Croatia Keeps its Mentally Ill Behind Closed Doors

It is a summer day in Ugljan, an island just opposite the city of Zadar, in central Croatia. Zadar is famous for its sunsets, which Alfred Hitchcock once described as “the most beautiful in the world”.

To reach Ugljan's psychiatric hospital from the mainland, you need to take a ferry, and then drive for about half an hour. The hospital, home to about 400 patients, some of whom have been here for more than ten years, is tucked away from the main road, almost on the beach, its breezy garden bursting into green.

Green is also the colour of the grimy uniform that patient V has been lying in for months, curled up in bed in the isolation cell. The room is tiny, just big enough to sqeeze a bed into. The heavy door is locked with a small window enabling staff to peek in.

But no human being has actually peeked through that window for a long time. The isolation cells at Ugljan all rely on video-surveillance.

One of patient V's arms is in a cast. According to staff, “he fell out of bed in his sleep”. The staff say V gets aggressive, which is why he has been in and out of the isolation cell for almost a year - mostly in.

“The psychiatrist decided that he should stay here,” is the staff response to why V has been denied basic liberty for such a long time, as well as being denied all privacy. He is video-monitored 24/7. “There is no maximum time. Mostly he is not tied up, just locked in,” one technician says, reassuringly.

Croatian law imposes no limits on the use of restraint and seclusion in such institutions. Hospitals have not developed their own policies on the issue, either.

There are no maximum periods for which someone can be tied up with a magnetic belt, put in a straitjacket, or locked inside an isolation room. It is dealt with case by case.

Like other countries in the region, Croatian institutions are short of staff and thus often cannot guarantee quality care. But some patients also suffer inhuman and degrading treatment and even abuse at the hands of staff and other patients.

Despite promises to promote the rights of people with disabilities, Croatia has not yet made moves to end institutionalization and provide community-based alternatives for an estimated 9,000 persons with intellectual disabilities and mental health problems.

People with these conditions remain in prison-like establishments and have to abide by prison-like rules. Some have not left their rooms for years.

Croatia is now in the final phase of its negotiations to the join the European Union. Closure of institutions and development of community-based services does not form part of the accession talks.

But respect for human rights is a prerequisite for entry, and the issue of deinstitutionalization was mentioned - and progress on it urged - in the Joint Inclusion Memorandum signed between Croatia and the EU on March 5, 2007.

This said that “Long stays in institutions need to be avoided and people with disabilities should have more frequent access to day or weekly programmes.

“Whenever possible, people should be motivated and encouraged to receive care and support at home… meaning that the support should be community- and family-based.

“The goal is for users to receive services in their homes and local communities (community-based services), thus creating the conditions for integration and rehabilitation within the community itself,” it added.

Many promises, little action:

Croatia was amongst the first countries to sign the UN Convention on the Rights of Persons with Disabilities, [adopted on 13 December 2006] which sets out their right to live in the community.

But in a report on Croatia published in September 2010, the advocacy group Human Rights Watch says Zagreb is not keeping its promises in this field.

“Thousands of people in Croatia with intellectual disabilities or mental health problems are forced to live in institutions that strip them of their privacy, autonomy, and dignity,” the report [“Once You Enter, You Never Leave”] maintains.

Croatia “has done little to provide alternatives to institutions, despite promises to the European Union and United Nations, and the number of people in institutions is growing,” it adds.

The report noted that the government is not only funding longstanding institutions but still building new ones. A new home opened in Dubrovnik in 2008. Human Rights Watch says plans exist to construct at least three more institutions.

The group calls on Croatia to act on its own pledges to replace institutions with support programmes that provide housing and assistance for life in the community.

Ante-Zvonimir Golem, state secretary in the Ministry of Health, did not respond to Balkan Insight’s queries on the report’s recommendations by the time of publication. Nor did Tatjana Katkic-Stanic, head of the ministry’s Directorate for Social Welfare.

As a result, it remains unclear what the government’s next steps will be on deinstitutionalization and the development of community-based alternatives, how it will finance the process and whether it even has plans to remove people from such institutions.

Like many European countries, Croatia has been hard hit by the global economic crisis and has cut spending on social programmes. But some international experts in the field say that the reason for the slow pace of reform in mental health is not only lack of money but lack of will.

“Croatia needs to stop building new institutions and stop undertaking significant refurbishment projects of old institutions,” Amanda McRae, author of the Human Rights Watch report, said. “This will free up funding to expand community-based services for persons with intellectual or mental disabilities.”

Alternative programmes are, in fact, cheaper than institutional care, costing about 5,400 kuna [729 euro] per month per resident to run, compared to the 7,100 kuna [959 euro] that state-run facilities currently obtain per resident.

Lobor Grad is a care home for 350 people with mental disabilities. The main block, a 17th-century castle, could one day perhaps be a prime tourist attraction. It is far less suitable as a residence for the 120 people lodged inside its huge rooms.

“The rooms are too big,” one social worker says. Many have as many as ten beds each, which means there is little privacy.
 
The same social worker says Lobor Grad lacks key staff members, including nurses, defectologists, psychologists and qualified therapists. But these posts cannot be filled, because of the cash-strapped government's freeze on new hires.

