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Conclusions

In the absence of an enforceable mental health law, everyone detained in Turkey’s institutions is illegally and arbitrarily detained as a matter of the European Convention on Human Rights (ECHR). Within institutions, Turkey subjects its citizens with mental disabilities to a broad range of serious human rights violations. The use of unmodified ECT is the most common and dangerous human rights violation documented by MDRI. Even for children and adults who do not receive ECT, detention in a public psychiatric facility or a rehabilitation center is a degrading and dangerous experience. The lack of active treatment and rehabilitation at these facilities for thousands of children and adults with mental disabilities leaves them segregated from society with no hope of returning to normal life. The total inactivity and social isolation experienced in these facilities presents a threat to their development and psychological well-being. Such custodial detention violates the right to health of all people so detained.

The lack of community-based mental health services creates enormous pressures on in-patient psychiatric facilities and undermines the treatment and care they can provide. By unnecessarily filling inpatient beds with “chronic” patients, there is a shortage of resources for people in need of acute care throughout the system. Large state facilities throughout Turkey are overwhelmed. As a result, people most in need of treatment – individuals undergoing an acute psychiatric crisis – are often deprived of the attention and care they need. Staff at two state psychiatric facilities reported that ECT is commonly used because it appears to produce a quick alleviation of symptoms and patients can be returned to the community. Yet the provision of ECT in 20-40% of acute cases is totally inappropriate. Its efficacy for a wide variety of indications is unproven or contra-indicated by internationally accepted standards of psychiatry. Many patients reported to MDRI that they would do or say anything to be discharged to avoid being subjected to ECT.
For people subject to the most extreme abuses – the long-term use of physical restraints, the coerced use of unmodified ECT, the lack of protection against violence, and the denial of medical care – detention in a facility can be painful, dangerous and life threatening. Such practices constitute the most extreme forms of inhuman and degrading

treatment prohibited by international law. People subjected to unmodified ECT as a form of punishment are being subjected to torture.

The structure of Turkey’s public mental health and social service system segregates people with mental disabilities from society and puts large numbers of its citizens with mental disabilities at risk of these abuses. The sole reliance on long-term custodial facilities is contrary to internationally accepted human rights standards as well as widely recognized best practices in mental health. At a gathering of European governments convened by the WHO in January 2005, Ministers of Health of the member states for the European Region affirmed their commitment to “develop community-based services to replace care in large institutions for those with severe mental health problems.”¹ They also agreed to adopt mental health legislation to protect against discrimination and “end inhumane and degrading care.”² European governments have

committed themselves to “offer people with mental health problems choice and involvement in their own care, sensitive to their needs and culture.”³ Turkish mental health services do not meet these standards.

As Turkey applies for membership in the European Union, it is under an obligation to take action to harmonize its laws and policies to meet European standards and to protect basic human rights of its citizens with disabilities. A major new commitment is urgently needed on the part of the government of Turkey to enforce these human rights — to protect people with mental disabilities against abuses within institutions and to develop positive programs to ensure their full integration into Turkish society.

Summary of Recommendations

MDRI recommends that the government of Turkey take immediate action to end conditions that are dangerous and life-threatening. Practices that constitute torture or inhuman or degrading treatment must be immediately terminated. The government of Turkey should:

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  Ban the use of unmodified ECT in all circumstances;
  
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  Establish guidelines to ensure that ECT is only used with appropriate medical safeguards, is only used in limited circumstances and within internationally accepted and proven indications for its use, and is never used without the free and informed consent of the individual subject to the treatment;
  
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  Stop the use of restraints and seclusion as a substitute for rehabilitation and lack of staff;
  
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  Ensure the availability of adequate food, staffing, and medical care to protect the basic health and safety of everyone detained in an institution;
  
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  Create oversight mechanisms to ensure that physical and sexual abuse in institutions is terminated;
  
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  Create a system of family support and supported foster care to ensure that all children with disabilities remain in a family-like environment rather than an institution; as soon as such programs are created, there should be
  

no new admissions of children to orphanages or rehabilitation centers in Turkey; and

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  Adopt an enforceable mental health law consistent with international human rights standards. This law must provide a right to independent review of any decision to detain a person in an institution.
  

The Government of Turkey must make a commitment to the full inclusion of people with mental disabilities in all aspects of Turkish society. This includes all people with psychiatric as well as intellectual disabilities. Fulfilling its human rights obligations toward this population will require the development of a comprehensive system of community-based mental health and social services. MDRI recommends that Turkey establish a public commission to begin immediate planning for the creation of a community-based mental health and social service system that will permit people with psychiatric and intellectual disabilities to live, work, and receive treatment in the community.

MDRI has provided detailed recommendations at the end of this report about steps that can be taken to end abuses in institutions and plan for the creation of an effective and comprehensive community-based system of mental health and social services.