Authors

Eric Rosenthal, JD, Georgetown University Law Center. Eric Rosenthal is the founder and Executive Director of Mental Disability Rights International (MDRI), Washington, D.C.

Dr. Robert Okin, MD, University of Chicago Medical School. Dr. Robert Okin is Chief of Psychiatry, San Francisco General Hospital; Vice Chair, Department of Psychiatry, University of California, San Francisco; Professor of Clinical Psychiatry, University of California, San Francisco.

Elizabeth W. Bauer, MA, Ohio State University. Elizabeth Bauer is Executive Director of the Michigan Protection and Advocacy Service and former President of the National Association of Protection and Advocacy Systems.

Ira Burnim, JD, Harvard Law School. Ira Burnim is Legal Director of the Bazelon Center for Mental Health Law, Washington, D.C.

Robert Dinerstein, JD, Yale University. Professor Robert Dinerstein is Director of Clinical Programs at the Washington College of Law, American University, Washington, D.C. Professor Dinerstein is also a member of the President's Commission on Mental Retardation.

Anita Bakos, JD, Etvos Lorand University. Anita Bakos is a former Legal Fellow at MDRI and is currently a Legal Intern at the Constitutional and Legislative Policy Institute, Budapest, Hungary.

Max Lapertosa, JD, University of Maryland Law School. Max Lapertosa is a former Advocacy Associate at MDRI and is currently an Associate at the Advocacy for Children's Rights, Los Angeles

Contents

Acknowledgments
Forward 
Conclusions and Recommendations
Preface: Goals and Methods of this Report

1. Introduction
   1. Mental Disability Rights: An International Concern
      1. Transformation of national laws, policies, and practices
      2. Recognition through the United Nations human rights system
      3. Developments in the European Community
      4. Requirements of the Principles for the Protection of Persons with Mental Illness
   2. Hungary's International Treaty Obligations
   3. Political and Economic Context
   4. Structure of Mental Health Services
2. II. Social Care Homes
   1. A. Arbitrary and Improper Detention
      1. 1. Lack of due process or judicial review of commitment to social care
         homes
      2. 2. Improper commitment standard
      3. 3. Wrongful detention of social care home population
      4. 4. Promoting continued dependence and increased disability
      5. 5. Detention of people with mental retardation or other disabilities
   2. B. Degrading and Dangerous Conditions
      1. 1. Remoteness from the community
      2. 2. Poor physical conditions
      3. 3. Detention in cages
      4. 4. Lack of rehabilitation
      5. 5. High rate of mortality
   3. C. Human Rights Ombudswoman's Report
      1. 1. Findings of the Gönczöl Report
      2. 2. Recommendation in the Gönczöl Report
3. III. Hospital and Community Care
   1. A. Inadequate Community-Based Services
      1. 1. Structure of services
      2. 2. Lack of services and support
      3. 3. Institution-based services
      4. 4. Lack of integrated services
      5. 5. Model Community Programs
   2. B. Unnecessary In-Patient Treatment
   3. C. Improper Incentives for In-Patient Care
      1. 1. In-patient bias of insurance and pension systems
      2. 2. Medicalization of social problems
   4. D. Inadequate In-Patient Care
      1. 1. Inactivity on the wards
      2. 2. Neglect of Achronic patients
      3. 3. Lack of staff leadership
      4. 4. Lack of case management/outplacement services
   5. E. Neglect on Back Wards
   6. F. Lack of Respect for Patient Choice/Rights
      1. 1. Rights in institutions
      2. 2. Informed consent to treatment
4. IV. Civil Commitment and Guardianship
   1. A. Civil Commitment
      1. 1. Inadequate right to counsel
      2. 2. Lack of financing for judicial review
      3. 3. Use of "voluntary" status to circumvent legal protections
      4. 4. Hearings held in institutions and hospitals
      5. 5. Failure to protect people most at risk
   2. B. Guardianship
      1. 1. Competence and Guardianship under Hungarian law
      2. 2. Improper delegation of duties to administrative authorities
      3. 3. Lack of periodic review
      4. 4. Lack of power to appeal decisions of the guardian
      5. 5. Discrimination and denial of political rights
5. V. Oversight
   1. A. Lack of Enforceable Standards
   2. B. Lack of Human Rights Oversight
   3. C. Insurance Reform without Public Participation
6. VI. Planning and Financing Reform
   1. A. International Obligations to Plan and Finance Reform
      1. 1. Immediate obligations of full enforcement
      2. 2. Progressive enforcement
   2. B. Strategies for Planning and Financing Reform
      1. 1. Need for comprehensive services and planning
      2. 2. Need for outreach and assertive treatment in the community
      3. 3. Consumer and family advocacy and support
      4. 4. Decentralization of authority
      5. 5. Financing community services 

Appendix A Responses By Hungarian Service Providers & Advocates

1. 1. Dr. András Veér
2. 2. Dr. Judit Harangozó
3. 3. Gábor Gombos
4. 4. Dr. Péter Szabó

Appendix B Principles for the Protection of Persons with Mental Illness
Appendix C Declaration on the Rights of Mentally Retarded Persons 

Acknowledgments 

MDRI is indebted to many people in Hungary who gave generously of their time to provide observations and insights about the human rights concerns of people with mental disabilities in Hungary. To protect their privacy, most of the individuals MDRI interviewed are not named in this report, including many people who use mental health services in Hungary, members of their families, mental health service providers, members of the psychiatric and nursing professions, government officials, members of the judiciary, and their staff. 

MDRI=s work on this report would not have been possible without the assistance of a number of human rights advocates and service providers in Hungary. Judit Fridli of the Hungarian Civil Liberties Union provided background information about human rights and mental health services, she arranged access to a number of psychiatric facilities, and she set up extensive meetings with government officials. Judith Klein of the Central European Mental Disability Advocacy Project, Ágnes Honecz and Noémi Danajka of the HCLA, and Dr. Judit Nemessuri of the Semmelweis University Medical toured institutions with MDRI investigators and translated interviews. 

