FIG1An APA committee wants the
Turkish Psychiatric Association to clarify allegations of human rights abuses
in Turkey's public psychiatric facilities that were raised in a recent report
by a Washington-based advocacy
Allegations of arbitrary detention and "inhumane" use of
electroconvulsive therapy must be addressed by Turkey's psychiatrists and
health officials, an APA committee maintains. See page 18.
© Mental Disability Rights International (2005)
At Bakirköy Psychiatric Hospital in Istanbul, patients lie about
the grounds with little to occupy their time.
© Mental Disability Rights International (2005)
"We're approaching [Turkish psychiatrists] as colleagues concerned
about the quality of care that they provide, the ethical and other protections
they have for patients, and how can we help them do something about it,"
said Alan Stone, M.D., a former APA president and the Touroff-Glueck Professor
of Law and Psychiatry at Harvard, in an interview with Psychiatric
The report, issued in September by Mental Disability Rights International
(MDRI), delineated the "pervasive" use of electroconvulsive
therapy (ECT) as punishment, its use with children and adolescents, and"
unmodified" by muscle relaxants, anesthesia, or oxygenation. It
pointed to the lack of mental health laws that protect patients from arbitrary
detention. The MDRI team also visited rehabilitation centers and orphanages
and observed improper use of restraints and seclusion, lack of rehabilitation
and medical care, and disabled children "emaciated from
"Inhuman and degrading conditions of confinement are widespread
throughout the Turkish mental health system," said the report."
Locked away and out of public view, people with psychiatric disorders
as well as people with intellectual disabilities, such as mental retardation,
are subjected to treatment practices that are tantamount to
In a statement issued in response, the Turkish Psychiatric Association and
the Turkish Medical Association said that some information in the MDRI report
was anecdotal, but they largely agreed with its
Alan Stone, M.D.: "As colleagues, we're concerned about questions
of care, what can be done, and how we can help them."
"We have to regretfully acknowledge that the deficiencies and
shortcomings pointed out.. .are consistent with the facts," said the two
associations. "It is a well-known fact that psychiatric services in
Turkey are well behind those in developed countries and even behind general
health standards in our country."
A Turkish government representative disputed MDRI's assessment of
conditions in Turkey, however.
"The report has been taken seriously in Ankara but the government
does not consider it accurate," said Fatih Yildiz, first secretary of
the Turkish Embassy in Washington, D.C. He said the report did not reflect the
current situation and rejected claims of arbitrary detention. ECT was not
performed on minors and was not used as punishment, he said, and according to
the Ministry of Health, "it is not always medically possible to provide
anesthesia for all patients receiving ECT."
MDRI investigators said they visited sites in Turkey in April 2005 and July
2005, and stood by the statements in their report.
APA's Corresponding Committee on the Misuse and Abuse of Psychiatry is
seeking more information about the practices reported by MDRI and to find ways
to support the Turkish Psychiatric Association's desire for reform of
standards and quality of care in Turkey, while acknowledging the inadequate
resources available there.
"My understanding is that the Turks have been aware of these concerns
since 1997, but they have not modified the conditions since then," said
Stone. "As colleagues, we're concerned about questions of care, what can
be done, and how we can help them."
The MDRI investigators included American and Turkish members. MDRI has
produced similar reports on the status of persons with mental disabilities in
Peru, Kosovo, Paraguay, and Mexico.
"The problem does not seem to be a lack of resources," said
investigator Robert Okin, M.D., a professor of clinical psychiatry at the
University of California, San Francisco, chief of psychiatry at San Francisco
General Hospital, and the only physician on the team. Okin cited the case of
Mexico, which he has also visited on behalf of MDRI and where unmodified ECT
is not used, despite modest available resources.
"The human rights violations we witnessed in Turkey are a result of
government policies, not the personal or professional trespasses of Turkish
psychiatrists," said Okin. "It is important that psychiatrists in
the U.S. join with them as allies and colleagues to focus on the source of the
"We chose Turkey because it was where we could be most
effective," said Laurie Ahern, associate director of MDRI and one of the
report's co-authors, in an interview. Turkey is in the spotlight at the
moment, pending its application to join the European Union (EU).
