What can San Francisco learn from Tehran?

December 21, 2022
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I’ve been hearing a lot lately about the difficulties in San Francisco related to severe SUDs among people experiencing homelessness. And more pointedly, I’ve been hearing about the death rate by overdose among those living in what I understand to be housing for these people provided by the city.

Simultaneously, I’ve heard reports about leaders in government (local, the state level, etc.) and in the SUD area at the national level, struggling with this puzzle in San Francisco.

Meanwhile, I’ve also had reports come across my view concerning significant financial allocations for broad use of contingency management to help people struggling in these ways, and to help cities improve their responses in these situations. And in that way improve the ecology of their cities.

A number of things come to mind for me in this context. One of them is the question, “What can San Francisco learn from Tehran?”

By that I mean, “What can leaders in the USA gain from partnering with those in other countries who have seemingly found locally relevant solutions, centered in people rather than professions, and are sustainable within existing local resources?”

An example of this kind of success is found in Iran and it’s called Congress 60.

For those not familiar with Congress 60 here are:

Sometimes it helps to learn from outside your discipline (a NIATx principle) and from an entirely different context (so we can see and hear and think in new ways).

The other thing that comes to mind for me is a set of lessons learned about contingency management.

During the lifespan of the Behavioral Health Recovery Management project (BHRM; 1998-2007 or so), we had a number of efforts including clinical dissemination of evidence based practices, best practices, and promising practices. These were per guidelines written for us by the first-author national experts in each area of improvement.

When we implemented contingency management in our outpatient methadone maintenance program (to help raise group attendance) we noticed that those pulling the “JUMBO” prize always returned the winning ticket to the fish bowl that held the tickets. We finally focused-grouped and asked “Why?” We were told very plainly that carrying the large screen TV down the street wasn’t safe.

In those years we partnered with other systems to build and run an FQHC (providing primary care, psychiatric care, SUD services, and access to public entitlements for housing and a whole range of those services). In doing so we were early innovators in embedding primary care and dentistry inside our OP psychiatric buildings. We found the show rate for a free dental cleaning was relatively high, and during that visit we could support with added psychiatric care down the hall.

The lesson learned was this: embed various kinds of services inside a location. People will come for what they want and need, and sometimes you can help by adding in less popular but equally critical assistance. That is to say, getting better initially in the way defined by the individual is contingency management (a relief and a reward). In that way you don’t define the “prize” and wellbeing begets other wellbeing.

In closing, here’s a link to a previous post about NA in Iran. That post includes a link to an audio upload that I find most inspiring. The upload comes to mind for me around the topic of culturally relevant local solutions that are sustainable and emerge from the community.

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