introductionthis report is the outcome of a long dialogue between monitoring ngos and administrators of the juridical and observational psychiatric institute (imei) in budapest, hungary, following a monitoring visit to that institution on the 17 and 18 december 2003. after this visit, monitors from the hungarian helsinki committee (mhb) and the mental disability advocacy center (mdac) held a meeting with dr albert antal, the director and chief physician of imei, as well as with other institutional physicians to share general observations and human rights issues which emerged during monitoring. following this meeting, imei management investigated the issues raised and informed mhb of the results in a letter dated 22 december 2003. the letter is published as an addendum to this report.the first version of this report was completed in april 2004 and shared with the director of imei. the director, dr albert antal, sent detailed comments on the text on 12 may 2004. on the basis of these comments, mhb and mdac amended the text in several places, and in july, sent the amended report to major-general dr istvin b|k|nyi, director general of the hungarian prison service, who responded in a letter dated 9 august 2004. we also addend dr istvin b|k|nyi’s full response to the end of this report.although responses from imei and prison administrators are included in full in addendums, in relevant sections of the report, their comments are also inserted in italics. this allows readers to see the diversity of opinion on certain issues from the point of view of human rights monitors as well as from the point of view of institution administrators. accordingly, the text consists of the following sections - the joint report of mhb and mdac with inserted comments from the director and chief physician of imei;- the letter from the director and chief physician of imei in relation to certain specific complaints; and- the comments of the director general of the hungarian prison service in respect to the final report.in addition to two concrete positive outcomes occurring as a result of the monitoring visit – modification of rules governing telephone contact between inmates and defence lawyers and the introduction of a complaints box system – a further positive development, according to information provided by the director of the health department of the hungarian prison service (dr .atalin heylmann), is that work has already begun within imei on the elaboration of patient risk-assessment guidelines.i consider the communication problems which occurred in certain departments […] very regrettable, since i could have been told about these immediately. the problem that was raised has been investigated, and the nurse has prepared a report. […] it is difficult to understand why your report did not mention that the member of staff who was just finishing his work, instructed another nurse who was present to assist the members of the committee in their work.general informationimei is the only high security psychiatric institution in hungary for those subject to involuntary treatment (i.e. those who have committed violent crimes against other persons or crimes that have endangered public safety and where there is a danger that they may commit similar crimes in the future). these individuals are committed to a psychiatric institution and to imei specifically if the initial offence is one which is punishable by a period of at least one year. aside from individuals subject to involuntary treatment, other individuals also placed in imei are those sent for temporary involuntary treatment as well as prisoners experiencing mental disabilities and other individuals who have been referred by prison officials (for example, prisoners who are referred with suspected personality disorders).the institution can accommodate 311 persons. at the time of the team’s visit, 253 people were accommodated there. after one year of involuntary treatment and with the permission of the director and chief physician, a patient may be released on “adaptive leave,” the aim of which is to prepare the patient for reintegration into society. “adaptive leave” lasts at most 30 days and may be extended once. according to the rules of imei, a patient must spend “adaptive leave” with a caregiver who undertakes in writing to care for the patient. the director and chief physician decides on the release of patients on adaptive leave, based upon the recommendation of the adaptation committee. committee members include the director and chief physician, the medical director, head physicians of the departments, the head of the clinical psychology department, the physician recommending adaptive leave, the heads of the institution’s other non-medical departments, as well as imei’s patients’ rights ombudsperson. adaptive leave may be granted on more than one occasion.at the time of the monitoring, just one person was on adaptive leave. according to information provided by the director and chief medical officer, in 2003, adaptive leave was granted to three persons only.the frequency of adaptive leave can only be examined in relation to the institution. within the limited time available to them, the visiting committee was not able to review the social circumstances of our patients (although we mentioned it several times), the way society views our patients and the changes in their families as a result of their criminal activities. the time that the committee spent here was not sufficient be possible to say that, in terms of accommodation, patients are in a better situation than the majority of hungary’s prison population. of course, as