developed the program.

Within the program, Practitioner Training is provided to counselors/psychological counselors working in Guidance and Research Centers and schools. Following this, trainers (master trainers) are trained from among the practitioners to train other implementers. A special software named OBMSoft has been prepared for recording and entering data for the identification of risky students by the trained practitioners and trainers in their schools. The software, based on the principle of confidentiality of recorded individuals' information, assists psychological counselors/guidance teachers in identifying risky students, evaluating the student's situation based on the risk and needs report generated by the software, and monitoring the process with ongoing follow-up meetings.

Tertiary prevention refers to protecting the individual from complications, permanent effects, and death caused by the disease. In the context of addiction, tertiary prevention efforts focus on preventing individuals who use substances from relapsing, avoiding the development of addiction in those who have quit substance use, and reducing the harm associated with substance use (such as infectious diseases, involvement in crime, and physical harm). Tertiary prevention activities may also be characterized as a psychological treatment method utilizing emotional and behavioral elements (Young and de Abreu, 2017).

In this context, among the initiatives conducted by the Green Crescent Movement, the Green Crescent Counseling Centers (YEDAM), developed and implemented nationwide by the Turkish Green Crescent, stand out as an important tertiary prevention program model.

YEDAM is a center established within the Turkish Green Crescent, providing psychological and social support by experts. It aims to identify the needs of individuals using addictive substances and support them in reintegrating into life through psychological and social assistance. It also supports individuals who perceive alcohol/substance use as a problem to overcome their addiction and lead a clean life with expert assistance.

Addiction is a disease that hinders individuals from recognizing and maintaining their strengths. At YEDAM, the individual's needs are identified in the first session, and interventions that support these needs are implemented. Detoxification from addictive substances can occur within a few weeks, but without ongoing psychosocial support, there is a risk of relapse. YEDAM serves as a center where expert psychologists and social workers provide psychological and social support to individuals in both the detoxification and cessation process.

Behind YEDAM's goal of creating a unique addiction psychosocial support model for Türkiye is a strong scientific board. Before the model was constructed, significant models in Türkiye and around the world were studied, and consultation was sought from leading figures in the field of addiction in Türkiye.

Fully equipped teams operate in YEDAM centers, working with a philosophy of lifelong learning and development. Teams regularly participate in weekly science meetings and case discussions with leading figures in the field. Wednesday Seminars, focusing on a specific topic in the field of addiction, are held each week with YEDAM team members providing in-service alternating seminars. The Green Crescent Scientific Board members, who played a crucial role in shaping the YEDAM Model, receive special training at certain times to support the team's professional and personal development.

The YEDAM Model is comprehensive and holistic, with a humanistic and client-centered approach. Individual sessions in the YEDAM Model are structured based on Cognitive-Behavioral Therapy, Motivational Interviewing Techniques, and Mindfulness-Based Therapies. Group therapies tailored for families, adults, and adolescents are implemented with reference to the SAMBA model.

Treatment Model:

The model applied at YEDAM is based on three different sets of values. These are:

• Cognitive Behavioral Therapy (CBT)
• Motivational Interviewing Technique
• Mindfulness Therapy

Scope of Services:

• YEDAM provides outpatient services.
• Inpatient treatment is not offered.
• The system operates on an appointment basis.
• Confidentiality is strictly adhered to.
• Services are free of charge.

Telephone Counseling:

YEDAM offers counseling services to individuals struggling with addiction, their family members, or those seeking information related to addiction through the YEDAM helpline number 115. The YEDAM Counseling Hotline, staffed by a team of psychologists specialized in the field of addiction, provides services across all regions in the areas of alcohol, tobacco, substance, gambling, and internet addiction. The hotline not only provides information but also encourages individuals dealing with addiction issues to take steps towards support. After the initial contact, information is transferred to the Yeşilay Counseling Centers in the respective city, and appointments are scheduled promptly. The Counseling Hotline, staffed by competent psychologists, ensures that individuals with questions or problems related to alcohol, tobacco, substance, gambling, and internet addiction have access to qualified information.

Child-Adolescent Addiction Counseling:

Specialized centers provide addiction counseling services for individuals aged 12 to 18. A tailored program is implemented for children and adolescents, providing psychosocial support based on their ages and needs. Additionally, meetings can be arranged in the form of external meetings involving the individual's family/circle in cases of low motivation for quitting or reluctance to continue/attend sessions.