Dr. Judit Harangozó, Professor of Psychiatry at Semmelweis University Medical School and Director of the Awakenings Foundation provided extensive assistance in learning about mental health services in Hungary. Staff at the Awakenings Foundation, including Dr. Erika Perczel, Zoltán Barcza, and Iván Radó arranged visits, translated interviews, and offered their warm hospitality to investigators throughout this project. Professor Judit Sandor of the Central European University provided background about Hungarian mental health law and translated the United Nations Principles for the Protection of Persons with Mental Illness into Hungarian. 

Many experts and volunteers provided assistance in the preparation of this report. Dr. Peter Statsny of the Manhattan Psychiatric Institute lent his expertise to this project by participating on a factfinding mission. Dr. Joseph Bevilaqua of the Bazelon Center for Mental Health Law and Dr. Leonard Stein, Professor Emeritus of Psychiatry at the University of Wisconsin Medical School, Madison, provided background information about mental health system planning and reform. Katherine Nahapetian, MDRI Program Associate, and interns Shlomit Levav, Javier Vasquez, Keith Bolek, Jennifer Elsea, and Marissa Maurer provided background research and help preparing the report for publication. 

Professor Herman Schwartz of the Washington College of Law, American University and Leonard S. Rubenstein of Physicians for Human Rights provided critical advice on the development of this report as part of the MDRI Central European Mental Disability Advocacy Initiative. Many members of the MDRI Board of Advisors provided important strategic advice on the design and development of this project. Special thanks to members of the fact-finding missions who donated their time to the project and payed many of their own expenses. The Echoing Green Foundation, the Cummings Foundation, and the Washington College of Law provided the support necessary to create Mental Disability Rights International and their continued support made this project possible. Translation and printing of the Hungarian version of the report were funded by the Jansen-Cilag of Hungary. On-site research expenses, report preparation, and publication costs were funded by a generous grant from the Open Society Institute.

Forward 

In this publication the reader will find a sincere, objective, and sobering report on the conditions of a large group of people with chronic mental disabilities. More generally, the report provides an overview of the current state of mental health care in Hungary. The report is based on a fact-finding mission conducted by Mental Disability Rights International (MDRI), a nongovernmental advocacy organization based in Washington, DC. The mission included experts in human rights and mental health professionals who visited Hungarian mental health facilities and nursing homes (or Asocial care homes@) for the mentally disabled . 

As documented in this report, the social care homes are Adead ends@ for people with mental disabilities. There are almost no opportunities for people placed in social care homes to return to a normal life, even though many of them have the ability to reach a degree of competence and sanity which would enable them to live and function in the community. From my experience, I would say that social care homes are more or less unique to Hungary. Other countries of the former Communist block have not created so many institutions of this particular kind, custodial institutions with limited psychiatric care. 

Social care homes were once regarded as progressive developments. People with chronic mental disabilities, rejected by their environment, families, and communities, were given some chance to survive. Paternalistic and hospital-orientated, Hungarian psychiatrists have felt that social care homes are preferable to alternatives we have heard about in Western countries. We were told that people with chronic mental disabilities in the West were simply Adumped@ on to the streets as institutions were closed, forcing many of them to live on the streets, homeless. As described in this report, the reality in Hungary and the West is much more complex. 

In Hungary, individuals who have advocated closing psychiatric hospitals and integrating patients into the community were branded as being under the evil influence of Anti-psychiatry. Anti-psychiatry, to this way of thinking, can encompass any criticism of traditional attitudes and practices of psychiatry. The author of these lines has been labeled as anti-psychiatric many times for claiming that psychiatry needs reform. My major claim: that psychiatric treatment must aim not only at the disappearance of symptoms but also at the restoration of the ability to fully participate in community life. I have also pointed out that social care homes helped the former political regime maintain an image of a perfect society - a society where patients could not be seen in the streets and would not disturb the public. 

Without social care homes in past years, many of their inmates would undoubtedly have died earlier through physical neglect or suicide. Communities were - and in many respects still are - rigid, closed, and rejecting, especially in rural areas. Until recently, there were no voluntary assistance organizations, no civil rights or civil protection programs, and no self-help or mutual aid groups. As a result, communities were unable or unwilling to absorb and shelter people with mental illness who were not always able to conform to the static rules of community life. There was no tolerance of diversity, no pluralism. This milieu was not supportive for people with mental disabilities, and there was little to counteract their isolation and alienation. 

Despite challenges throughout society, some psychiatrists working in social care homes have, over the years, tried to pinpoint the dysfunctional characteristics of these institutions. A number of psychiatrists have criticized the inadequate legal protections for the rights of people in institutions, including the superficial and mechanical application of guardianship laws. For years, individuals who tried to bring about change received little support. 

After the political transition of 1989, changes have been slow with regard to both community development and mental health system reform. As the MDRI report describes, the country has adopted progressive new mental health legislation, but implementation is limited and has not reached much of the mentally disabled population. The protections of the new civil commitment law are only beginning to reach people in facilities for acute and chronic mental health care. On the whole, Hungarian psychiatrists are used to the status quo with regard to life and work in the mental health care system. They have become comfortable with ideologies that rationalize life in a social care home; placement in an institution is widely considered to be better than living at home and continuing the odyssey of the revolving door, going in and out of psychiatric care. 

This report draws our attention back to the cold facts. We must be aware that comprehensive changes and radical reforms are needed urgently and quickly. Hungarian experts cannot avoid facing this fact. Mr. Rosenthal and members of the fact-finding mission give voice to the reality that living conditions in social care homes are often inhumane and degrading; conditions are sometimes poor in other places of treatment and care, as well. 

Some reformers have claimed that the reintegration of people into the community is less expensive than keeping people in large institutions. Unfortunately, as this report points out, this may not be correct. Most follow-up studies of deinstitutionalization and subsequent community placement have shown that costs are higher. In Hungary, I believe that proper community integration of people with mental disabilities would be very difficult and expensive, except in some urban areas (just like in some northern cities of Italy). Nevertheless, this effort should begin as soon as possible if Hungary wants to become a member in the larger European network of countries. The cost of reform should be accepted as part of the price of enforcing human rights. 