the director and chief physician emphasized several times, residents of the institution are not prisoners but patients, and therefore the fact that they live in more pleasant surroundings than convicted prisoners is not, in itself, remarkable. in the buildings, which are more than 100 years old, there are, naturally, some rooms that are darker and some that are colder and in certain cases lack decorations, but it is an exaggeration to state that this is the general situation. our staff, in cooperation with the patients, ensure that the rooms have decorations. our patients have the right to adapt their surroundings according to their own tastes. […] the wards in building i are by no means dark, since the windows have been replaced. building iii can be said to be dark, but the windows there cannot be changed because it is listed as a historic building.during the day, patients wear a brown uniform resembling pyjamas. the observer team witnessed one case in which a patient asked one of the institution’s employees for warmer clothes due to cold. the employee replied that there were no more warm clothes available for the patients. according to the judgment of the team, the patient’s cell was, indeed, cold.in 2003, we inspected and repaired the entire heating system. this was necessary because over the years there had been many problems with the heating. this year during the heating season, only rarely were there complaints that the heating in a given ward was not optimal, but in such cases steps were taken immediately to repair the heating system and blankets were issued from the stocks held in the departmental stores. it would be impossible to replace the entire heating system without remodelling the whole building. the complaint of the patient who said that he had not received warms clothes really makes no sense, since all patients across the board receive winter clothes appropriate for the season. […] it is difficult to appraise the statement that the patients wear a brown uniform resembling pyjamas both day and night. the clothing described in the report is the coercive uniform, the wearing of which is required by law. at the same time, we inform the respected committee that it is not mandatory to wear the uniform at night; in our institution, the system is to wear “pyjamas” at night. it is undoubtedly true that our financial resources do not make it possible for us to provide our patients with the quality of uniform we would like.every department has a common room. these rooms are scantily furnished and bleak. judging from the way they are furnished, they are used primarily for watching television. the common areas are unheated and smoky. moreover, practically everywhere in imei, there is exceptionally dense cigarette smoke which, we believe, represents a hazard to both health and safety. indeed, we saw smoking not just in designated areas, but practically everywhere, including in rooms in the wards. one patient alleged that in the neuro-psychiatric department, smoking is only forbidden in the evening after patients are in bed. if this is true, then the practice does not comply with house rules provided to us (which strictly forbid smoking in wards of patients subject to involuntary treatment).treatmentaccording to information from imei doctors, 80% of the patients suffer from schizophrenia. treatment consists mainly of drug therapy. one psychiatrist told the observer group that the majority of patients receive new atypical anti-psychotics [most receive risperidon (risperdal), while a smaller number receive olanzapin (zypraxa)]. a smaller proportion of patients, however, receive traditional anti-psychotics, which represent outdated modes of drug therapy and often have severe side effects.on admission to imei, 70% of patients are started on depot drug therapyҙ for the first time in their lives. typically, patients receive a combination of haloperidol and clozapine, supplemented by depot neuroleptics. only a few patients are treated with atypical neuroleptics.the side effects of psychiatric treatment (especially sedation and weight-gain) were noticed in numerous patients. some of these side effects are offset by anti-cholinergic treatments (which, however, produce further side-effects). to monitor side-effects (primarily in the case of clozapine), blood tests are regularly administered to patients. the majority of patients we spoke with found side-effects worrying, particularly excess weight and the related risk of diabetes (in the men’s psychiatric rehabilitation department no. 1, nearly 10% of patients suffer from diabetes) and increased risk of heart and vascular problems accompanying weight-gain.the treatment of patients is based on professional norms, the patient’s condition and the doctor’s judgement. in our institution, in the majority of cases, the opinion and experience of the patient are also instrumental in the determination of the treatment. we consider it doubtful that any of our colleagues would have declared that the majority of their patients received the so-called atypical anti-psychotics. these drugs are prescribed if this is justified by the patient’s condition and the experience gained from the patient’s treatment. financial reasons do not make it possible for every patient to receive atypical anti-psychotic drugs. it is with particular and genuine curiosity that we received the committee’s conclusion that our treatment protocol is based 70% on the use of depot neuroleptics.it seems that the professional consultant invited by the committee did not bear in mind which drugs are classified by the psychiatric profession – whether within