During external meetings, the family member is informed about the addiction process, approaches to the addicted individual, and the recovery process.

Adult Sessions:

Structured individual sessions are conducted at YEDAM. The content of the session varies depending on the type of application, covering services related to tobacco, alcohol, substance, gambling, and internet addiction at YEDAM centers. Psychological support sessions are conducted by clinical psychologists, and social service sessions are led by social work specialists. Emphasis is placed on confidentiality, and client information is not shared with third parties outside the institution.

Psychological Support:

Upon arrival at YEDAM centers, clinical psychologists welcome clients. They assist in issues related to tobacco, alcohol, substance, gambling, and the internet, sharing coping mechanisms for dealing with cravings and risky situations.

Social Support:

Change implies new habits, a new environment, and a new life. In this regard, Social Service Specialists at YEDAM provide assistance in organizing life in areas where support is needed (health insurance, education, employment, hobby acquisition).

Family Support:

As known, addiction is a family disease, affecting and being affected by the family. Therefore, for the recovery of the addicted individual, families also need support in certain matters. YEDAM experts provide information on:

• Methods to motivate the person for treatment,

• Approaches to individuals using alcohol and substances, and those with gambling addiction,

• Coping strategies for insistence situations,

• Actions to be taken in emergency situations.

Moreover, families can consult YEDAM experts regarding their own mental health issues.

Notes

• YEDAM continues to provide its services.

• Inpatient treatment is not offered.

• Appointments are scheduled through a reservation system.

• Services are conducted in accordance with the principle of confidentiality.

• Our services are free of charge.

Family Meetings

Even if the dependent family member does not attend, meetings with the family are initiated and maintained. Meetings with the family of each consultant who attends are conducted by the relevant clinical psychologist. The content of the meetings is protected within the framework of the principle of confidentiality. Families can participate in group sessions during the process. Meetings can be planned to provide support for the family in non-addiction-related issues based on the assessment of the family's needs.

External Person Meetings

In cases where the addicted/user individual does not want to attend the meeting, if the caller to the helpline is a family member of the consultant, they are informed about the addiction process, approaching the addict, and the recovery process. If the consultant's family resides in a location with YEDAM, they are directly referred to YEDAM for External Person Meetings.

Independent Generation Program

The Independent Generation Program is a support program prepared within the scope of secondary prevention for the children, aged 7-16, of individuals undergoing the recovery process for addiction at YEDAM and who are assessed within the risk category.

This program aims to keep the children of addicted families, including non-addicted parents, away from alcohol-substance use and to raise them as mentally healthy individuals through awareness and consciousness gained by the family.

• Families with children growing up in homes with addicted individuals are included in the program.

• The program is completed in a single session, lasting 45-50 minutes.

• The content of the program consists of the dangers awaiting the children in addicted families and what needs to be done to address these dangers.

• If a psychiatric disorder is detected in children at home through meetings with parents or relatives, necessary referrals are made.

Group Therapies

The problems we face become more noticeable when we interact with others. Resolving some of the problems arising from addiction in a therapy environment with a group is easier. Therefore, group therapies facilitate personal enrichment, gaining different perspectives, encountering alternative solutions, and self-recognition through the eyes of others. Group therapies, with much more interaction than individual therapy, allow individuals to participate through sharing or simply benefit as listeners.

Group therapy is a type of therapy method where individuals with similar problems (thematic groups) or individuals coming together due to different problems (experience groups-mixed groups) meet under the leadership of a group leader and an assistant.

Effectiveness of Group Therapy in Addiction Treatment

In a study conducted by Kültegin Ögel and colleagues (2016), they applied the Smoking, Alcohol, Substance Addiction Treatment Program (SAMBA) to 214 substance users under supervised release at the Alcohol and Substance Treatment Center (AMATEM) Clinic of Erenköy Mental and Nervous Diseases Hospital, and investigated the impact of this structured treatment program on the treatment process. They participated in the SAMBA program six times every fifteen days, and urine tests were performed each time they attended the program for six weeks. Participants with positive urine tests once were considered non-compliant with treatment. When the scores obtained from scales administered to participants before and after the program were compared, it was found that the Addiction Profile Index total score, the score from the substance craving scale, and the depression and anxiety scores decreased, while the motivation to quit substance scale score increased. There was a significant increase in Knowledge Assessment Survey scores. The result of the research indicated that the SAMBA program was a factor increasing treatment compliance in substance users directed to treatment due to supervised release (Anatolian Journal of Psychiatry 2016; 17(4):270-277).