We should thank Mr. Rosenthal and Mental Disability Rights International for this investigation and report, whose observations and recommendations should be taken seriously. We must face the tremendous need for reform of psychiatry, with respect to human rights and quality control for mental health care and therapy. This report raises issues that are serious and timely. This report will be a catalyst for change and will help bring about the development of mental health and human rights reform in Hungary. 

Béla Buda, M.D. 
Director, Department of Communication 
Semmelweis University of Medicine 
Institute of Behavioral Sciences 
Budapest, Hungary

Conclusions and Recommendations 

This report is a product of a fact-finding investigation conducted by Mental Disability Rights International (MDRI), a non-governmental advocacy organization dedicated to the international recognition and enforcement of the rights of people with mental disabilities.1 The MDRI investigation was conducted during a series of site visits in 1995 and 1996 by a team of experts in disability law and psychiatry. The MDRI team spent several weeks visiting social care homes, psychiatric institutions, psychiatric wards of general hospitals, outpatient clinics, and one community-based rehabilitation program. The team interviewed psychiatrists, nurses, and other medical professionals in practice and in academia, governmental officials at the Ministry of Health and Social Welfare, judges, judicial experts, practicing attorneys, human rights advocates, and the National Human Rights Ombudswoman. We also interviewed users and former users of the mental health system (referred to in this report as Aconsumers@), their families, friends, and representatives of consumer advocacy and family organizations. 

We are aware of the limitations inherent in describing a complex system of services, laws, financing and advocacy in a relatively short period of time in an unfamiliar context. Through repeated cross-checking of our observations, however, and with the assistance of many people in Hungary who spoke candidly and gave generously of their time, we believe that we have been able to develop an accurate picture of Hungary's mental health system. We recognize that there are a number of important programs and initiatives that are not included in this report.2 We also recognize that important changes are taking place within the system within recent months that may not be reflected in this report. 

This report is intended to add to the spirited discussion now taking place in Hungary about mental health system reform and the human rights of people with mental disabilities. We believe that one of the contributions we can make comes from our perspective as independent outsiders, as well as our experience examining the mental health systems of other parts of Central and Eastern Europe, Latin America, and the United States. The experiences of the co-authors of this report include extensive involvement in mental health treatment, mental health system planning and reform, and human rights advocacy in the United States and other countries. We hope that this report will add to the already extensive knowledge of people in Hungary. Drawing on the experiences of the United States and other countries, Hungarians can build upon the achievements of other countries in bringing about successful mental health system reform and can avoid mistakes that have been made in the United States and other countries. We present this report in the spirit of collaboration and dialogue. 

This report identifies Hungary's obligations to enforce the rights of people with mental disabilities under the International Covenant on Civil and Political Rights (the ICCPR), the European Convention on Human Rights (the ECHR), and the International Covenant on Economic, Social, and Cultural Rights (the ICESCR). This report relies primarily on the Principles for the Protection of Persons with Mental Illness (the MI Principles), adopted by the United Nations General Assembly in 1991, as a body of internationally recognized minimum standards for the treatment of people with mental disabilities.3 

Overview of Hungary's Mental Health System 

Hungary's mental health system includes approximately 10,000 inpatient beds, divided between psychiatric institutions and psychiatric wards of general hospitals. An extensive network of out-patient clinics exist, and approximately one-third of psychiatrists in Hungary are employed in these clinics. Outside the officially recognized mental health system, people with mental disabilities are placed in long-term institutions (social care homes), usually for a lifetime. There are 7,000 people living in social care homes designated for people with mental illness. In addition, there is an extensive system of social care homes designated for elders and for people with mental retardation.4 Children with mental disabilities are also excluded from schools and placed in institutions, leading to a lifetime of institutionalization.

Hungary's system of outpatient clinics, while extensive, provides a limited array of services and support. A large proportion of outpatient resources is devoted to providing psychotherapy for a few individuals, while the majority of people in outpatient treatment have limited contact with psychiatrists or other mental health professionals. For most people receiving outpatient services, treatment is limited to the provision of psychotropic medications. Aside from a few innovative rehabilitation programs, the services and support needed to maintain stability in the community for people with mental disabilities do not exist. Case management, supportive vocational programs, supported residential programs, and crisis intervention (crisis resolution teams that can help stabilize people in their homes, respite beds, crisis hostels, etc.) are not available to the vast majority of people with mental disabilities. In the absence of these services, thousands of people with mental disabilities are forced to seek or receive treatment in hospitals and other non-medical institutions for short or long periods of time. In most cases of chronic mental illness, people are forced to choose from a narrow and limited range of medication-oriented outpatient services or long term, custodial care in institutions or social care homes. Institutionalization of this kind cuts off people from their families and friends and leads to an unnecessary breakdown in ties with the community. Despite caring and dedicated efforts of staff, long-term institutionalization creates social isolation and contributes to increased dependency and mental disability. 

In some locations, conditions within social care homes, psychiatric institutions, and psychiatric wards of general hospitals are inhuman and degrading. Basic rights of people in these institutions to make large or small decisions about treatment or daily routine are not recognized. Closed from public view in institutions without human rights oversight or advocacy available to them, people are vulnerable to the most serious human rights violations prohibited by international law. Major restrictions on individual liberty are routinely delegated to the administrative discretion of ward staff without due process of law. In some areas, the MDRI team observed people placed in cages for unlimited time periods without supervision. 

Over the last year, the human rights of people with mental disabilities have come to national attention. On July 17, 1996, the Human Rights Ombudswoman, Katalin Gönczöl, issued a report documenting serious human rights abuses in social care homes. The Gönczöl report found that these abuses violate the Hungarian Constitution and called for immediate action to improve the conditions in these settings. In the view of the MDRI investigators, the human rights issues at stake are not limited to the degrading internal conditions in social care homes. Even if these conditions are improved, the use of such institutions to segregate people from society deprives them of adequate treatment and opportunity for rehabilitation. As currently structured and operated, the mental health system of Hungary deprives people with mental disabilities of the right to work and live in the community and to participate as full members of society. 