hungary or elsewhere – as being among the atypical – i.e. second generation – anti-psychotics (e.g. clozapine). the professional consultant did not draw the committee’s attention to the fact that one of the problematic side effects of the above-mentioned atypical anti-psychotics is an increase in weight and a sedative effect. so, the statement that the professional diagnoses are not in accordance with the current recognised literature reflects a subjective conclusion which seeks to find fault with our therapeutic protocol.the use of anti-psychotics is a professional stipulation. according to the prevailing professional view, a psychotic patient must be treated with anti-psychotics. similarly, based on professional stipulations, maintenance treatment must be continued depot drug therapy refers to depot injections which are anti-psychotic drugs suspended in vegetable oil and given directly into the muscle of the buttock, where they form a pocket of the drug to be absorbed slowly over time. according to professional literature, depot antipsychotic injections should not be routinely prescribed, and should not be given to a patient who is also taking anti-psychotic medication orally. form them about their illness and teach them how to live with their illness. contrary to the committee’s professional psychiatric opinion, our staff continually assist patients in “coping with mental problems”.9ery few patients have any real contact with their families (not necessarily the fault of the institution). however, the extremely restricted use of the “adaptive leave” might be a tool for greater contact, were it approved by imei authorities more often. on a positive note, we can highlight the fact that, during our visits, doctors and nurses communicated with patients in a friendly tone and were open to patients’ questions and complaints. nurses appeared to be constantly available to the patients.we are glad to hear that the members of the committee consider the relationships between the staff and the patients to be friendly, but for us this is natural and, we hope, is generally the case in civilian hospitals as well.as in penal institutions generally, security is also one of the most important considerations at imei. in the context of involuntary treatment, where the use of restraints is severely restricted, the monitoring team observed that in order to avoid possible aggression and violence, staff rely primarily on the effects of sedative medications. with the emphasis on sedation, there is less attention to achievement of a beneficial treatment combination (which might involve greater use of talk and occupational therapy and fewer sedatives, for instance). it follows from the penal nature of the institution that security is, indeed, an important consideration. we do not know, however, on what basis the committee members drew the conclusion that this is one of the most important in a psychiatric institution. it is not the danger, but rather the professional rules already detailed above, that determine the treatment with drugs. the use of restraints is legally regulated. the committee, in its professional statement that “a more beneficial combination for the patient, [is one] involving more occupational therapy and less drugs” is, in general, correct, but let us not forget the professional rule that the continuing treatment in our institution is carried out in accordance with professional prescriptions and with the appropriate dosages of drugs. professionally, it is incorrect to imagine that in connection with continuing treatment, the quantity of drugs can be significantly reduced by combining them with psychotherapy and sociotherapy. it seems that the committee is not aware of the fact that while supplementing drug treatment with educative therapy can reduce the chances of relapse, the effective dosage must still be given. our institution, therefore, uses this combination in its professional protocol.all non-drug therapy is voluntary (i.e. drug therapy is the only treatment which is given involuntarily). if a patient wants to spend the whole day in bed, he/she may do so. 9isits to the departments are made daily by departmental doctors and twice weekly by the head doctor of any given department. monitors did not receive any information as to whether multi-disciplinary team discussions are ever held by these doctors, nor as to whether, in specific cases, detailed case discussions are held.we believe that multidisciplinary team discussions are necessary, if justified by the patient’s condition. in view of the fact that this is a daily routine and that we did not receive a question about this, it is natural that the committee is not informed about this. 11we are also of the opinion that in the institution we provide our patients with a wide-ranging socio-therapeutic programme which is perhaps more extensive than those offered in civilian psychiatric practice. the psycho-pedagogues carry out their work in teams in our patients departments, under the direction of the departmental head physician and in coordination with the attending physicians, the psychologist and the nursing staff. in addition to their daily administrative tasks and their work involved in helping certain patients maintain social contact with the outside world, they also run the various activities listed in the attachment to the director’s letter. they organise different cultural and sports events. they do this in such a way that each educator is responsible for around 50 – 60 mental patients. day after day, they have to deal with and sort out the patients’ worries, problems, correspondence, visits