YEDAM's SAMBA Groups:

SAMBA Group applications are developed as a psychoeducation program to be implemented in group format. Sessions include didactic elements and activities, conducted interactively. Group therapies are scheduled at each center on specific days and times, once a week. Session contents include:

• Providing information on alcohol/substance use and addiction,

• Increasing motivation for change,

• Reducing harm and ensuring protection from infectious diseases,

• Teaching skills to prevent relapse of alcohol/substance use,

• Coping with anger and stress,

• Enhancing problem-solving and communication skills,

among other areas. All programs implemented within the scope of the YEDAM model are structured programs and are conducted only by experts trained in this field.

Adult SAMBA Groups:

Group therapies are planned to be regular, taking place at each center on specific days and times determined by the center. The sessions are conducted by professionals who are experts in the field and have received training. Sessions specific to individuals using alcohol/substances and their families are conducted separately. In group therapies, informative sessions about addiction and the effects of substances used, sessions focusing on change, sessions dealing with emotions and thoughts, and sessions recognizing and coping with risky situations are organized.

Family SAMBA Groups:

Family SAMBA groups are organized for spouses, parents, or adult children of individuals using alcohol or substances. Sessions are arranged in an interactive format and include activities and informative elements. Trained individuals can implement this program.

Adolescent SAMBA Groups:

Counseling services are provided to individuals aged 12 and older at Yeşilay Counseling Centers. SAMBA groups are organized for adolescents aged 16 and above receiving services from YEDAM, following SAMBA group rules and processes.

Social Support Services:

Individuals and families are provided with face-to-face meetings with counselors and their families, organizing social activities, coordinating with the Employment Agency and the Istanbul Metropolitan Municipality to run Art and Vocational Training Courses, conducting collaborative meetings, and making referrals based on the needs of individuals, all aimed at improving social adaptation and life skills.

Social workers intervene in the following areas according to the needs of individuals and families:

• Utilizing leisure time
• Regulating social relationships
• Coping with the environment
• Regulating family relationships
• Providing support in employment
• Supporting the education process
• Contributing to the vocational acquisition process
• Providing support for individuals without health insurance
• Providing support for economic problems
• Providing support for housing needs
• Coping with life challenges
• Providing support for physical problems
• Providing support in dealing with legal issues
• Developing social skills

YEDAM Workshop

The YEDAM Workshop, located within Yeşilay Counseling Centers, is a standing rehabilitation center. Within the scope of YEDAM, the aim is to develop social adaptation and job skills for high-risk groups receiving services, to reach a certain level of psychosocial access. The branches of courses to be established in the workshop are determined based on the culture, abilities, and interests of the clients. Group workshops on relapse prevention and recovery are organized, and the creation of workshop workspaces aims to increase their participation in social life.

In YEDAM WORKSHOP, clients are intended to:

• Spend their leisure time with activities that suit their interests, ensuring they stay away from risky environments.

• Reduce mental problems and improve personal characteristics, thereby reducing the likelihood of substance use relapse.

• Enhance skills to prevent substance use relapse, thus preventing the recurrence of addiction.

• Improve social and life skills, ensuring social adaptation.

• Enhance vocational skills to contribute to their ability to sustain their own lives.

• Maintain the client within the support system.

Current Workshops

The current workshops conducted in YEDAM Workshops include:

Art Workshops; mandala painting, rock painting, model painting, canvas painting, ceramic painting, fabric bag painting.

Craft Workshops; macramé, wooden model making, wood shaping, filigree, jewelry design, stamp art.

Kitchen Workshops; gastronomy, pastry.

Sports Workshops

Graphic Design Workshops

Plant Workshops; planting, cultivation, terrarium making.

Sources

“Yeşilay Eğitim Faaliyetleri Hız Kesmiyor”, Yeşilay  Dergi, Eylül 2020, Sayı 1040, s.36-39.

Ayşe Hümeyra Kutluoğlu (2018) “Madde Bağımlılığı ve Mücadele” İNSAMER Report.

Azize Ummanel, Yaşam Becerileri, İstanbul Üniversitesi Yay., 2020.

Kültegin Ögel, “Sigara, Alkol, Uyuşturucu ve Diğer Bağımlılıklar”.