The lack of community-based service and support systems critically limits the rights of people with mental disabilities throughout society, not just in social care homes. Hungary has a network of psychiatric wards in general hospitals, for example, that are generally located near the community. Without a network of community-based services and support systems, however, it is difficult to integrate people from these wards into the community. Discharge options are limited, and psychiatrists are forced to discharge people back into society with only a fraction of the kinds of support they need to remain stable, much less flourish as human beings. Under these conditions, many people become a burden on their families. Inside or outside institutions, often awaiting placement in social care homes, people spend their lives vegetating. Most people never obtain assistance to learn the vocational or survival skills needed to lead an independent life. Many people decompensate repeatedly and are forced to return over and over to hospitals. This is not only a waste of their human potential, it is a wasteful and inefficient use of hospital beds and mental health system resources. The absence of comprehensive community services traps Hungary in a cycle in which the vast majority of mental health resources are allocated to institutional care, leaving few resources to promote or sustain community living. 

Human rights enforcement: recommendations and warnings 

Proposals currently under consideration to reform mental health legislation and up-date Hungary=s system of health care finance and insurance reimbursement create enormous opportunities for improvements in the human rights of people with mental disabilities. A failure to recognize the rights of people with mental disabilities and plan for their integration into society, however, could lead to a further entrenchment of the current system of segregation and inadequate community support. 

Hungary has recently adopted new legislation governing civil commitment to psychiatric institutions and general hospital psychiatric units. The Ministry of Health and Social Welfare is also conducting an extensive review of current law and is drafting new legislation regulating health care practices. These legal initiatives represent an important step toward the recognition of the rights of people with mental disabilities, but they do not address the fundamental structural problems of the mental health system, i.e. the segregation of people with mental disabilities and the need to create community-based alternatives to psychiatric institutionalization. 

Many of the current reform efforts are intended to remedy the inhuman and degrading conditions in social care homes identified in the Gönczöl report. Without a reduction in the census of social care homes, however, it will be difficult for Hungary to free up financial resources to improve conditions within institutions. Without the creation of an improved system of health care financing and insurance reimbursement that recognizes and prioritizes community-mental health service and supports, people with mental disabilities will not have true alternatives to institutionalization. Without planning for the creation of a comprehensive system of community services, resources now directed to general hospital psychiatric units and outpatient services will continue to provide isolated pockets of treatment that do not provide the full support people need to avoid unnecessary institutionalization. 

The history of mental health system reform in the United States and other countries demonstrates that there are dangers associated with legal reform not accompanied by a national commitment to plan and finance community services. Full enforcement of commitment laws without the establishment of community-based alternatives to institutions could lead to irresponsible discharge of people from hospitals and social care homes without adequate services and protection in the community. In practice, failure to develop community- based services is usually accompanied by a failure to enforce civil commitment and other human rights laws. The recognition of patients= rights without the creation of real choices for people with mental disabilities may be changes in form rather than substance. Without meaningful choices, many of the new legal rights now under consideration may be a dead letter from the moment they are enacted.

The rights of people with mental disabilities, including legally enforceable minimum standards of treatment, should be established both in institutions and in the community as part of a comprehensive system of support and care. Human rights oversight and advocacy systems must be established to ensure that these rights are enforced throughout the mental health system. As part of this system of support and advocacy, the government should recognize and finance consumercontrolled support and advocacy programs. The process of reforming the mental health system must be fully informed by a recognition of rights of people with mental disabilities and must include full public participation. In addition to the participation of existing civic and professional organizations, people with mental disabilities and their representatives must be included in the process of conceptualizing and planning mental health system reform and human rights enforcement. 

A. Social Care Homes 

Approximately 7,000 adults of all ages live in long-term institutions, known as Asocial care homes,@ designated for people with mental illness. The Social Care Act regulating social care homes does not require the provision of rehabilitation. Thus, social care homes are not officially recognized as part of the Amental health system.@5 Additional institutions exist for children and people with other mental or physical disabilities. An estimated 14,000 people live in similar longterm institutions designated for people with mental retardation. 

1. Isolation from the community - Social care homes are located in remote parts of Hungary, often on Hungary=s borders, isolated from major population centers. Once a person is placed in a social care home, he or she is considered to be beyond rehabilitation. Thus, there is little or no effort at active treatment, rehabilitation, or reintegration into the community. The vast majority of people placed in social care homes remain there for life. 

Χ MDRI finds that the system of social care homes unnecessarily isolates and segregates people with mental illness from normal life. Individuals placed in social care homes are denied the right to live, work, and receive treatment in the community. Isolation and failure to make efforts to return people to the community violate the right Ato be treated near his or her home or the home of his or her relatives and friends and ... the right to return to the community as soon as possible.@ MI Principles, principle 7(2). People in social care homes are deprived of the right to treatment Adirected towards preserving and enhancing personal autonomy.@ Principle 9(1). Detention without any meaningful effort at rehabilitation violates article 10 of the ICCPR (A[a]ll persons deprived of their liberty shall be treated with humanity and with respect for the inherent dignity of the human person.@

2. Arbitrary placement in social care homes - There is no legal process for placement in a social care home. There is a law in Hungary governing civil commitment to psychiatric institutions, but this law is not applied to placement in facilities designated as social care homes. Most people in social care homes are placed there by family members or other individuals designated as their legal Aguardians.@ Hungary=s guardianship law does not require independent judicial review of placement in a social care home. Nor does it require review or reconsideration over the course of the individual=s lifetime. Many people interviewed by MDRI investigators had been placed under guardianship as children and have gone for years without any contact with their guardians. 

Χ MDRI finds that Hungary=s practices for placement in social care homes are arbitrary and without appropriate legal process. The failure to provide independent review of commitment to social care homes, with appropriate procedural protections for people subject to commitment violates the MI Principles (principles 15, 16, 17, 18). The lack of due process for placement in a social care home, including independent review of commitment, constitutes Aarbitrary detention@ under article 13 of the ICCPR and article 5 of the ECHR.