Three years ago, Lobor Grad obtained money from Sweden to rent and refurbish a house in the nearby village. Now it runs four such houses in which 17 people live. When we visit one, a resident had just baked a cake, that she proudly presented. While she lived in the castle, she was not able to cook at all.

The director of Lobor Grad agrees that the way forward is deistitutionalization and development of more small group homes.

Five more houses for supported living were planned for 2011. But the project, together with similar projects across the country, is on hold because of the financial crisis. As a result most patients in Lobor Gad will remain in the vast, semi-communal rooms of the castle for now.

Kornelia Videc, owner of the relatively new, private institution, called Nada, [“Hope”] in the town of Vojnic, does not believe that closing insitutions and putting people in the community is right for everyone.

“People placed in community are living together in an artificial way,” she says. “They are not friends and they did not choose each other.”  

The Nada Centre for Rehabilitation houses 175 people with intellectual disabilities and mental health problems, between the ages of 18 and 80. Housing is permanent, meaning that people come here and die here.

It remains unclear why the government financially supports privately-run institutions, which share most of the problems of state-run facilities; and doesn't support more community-based living programmes instead.

Nada receives 5,400 kune [729 euros] a month per patient from the state, which undertakes to inspect the quality of the services it provides.

Nada is a highly controlled environment. Patients are are not allowed to go alone to the village, but only in groups, accompanied by staff. In the common room, people sit at tables, doing nothing. When someone stretches out an arm to say hello, the arm is pulled down by a staff member.

Nada also has an isolation cell on the top floor, “in case someone becomes aggressive”, the staff say. It is a cupboard-like space, about four square metres in size, with thick green plastic insulation covering the walls and floor. There is no bed, no window, low ventilation and low light. The staff insist they use it rarely and only temporarily.

The staff also say they have used the isolation cell only once in the last 12 months; and they do not tie anyone to their beds. But one male resident says he has been tied to his bed several times. Another resident claims people are left in diapers in the isolation cell and that she herself was held there for a day, a year ago, in diapers.

Kristijan Grdjan, of Sjaj, a human-rights organisation, notes that Croatia’s 1998 Act on Protection of Persons with Mental Disabilities does not permit social care homes to use restraint measures and seclusion cells at all.

Grdjan was part of the monitoring team of the Mental Disability Advocacy Center, a Budapest-based international rights organisation that inspected Croatia's mental health institutions in summer 2010 and is due to produce a report in spring 2011*

Grdjan says the material conditions at Nada are satisfactory “but it completely lacks humanity. It looks more like a penal institution than a social care home”.

Kornelia Videc, the director, profoundly disagrees. She is proud of her institution and says its size is a major plus point. “Bigger institutions give you a choice – you can choose your friends and partners,” she says.

Taken outside twice in five years:

Osijek's Home for Adult People with Mental Health problems is a social care home for permanent stay, housing about 200 people. According to staff, in the last 20 years only three people went back to the community. Most residents are between 35 and 65.

Resident R, 19, came here last year. R looks like a typical teenager. She says she would like to leave the institution and finish school. But she mostly sleeps during the day, a side-effect of the strong medication she receives.

R is a typical social case. Placed in a children's home at the age of seven, she later ended up in a foster home, which was “horrible, as I was always locked in.” Now, because of a lack of  alternatives to institutional homes in the country, she has nowhere else to go.

The staff at Osijek say they do not have an isolation room. When we find it in a dark corridor on the ground floor, they change the story, possibly because the 1998 mental disabilities act says they should not have one at all. They then say it is used only for admissions.

But R says she was placed in the isolation room several times, most recently two months ago, when she escaped institution and later returned, drunk. Other residents confirm that the room is in active use.

Some people have been effectiely abandoned at Osijek purely on account of their physical disabilities, like resident A, who has been here for 16 years, after undergoing surgery on her spine that left her unable to walk.

“In the last 5 years I've been out in the yard twice,” she says. Another woman who has been in the Osijek home for almost two years claims that she has never been taken outside. The furthest she's been is the corridor.

It is hard to detect signs of real progress towards deinstitutionalization in Croatia.

In many places, there is resistance at the level of management even to the idea of providing community-based alternatives to institutional care. At the psychiatric hospital on the island of Rab, the deputy director Gordan Bošković says he does not know of “a country where deinstutionalization produces positive results”.

Back in Ugljan, when patients leave, it is usually to be moved to a social care home, and rarely to a foster care home. Almost no one returns to the community.

Ugljan's hospital garden is breezy and bursting into flower. But indoots, the atmosphere is different. No wind of change is blowing through these corridors. In the isolation cell, patient A sits in excrement on the floor, with a large wound on his foot from last week when he broke the window.

If Croatia is reforming its treatment of people with intellectual disabilities and mental health problems, patient A has yet to see or feel the results. He mostly sleeps in the isolation room. The staff see nothing strange in that. “There’s no maximum time limit,” one says. “It’s all individual.”

*The reporting for this article has been done as representative of the Bulgarian Helsinki Committee, joining the MDAC monitoring team.

Yana Buhrer Tavanier is a free-lance Sofia based journalist and 2009 fellow in Birn's Balkan Fellowship for journalistic excellence program. Balkan Insight is BIRN's online publication.