etc. in hungarian prisons, the number of prisoners to each educator is the same. since we are dealing with patients subject to involuntary treatment, this ratio can be regarded as being much worse. given these circumstances, the quantity of programmes listed earlier is even more noteworthy, in our opinion, all of the activities listed in the director’s letter of 22 december are of therapeutic value, since even if something is required “ by law” it can have a therapeutic effect. in a similar way, the carrying out of work related to the running of the institution is also of therapeutic value. this in no way differs from the work therapy activities carried out in civilian institutions, and which are, on the contrary, declared to be a form of social therapy. we also note that if we are already comparing institutional practice with the programmes offered by other penal institutions, the fundamental differences lies not in what a programme is called, but rather in the use of the educational tools and methods employed. this corresponds to the “particular” needs of those placed in the imei.risk assessmentdoctors in imei do not have established professional guidelines to assess risks which might emerge from an involuntary patient population. imei does not have a written policy on risk assessment. and, even though risk assessment is an important concept in forensic psychiatry, on the basis of discussions with imei psychiatrists, the concept did not appear to be in use at all within the institution.monitors did note that imei psychiatrists use a few general and easily applicable principles when preparing cases for the annual judicial review of involuntary treatment. the psychiatric member of the monitoring group, however, observed that imei doctors appear to base their risk and relapse assessments on random empirical experience rather than on facts that have been gathered and systematised scientifically. this psychiatrist added that compounding this issue in hungary, is the lack of medium secure units and community psychiatry to enable reintegration of forensic patients. continuity of treatment remains an insoluble task for the authorities. we were similarly surprised by the committee’s mention of a lack of “risk assessment” – a term which presumably conforms to modern terminology. we believe that our activity, by virtue of the laws in force, involves continuous risk 13in imei, restraint usually involves tying a patient to a bed and administering anti-psychotics. generally, an order to thus restrain a patient is made by a physician, but a nurse can also prescribe restraint (on the condition that the physician approves this within two hours). it appeared to monitors that the professional restraint guidelines applicable to the institution had not been adopted. in the list of appendices to house rules issued to those patients subject to involuntary treatment, a guide on the use of personal restraint in healthcare institutions was indicated. despite our requests, however, we did not receive a copy of this appendix (though other appendices, such as those dealing with fire safety and safety at work, were afforded to us). we are therefore not in a position to judge whether imei patients have received satisfactory information regarding restraint regulation.the decisions relating to personal restraint in healthcare are determined in the health act and in the act on penal institutions. our institution has never needed any rules deviating from these, nor would any other such rules be allowed by law.in the imei, the carrying out and documentation of personal restraint in healthcare is performed precisely as prescribed by the health act referred to above. amongst the other regulations it is even required that we send a copy of the restraint documentation to the public prosecutor who provides legal supervision over us. […] the guide is not just an appendix to the house rules that we display there as one of a list of the house rules. the handing over of the guide is attested by a signed acknowledgement of receipt, which everyone signs when they receive the guide. the handing over of the house rules is also carried out in writing in a similar way.suicide risksa separate section of imei accommodates patients under observation because they have attempted or threatened to commit suicide. in this section, suicide watches are arranged as follows two convicted prisoners from the budapest prison are placed in each ward, and they keep an eye on the imei patients to ensure that no acts of self-harm are committed. these prisoners, who are performing “prison work” tasks for payment, do not receive any special training and they have no right to take any direct action; they only have a reporting obligation. some of those under suicide watch alleged that the convicted prisoners, using their prerogative, acted as if they were the bosses of patients under observation. at mealtimes, the prisoners sit at the table, and those under suicide watch can only sit down once the prisoners have finished eating.although we understand that the use of prisoners to observe patients is due to the lack of available nursing staff, we draw attention to the fact that some people sent to imei are on remand. in the case of remand prisoners in particular, the current suicide watch procedure breaches section 119 of the act on penal institutions, according to which remand prisoners must be separated from convicted prisoners.the imei runs a separate department for those held on remand and convicted prisoners. within this department in the “observation wards” prisoners are employed to 15lawyers once a week (in addition