3. Improper detention - Officially, people are placed in social care homes because they are considered untreatable or beyond rehabilitation. Despite this, authorities at two social care homes investigated by MDRI estimated that one third to one half of social care home residents could live in the community if they had family to take them in or if other social support networks existed. We believe this estimate is low. Many people in social care homes do not have a major psychiatric diagnosis. Some people are placed in the institution for alcoholism or mental retardation. Others have lost contact with the outside world because they have been in the institution so long they have lost the skills necessary to live in the community. Many people have no experience other than life in an institution, having grown up in an institution since they were children. With appropriate service and support programs, modern social service and psychiatric practice have demonstrated that the majority of these individuals can be reintegrated into the community. 

Χ MDRI finds that the majority of people placed in social care homes do not meet internationally recognized standards for in-patient commitment. People are detained in social care homes in violation of the standards set forth in the MI Principles (principle 16, limiting involuntary commitment to people for whom there is a Aserious likelihood of immediate or imminent harm@ or to avoid Aserious deterioration in his or her condition....[for which treatment] can only be given by admission to a mental health facility in accordance with the principle of the least restrictive alternative.@) Failure to require that people meet internationally recognized substantive standards for commitment constitutes Aarbitrary detention@ under article 13 of the ICCPR and article 5 of the ECHR.

4. Inhuman and degrading treatment - Placement in social care homes creates isolation and results in the loss of ties with friends and family in the community. In the absence of activities to structure the day and engage peoples= interests, residents of social care homes are left to long hours, days, and years of boredom. Individuals live in dormitory-like rooms and lack privacy or control over their daily lives. In some wards, lights are turned off late in the afternoon and people spend the remainder of the day in the darkness. Clothing is drab, impersonal and often inappropriate. In the worst areas, people have little or no clothing. While some buildings are modern and clean, others are old, decaying, and unhygienic. In some areas, people are allowed to languish in filth, covered in dirt or their own feces. Oral hygiene is lacking for a large number of social care home residents, who lose their teeth and cannot eat solid food. Patient choice, including the rights of patients to informed consent to treatment, is not recognized under Hungarian law. People in social care homes are subject to the arbitrary use of physical restraints. 

Χ MDRI finds that conditions in social care homes are inhuman and degrading. Isolation, inactivity, and lack of stimulus leads to the loss of social functioning and a degeneration of mental health. Treatment in social care homes violates numerous provisions of the MI Principles, including the right to be treated Awith humanity and respect for the inherent dignity of the human person,@ principle 1(2) ; the right to protection against harm, principle 8(2), and the right to an Aenvironment and living conditions ... as close as possible to those of normal life...@ principle 13(2). Conditions in social care homes constitute inhuman and degrading treatment, in violation of article 7 of the ICCPR and article 3 of the ECHR. Placement in a social care home promotes further mental deterioration, violating the right to the highest attainable standard of mental health under article 12 of the ICESC.

5. Improper physical restraints and use of cages - Some people are placed in cages as a form of physical restraint and permanent detention. Cages are constructed of a metal frame supporting a cloth or wire mesh over a bed. People can sit up or roll over in the cage, but they cannot stand up. Some individuals are placed in cages for weeks or months for behavioral control. Other individuals are kept permanently in cages because of lack of staff to supervise them. With such limited movement, people in cages are subject to dangerous, and potentially life threatening pressure ulcers (bed sores). Unable to leave the cage to go to the toilet, people are often covered in their own feces. 

Χ Use of cages constitutes inhuman and degrading treatment, and creates life threatening dangers. Detention in cages violates the strict standards for the use of physical restraints and protection from harm, established under the MI Principles, principle 11(11). Such detention constitutes inhuman and degrading treatment under article 7 of the ICCPR and article 3 of the ECHR. Placement in cages is dangerous and can be life threatening, in violation of article 6 of the ICCPR and article 2 of the ECHR.

Recommendations: 

A-1 Inhuman and degrading treatment practices should be terminated at once. 

A-2 The use of cages should be prohibited as a means of detention, physical restraint, or ward management. 

A-3 The national legislature of Hungary should adopt a body of enforceable patients rights that will apply to all people in Hungary=s mental health and social care system. Consistent with internationally recognized human rights standards, this legislation should recognize the right of individuals to live in the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the individual=s health needs and the need to protect the safety of others. Every individual should have the right to live, work, and be treated and cared for in the community to the extent his or her condition permits. Until such time as this new legislation is adopted, the Ministry of Health and Social Welfare and local governments should issue guidelines for the respect of patients rights. 

A-4 All people in institutions should be notified of their rights under Hungarian and international law in a form and language which they understand. 

A-5 All new admissions to social care homes for people with mental illness or mental retardation should be stopped immediately. 

A-6 A comprehensive review of placements in all social care homes should be conducted. People who no longer require guardianship should have the recognition of their legal capacity restored. 

A-7 Immediate efforts should be made to provide alternative accommodations and support for every social care home resident capable of living in the community. Individuals who meet internationally recognized standards for in-patient commitment should be transferred to facilities as close as possible to the community from which they originated 

A-8 The government of Hungary should develop a plan to phase down the system of social care homes.

B. Institutional and Community Care 

The officially designated mental health system of Hungary provides services for 10,000 people as in-patients and many more people as out-patients. The National Psychiatric Institute (known by its Hungarian acronym as OPNI) in Budapest is responsible for regulating all aspects of treatment and quality of care throughout the mental health system. The majority of in-patient care takes place in psychiatric wards of general hospitals. The OPNI administers the largest psychiatric institution, also known as OPNI or Lipót. Lipót has 800 to 1,000 in-patient beds, and it serves 70,000 out-patients in the community. An additional 30,000 receive out-patient psychiatric treatment through clinics administered by local hospitals. The majority of patients are reported to remain in the institution from three weeks to three months, but some people remain in the institution much longer. Individuals deemed Achronic patients@ or individuals who cannot take care of themselves and who lack a family to support them may remain in the institution for years. Every year, approximately ten percent of all patients at Lipót are designated for transfer to social care homes. 

1. Unnecessarily restrictive environment - The great majority of Hungary=s mental health system resources are directed toward in-patient care, at the expense of providing adequate outpatient and community-based treatment. The existence of psychiatric wards of general hospitals creates potential for inpatient care close to the community. In practice, however, people in such wards are often isolated from the community. In some cases, psychiatric wards of general hospitals are used for long-term care. Even when treatment is short-term, general hospital psychiatric wards are often not effectively integrated into community-based service or health care systems. This is due to the limited availability of community services and to the lack of coordination with existing services. 