The Commission on Enlargement of the EU will release a report on the
general progress made by Turkey on November 9, said Krisztina Nagy, an EU
spokesperson in Brussels. "What we can say at this stage is that the
commission follows very closely the situation of vulnerable groups in the
candidate countries, including mentally disabled people. The commission's
experts will study in detail the report of Mental Disability Rights
International, but at this stage we have no particular comment to the content
of this specific report."
After a two-year investigation, MDRI described human rights abuses in
several aspects of psychiatric care. While most Turkish persons with mental
disabilities live with family members, existing social or mental health
services are not enough to cover treatment or support in the community. Lack
of community-based care has filled state psychiatric facilities with chronic
patients while draining resources for persons needing acute care for
Care at state facilities was largely custodial. At the Bakirköy and
Erenköy hospitals in Istanbul, said co-authors Ahern and Eric Rosenthal,
J.D., "people sat in beds or chairs or wandered the grounds of the
facility with little to occupy them."
Legal protections for the mentally ill in Turkey are almost nonexistent,
said the report. Persons facing confinement may be arbitrarily detained in
psychiatric facilities, have no right to appeal of their commitment, and are
denied the right to informed consent or to refuse treatment.
The country will need more than formal legal protections for the mentally
ill, said Okin, in an interview. At present, Turkey lacks the judicial
structures (such as hearing officers or special courts) to carry out laws and
judges trained in human rights.
A total of 359 staff psychiatrists serve the 5,500 beds in five public
psychiatric hospitals, said the report. Treatment is minimal and consists
mainly of medications and ECT.
"The most widespread and serious human rights violation MDRI observed
in Turkey's mental health system is the common practice of using
electroconvulsive therapy (ECT) in `unmodified' forms without anesthesia,
muscle relaxants, or oxygenation," said the authors. ECT was used for
children and the elderly and for a longer list of indications than the four
that Turkish Ministry of Health agreed to with the European Committee for the
Prevention of Torture in 1997.
"The misuses of ECT were already established as inhumane and
degrading before we came along," said Ahern. MDRI was told that high use
of ECT allowed institution officials to release patients and free up beds for
new ones. Often, ECT was the only treatment these patients received. Patients
sent home after ECT frequently had little access to psychiatric medications,
either because they could not afford them or because they lived in rural areas
where such drugs were not available or where there were no psychiatrists to
write frequent prescriptions, as required under current regulations.
"I don't link it to Turkish culture or Turkish psychiatrists because
it's not happening in university hospitals," said Okin. "There is
some lack of recognition on the part of the Turkish government that this is a
real human-rights violation."
Besides its findings, the report also includes MDRI's recommendations to
improve Turkey's mental health system, including "ending the abuse of
ECT; protecting against inhuman and degrading conditions in institutions; [and
ending] improper and arbitrary detention."
MDRI also offered an assessment of a proposed mental health law drafted by
the Turkish Psychiatric Association, lauding its goals but expressing concern
for its perceived deficiencies and offering suggestions for improving it.
"We have reason to believe that Turkey has professionals who care
about these issues and has the resources to make changes," said Ahern."
We had support from Turkish advocates, psychiatrists, and human-rights
lawyers. Our goal is to support reform in Turkey."
The APA committee is drafting a letter of inquiry, urging Turkey to put
international norms for ECT into effect immediately, not to use ECT on
children, and to publish standards of care and make them available to the
public, patients, and physicians. Perhaps the scheduled presence of a World
Psychiatric Association congress in Istanbul in July 2006, will spur Turkey to
institute reforms, said Stone.
"What Turkey really needs to do is create community alternatives, a
legal framework and a legal structure, and make changes in its
institutions," said Okin. "If the European Union is firm and
vigorous in insisting that human-rights violations in parts of Turkey will be
corrected, then Turkey will make the needed changes."
The report "Behind Closed Doors: Human Rights Abuses in the
Psychiatric Facilities, Orphanages, and Rehabilitation Centers of
Turkey" is posted at<www.mdri.org/projects/turkey/turkey%20final%209-26-05.pdf>.▪