to the five minutes’ of telephone calls which are provided to everyone). according to section 135, paragraph (3) of the criminal proceedings act, defendants held on remand cannot be restricted in the exercise of their procedural rights. the right to a defence is one of the most important procedural rights, of which the right to contact with a lawyer is an integral part (especially in the case of those deprived involuntarily of their freedom). according to the criminal proceedings act, it must be ensured that the accused can contact his lawyer. an accused person held on remand can only be subjected to restrictions that ensue from the nature of the criminal proceedings or which are necessitated by the arrangements within the custodial institution. in our view, it thus follows that if someone held on remand wishes to contact his lawyer and if this does not disturb the arrangements within the institution to a disproportionate extent (for example, he does not demand contact with his lawyer several times a day), then he should be provided with the opportunity to do so.(the institution did not issue us with the rules related to the use of phones by patients, so we are not able to express an opinion about the telephone rules). telephone contact with a lawyer can greatly influence the condition of the referred patient. since i agree with the committee’s recommendation, i have amended the access to telephones and have ensured that daily use of the telephone is made possible. grievance proceduresseveral patients reported that their complaints did not reach the appropriate person. the director and chief medical officer replied to this allegation with the following “the patients may turn at any time to me or to my deputy, whether this be orally or in writing in a sealed envelope. no one has ever been adversely affected by taking such a step, and i categorically reject the suggestions made in connection with this.” all three sets of house rules issued to us include information about the grievance procedure. according to house rules issued to patients, patients can forward their complaints and comments in letters in sealed envelopes to the director and chief physician by handing the sealed envelope to an instructor who will then pass it on to the director. however, if the subject of the complaint is that instructor, the patient will not necessarily want the instructor to handle it.house rules issued to those patients referred by prison officials and to those that have been admitted via the neuro-psychiatric department do not even mention the possibility of making a complaint in a sealed letter; instead, the patient must fill in a request sheet and hand this over personally to the instructor. here is it even more questionable as to whether the process is appropriate if the complaint happens to concern the instructor. we therefore believe that it is worth considering whether, as in other penal institutions, imei should make it possible for patients and prisoners to place complaints into sealed “director’s” complaint boxes. 172. specific issues and general questions raised (letter of dr albert antal)dear mr. .ęszeg, in respect to the questions raised during your visit to our institution on 17 and 18 december 2003, i would like to give you the following information 1. cs. .. [«] convicted prisoner(according to his account, he had been released.)i. sentence of the szabolcs-szatmir-bereg county court sentence no. [«]7 months in prisonconditional release authorised on 25 november 2003.ii. sentence of the nytregyhiz city courtsentence no. [«]6 months in prisonsentence reduced by 25% for good behaviour. will be released conditionally on 1 march 2004having fulfilled full sentence will be released on 13 april 2004.(he is currently fulfilling his sentence).iii. sentence of the nytregyhiz city court[…]7 months in prisonsentence reduced by 25% remission for good behaviour. will be released on 22 september 2004.having complete full sentence, will be released on 13 november 2004.2. t.b. […] held on remand[…]the person with whom he indicated he would like to get contact is his sister-in-law a. b., who lives at [«]according to the telephone information service, there is no landline telephone at the given address. the mobile phone companies are not able to give any information either. with the inmate, we wrote a request to the miskolc city court, the court acting in the case. 19at the same time, i drew the attention of the department’s nursing staff to the importance of complying fully with the rules for giving injections.8. for 18 years, our institution has been monitoring the costs and use of drugs so that we can compare our use of drugs with that of other institutions. in 2001, we spent 41% less on drugs than similar civilian institutions. /ooking back over the last 18 years, this can be said to be the average annual situation.9. i attach the list of activities, other events and study circles organised by the psycho-pedagogical department. as this shows, the patients can choose from amongst a wide range of programmes every week. 10. i attach the clinical psychology department’s letter on methodology.11. the patients can turn to me or to my deputy at any time, either in writing in a sealed envelope, or orally.no one has ever been adversely affected by taking such a step.i categorically reject the suggestions made in connection with this.in the points above, i have responded to the problems which you and your colleagues raised.we consider that the continuation of your work is also in our interests and we shall fully support this in the future as well. budapest, 22 december 2003