In some cases, the national insurance and pension systems promote unnecessary in-patient treatment by providing benefits to individuals in in-patient care who could function in the community if they received necessary support. As a result of limited community-based services, many people are forced to seek treatment in an in-patient setting even though they are capable of living, working, and receiving treatment from out-patient services in the community. This is true for people diagnosed with major mental illnesses and for people diagnosed as neurotic. 

According to the Director of the National Psychiatric Institute, approximately 25 percent of people receiving treatment as in-patients are diagnosed as Aneurotic@ and do not have any major psychiatric diagnosis. In one institution visited by MDRI, the Director estimated that only 30 percent of in-patients have major psychiatric diagnoses. Some Hungarian psychiatrists estimate that 90 to 100 percent of individuals without a major psychiatric diagnosis could live and receive treatment in the community. The practice of unnecessary in-patient treatment for people with major mental illness and neuroses creates social dislocation, stigma, and often the loss of work or other social ties. In many cases, this breakdown in ties to the community leads to long-term in-patient care and segregation from the community. 

Χ MDRI finds that the structure of services in Hungary forces many people to seek inpatient treatment when they are capable of living, working, and receiving treatment in the community. These services often lead to unnecessary, long-term segregation of people with mental illness in institutional settings. Unnecessary in-patient treatment and the failure to provide community based alternatives violate the Aright to be treated in the least restrictive environment ... appropriate to the patient=s health needs....@ under the MI Principles, principle 9(1). The practice of unnecessary in-patient treatment violates the right under article 12 of the ICESCR to the Ahighest attainable standard of physical and mental health@ of which people with mental disabilities are capable.

2. Inhuman and degrading conditions - Conditions in Hungary=s psychiatric institutions vary widely. In some areas, impressive efforts have been made in recent years to improve conditions. Even in some of the clean, modern buildings, however, people lack privacy, living conditions are impersonal, and inactivity is the rule. Long-term patients may spend years awaiting placement in a social care home without active rehabilitation programs or other activities. There is no recognition of the rights of patients to make basic choices about their lives or to provide informed consent to treatment, as required by the MI Principles. In other areas, conditions are worse, particularly in locked wards and wards for chronic patients. In some wards of this kind, people receive less staff attention and their conditions degenerate. Physical and oral hygiene is lacking, clothing is inappropriate, and some people are not allowed outdoors for weeks or months. Some residential areas are large and dormitory-like with ten to twenty beds in a room. In a small number of cases, people are restrained (tied to chairs or belted to beds) or placed in cages because of the lack of staff to provide them with adequate supervision. As in social care homes, described above, people in cages are unable to leave to go to the toilet, and they are at risk of bed sores from lack of movement. 

Χ Some in-patient psychiatric facilities subject patients to inhuman and degrading treatment. The failure to provide a clean, safe, and socially appropriate environment, creates unnecessary suffering and undermines opportunities for rehabilitation and reintegration into the community. The lack of an environment conducive to rehabilitation violates the MI Principles, principle 13, and the right to Atreatment ... directed towards preserving and enhancing personal autonomy,@ principle 9(4). The failure to inform people of their rights, and to enforce those rights, violates principles 11, 12 and 23. The use of physical restraints at the discretion of ward staff, without time limitations or adequate safeguards, violates principle 11(11), and the failure to protect against harm violates principle 8(2). These conditions cause needless degradation and suffering, in violation of article 7 of the ICCPR and article 3 of the ECHR.

3. Inadequate community services and support - Out-patient treatment for many people consists almost exclusively of psychotropic medication. While a small number of people receive individual or group psychotherapy, other services such as psychosocial rehabilitation, vocational support, and supported living programs are lacking. Due to the large case load of psychiatrists in out-patient practice, many people are not able to see a psychiatrist more than once a month, and some psychotropic medications cannot always be used as needed (such as lithium). 

Χ MDRI finds that the lack of community-based services and support leads to unnecessary institutionalization and inappropriate care in the community. The use of psychotropic medications without adequate monitoring can lead to unnecessary and debilitating side effects and life-threatening danger. The lack of community based services and supports leads to a violation of the right to Ahealth and social care as is appropriate to his or her health needs,@ including the protection from harm against inappropriate medications. MI Principles, principle 8.

Recommendations: 

B-1 Immediate steps should be taken to create a comprehensive community-based service and support system to permit people to live, work, and receive care in the community to the extent possible. Community-based services should include: supported housing, supported employment, crisis services, case management, respite care, consumer-controlled supportive clubhouses, consumer and family advocacy, and legal advocacy. 

B-2 The national plan for mental health service reform should identify the cost of reform and should allocate resources necessary to protect fundamental human rights. An additional infusion of funds will be necessary during the transition to a community-based system. Effective national planning will be necessary to permit a quick (two to five years) and efficient reform of the service system. 

B-3 Community based service and support systems and integrated educational programs for people with mental retardation should be established. 

B-4 The insurance and pension systems should be revised to end incentives for in-patient treatment at the expense of out-patient treatment. These programs should provide the funding necessary to permit people to live and work in the community to the extent possible. 

B-5 Standards for in-patient and out-patient services should be established, consistent with internationally accepted practice standards and human rights. These should include individual habilitation or rehabilitation plans for adults and individualized educational plans for children. 

B-6 Continuing education programs should be established for all staff. 

B-7 Legislation should be adopted to ban discrimination against people with mental disabilities, including discrimination in education, employment, housing, public services and public accommodations.

C. Civil Commitment and Guardianship 

Hungary has recently amended its laws governing civil commitment to psychiatric facilities to harmonize them with international human rights law, as well as standards recently established by the Council of Europe. Hungary=s new legislation limits involuntary detention to people who are diagnosed as mentally ill and constitute an Aimmediate and serious danger@ to themselves or others. The commitment standard established by Hungary=s new law is consistent with international human rights law. However, the commitment law is severely limited by its failure to provide the procedural protections required by international law. 

1. Inadequate right to counsel - In practice, many people with mental disabilities cannot take advantage of the new commitment law=s protection because they do not have adequate access to counsel. The commitment law does not have a clearly defined right to counsel, as required by international human rights standards. The legal representative of the person subject to commitment is referred to as a Acasual guardian,@ leaving judges and official legal representatives with the impression that the position is actually that of a guardian. A guardian, unlike a true legal advocate, represents what he or she thinks is best for the client, not necessarily what the client wants. The legislation also fails to provide the client a right to be heard, to cross examine witnesses, or to obtain an independent psychiatric evaluation. 

Χ MDRI finds that Hungary=s civil commitment law lacks necessary procedural protections, including the right to counsel. The lack of adequate right to counsel violates the MI Principles, Principle 18. 

2. Lack of resources for effective review - When the new commitment law was enacted, no new resources were provided to the judicial system to handle the enormous new caseload. As a result, hearings are forced to take place on psychiatric wards, often without adequate protection of privacy. Judges and legal representatives have such a large case load that each review usually lasts about ten minutes. Legal representatives usually do not meet their clients or hear about the facts of the case until the moment of the hearing. Civil commitment hearings are so cursory as to be nearly meaningless. In an environment in which decisions about every aspect of care and treatment is left to the discretion of psychiatrists, judges are hesitant to override the recommendation of a psychiatrist based upon the judges= limited exposure to the facts of the case. 

Χ MDRI finds that, due to a lack of resources for civil commitment cases, judicial review is cursory and close to meaningless. Psychiatric commitment is effectively left to the discretion of psychiatrists. Independent review of psychiatric commitment is guaranteed by the MI Principles, principle 16, the ICCPR, article 9, and the ECHR, article 5 . The MI Principles and international conventions protecting arbitrary detention require that states make the minimal investments necessary to ensure adequate, independent review of psychiatric commitments. 

3. Failure to protect people committed to social care homes - Hungary=s civil commitment law does not apply to the people who need its protections the most - people who are placed in social care homes. In most cases, people are placed in social care homes by family members or othe Alegal guardians@ without any judicial review. Since most people are placed under guardianship, the detention in a social care home is treated as a Avoluntary@ process. A Aguardianship authority@ may be required to approve a social care home placement, but this is a purely administrative review process with no established standards or procedural protections. 

Χ Taken together, Hungarian civil commitment and guardianship laws improperly deny the right of people with mental disabilities to protection against arbitrary detention in a social care home. Neither the social care home nor the guardianship authority is required to submit to the substantive standards or procedural protections set forth in the MI Principles, principles 15-18. The procedure for detention in a social care home constitutes arbitrary detention under article 9 of the ICCPR and article 5 of the ECHR. 

4. Lack of judicial review in guardianship proceedings - Judicial review of guardianship is limited to a single determination of whether a person can Amanage his or her own affairs.@ A judge may decide whether a person is put under partial guardianship (under which the ward retains some legal capacity) or plenary (Afull@) guardianship (under which the ward is held to have no legal capacity), but the judge may not specify exactly what powers the guardian has and what legal capacity the ward retains. Once a court determines that a guardian is required, an administrative agency known as a Aguardianship authority@ appoints a guardian. There is no judicial review of the guardian=s possible conflict of interest with the ward. The judge cannot limit the guardianship over specific duties and cannot review any decision of the guardian. Once a guardian is appointed, there is no further requirement of judicial review for the most important decisions, including the decision to detain a person in an institution. There is no requirement of periodic review of guardianship. MDRI interviewed many people who had been placed under guardianship as children and had not met their guardian in decades. People subject to plenary guardianship have their legal identity taken away from them, subjecting them to an almost complete denial of legal rights in the community. 

Χ MDRI finds that Hungary=s guardianship law unlawfully and improperly limits the scope of judicial review in the guardianship process and delegates a person=s legal rights to a guardian or an administrative guardianship authority. The guardianship process arbitrarily strips people of their legal rights far beyond what may be necessary. Hungary=s guardianship law fails to provide the procedural protections required by the MI Principles, including the right to counsel and the right to periodic review. MI Principles, principle 1(6). The guardianship process denies people with mental disabilities the ability to exercise the same rights as all other people, except to the extent Anecessary to protect@ the rights of that person or others. MI Principles, principle 1(4). Thus, the guardianship law constitutes illegal discrimination under the MI Principles and article 26 of the ICCPR and article 14 of the ECHR. 

Recommendations: 

C-1 Hungary=s civil commitment law should be amended to provide due process protections, including a right to participate fully in a hearing, the right to cross examine witnesses, and the clear and unequivocal right to counsel representing the views of the person subject to commitment.

C-2 Additional resources should be provided to the judicial system to ensure that judges and legal representatives can devote the time and attention needed to each case. 

C-3 The guardianship law should be revised, in accordance with international law, to provide the assurance that people with mental disabilities will retain the same rights as all other people. The guardianship law should explicitly: 
a. require that any restriction on a person=s legal capacity be made by an independent and impartial decision-maker after a full hearing, at which the person subject to guardianship has the right to effective assistance of counsel; 
b. provide that the judge, not the administrative agency, shall determine who will serve as guardian and shall review the guardian=s fitness and potential conflict of interests; 
c. require periodic review of the necessity of continued guardianship at regular intervals established by law, after a full hearing by an appropriate, independent review body; 
d. require that any restriction on a person=s rights be specified precisely by a court based on findings of fact that an individual lacks the capacity to engage in each specific activity that is limited; 
e. limit the discretion of a court to restrict a person=s legal capacity to situations in which such a limitation is strictly necessary to protect the rights of the person with a mental disability.

D. Quality Assurance and Oversight 

Apart from basic regulation of physical conditions and staffing, there are no legally enforceable minimum standards or guidelines for the treatment of people with mental disabilities in Hungary=s psychiatric institutions, social care homes, or out-patient programs. Without minimum legal standards, psychiatrists have the discretion to engage in improper, unproven or dangerous treatment practices. No standards exist for the use of physical restraints, and no regulations prohibit the use of cages. No procedures exist for regularly and systematically monitoring living conditions or treatment practices, and no special procedures exist to investigate unusual incidents or allegations of abuse by staff or other patients. The Ministry of Health and Social Welfare has taken the lead in drafting important new legislation regulating mental health care and patients rights. However, there is no official commitment to a policy of social integration for people with mental disabilities and no public, national planning process to end the unnecessary institutionalization of people in psychiatric institutions and social care homes. 

Χ MDRI finds a lack of quality assurance and human rights oversight in Hungary=s mental health system. The absence of standards for treatment in institutions creates an environment that permits improper and potentially dangerous treatment practices. The lack of enforceable minimum standards to ensure compliance with the MI Principles and other internationally recognized human rights violates the MI Principles (principles 22 and 23). The failure to provide protections against inhuman and degrading treatment also violates article 2 of the ICCPR, article 1 of the ECHR and article 2 of the ICESCR, requiring States to ensure the enforcement of internationally recognized human rights.

Χ MDRI finds a lack of a national planning to ensure enforcement of the rights of people with mental disabilities and provide for equality, full participation, and reintegration into the community. People with mental disabilities are not included in the planning that takes place. The lack of a national planning process to ensure human rights enforcement and full participation of people with mental disabilities violates the Rules on Equalization (rules 3, 4, 15), as does the failure to include people with mental disabilities in the planning that is now taking place. (Rule 14.2). The misallocation of resources leading to improper and unnecessarily restrictive treatment of people with mental disabilities violates article 2 of the ICCPR, article 1 of the ECHR and article 2 of the ICESCR, requiring States to ensure the enforcement of internationally recognized human rights.

Recommendations: 

D-1 Establish enforceable minimum standards for treatment in in-patient and out-patient services. 

D-2 Create independent patient advocacy programs to assist people in in-patient programs to seek enforcement of their rights 

D-3 Create policies and practices for investigating allegations of abuse or improper treatment in institutions. This should include a public report of complaints and action taken, with protection for complainants and respect for the privacy of individuals involved. 

D-4 Create effective oversight mechanisms to ensure enforcement of treatment standards and internationally recognized human rights. 

D-5 Initiate an inclusive, national planning process to bring about the structural reforms needed to ensure human rights enforcement, equalization of opportunities, and full integration of people with mental disabilities. This process should include: 
a. participation of people with mental disabilities in any governmental planning body; 
b. the identification of immediate steps that can be taken to bring Hungary into conformity with international human rights law; 
c. development of a plan to create community-based service and support systems on a national level; 
d. development of a plan for financing reform, including a targeted reallocation of funds from psychiatric hospitals to in-patient to out-patient programs, as community services are developed. Additional funds will be needed to finance the extra costs of transition. 

D-6 Provide support to independent consumer and family advocacy organizations. 

D-7 Create and fund disability councils to promote the inclusion of people with mental disabilities and their families in the process of identifying human rights concerns and developing reform plans. Disability Councils should be consumer controlled, and they should meet at regularly appointed times during the year to take the testimony of psychiatric system users and former users, family members, service providers, and other concerned citizens. The government should also fund a permanent staff for the Disability Councils to prepare recommendations, subject to approval of a majority of members of the Disability Councils, for government action to respond to the concerns of people with mental disabilities.

E. Recommendations to Advocates and the International Community

To create political support for mental health system reform, advocates in Hungary should: 

E-1 Educate the public about the human rights conditions of people with mental disabilities, and publicize positive models of community integration and effective citizen action. 

E-2 Bring together a broad base of constituents for reform, including system users, family groups, community service providers, mental health professionals, human rights advocates, and other concerned citizens. 

E-3 Establish cross disability coalitions of interest groups concerned about the recognition of rights and the reform of services designated for people with mental illness, mental retardation, and other mental and physical disabilities. 

E-4 Establish community-based service programs informed by the best programs from other countries. Innovative service providers should be sure to document their work so that their programs can serve as models for similar kinds of work throughout Hungary. The international community should press for the enforcement of international human rights law and should provide support to innovate service and advocacy programs in Hungary: 

E-5 International support should be provided for the innovative, nongovernmental service and advocacy programs now being established advocating for the rights of people with mental disabilities in Hungary. 

E-6 Once Hungary has established the national goal of full community integration and support for people with mental disabilities, loans and development assistance should be provided to the government of Hungary to promote the reform of the service system. Special support will be especially important during the time of transition to a community-based service system. As a condition of such assistance, international funders should require the government of Hungary to agree to provide full funding for community-based services once the transition period is complete. 

E-7 The United Nations Special Rapporteur on the Equalization of Opportunities for Persons with Disabilities should evaluate the conditions of people with mental disabilities in Hungary and should evaluate Hungary=s efforts to create services and programs that will provide people with mental disabilities the full opportunity to live and work in the community. The Special Rapporteur should provide special assistance to Hungary to create service programs in the community and should help raise international financial support for the development of such programs. 

E-8 The United Nations Human Rights Committee should review Hungary=s enforcement of the rights of people with mental disabilities under the ICCPR. E-9 The United Nations Committee on Economic, Social, and Cultural Rights should review Hungary=s enforcement of rights of people with mental disabilities under the ICESCR.

Preface: Goals and Methods of this Report

Mental Disability Rights International (MDRI) is a non-governmental advocacy organization dedicated to the international recognition and enforcement of the rights of people with mental disabilities. MDRI documents human rights abuses, supports the development of mental disability advocacy abroad, assists advocates seeking legal and service system reform, and promotes international oversight of the rights of people with mental disabilities in the United States and abroad. 

This report documents human rights conditions in Hungary=s mental health system and recommends steps necessary to bring the system into conformity with internationally recognized human rights standards. This report is not intended to single out Hungary for criticism but to examine the enforcement of international human rights law that applies universally to people with mental disabilities. Indeed, many of the observations and recommendations in the report are relevant to other countries of Central and Eastern Europe where the vast majority of people with mental disabilities remain segregated in closed institutions without adequate opportunity for community integration. 

We hope that this report will promote the efforts of the many service providers, consumers, family members, and other human rights advocates in Hungary who have worked so hard to protect the rights and improve opportunities for people with mental disabilities. We also hope that this report will provide guidance to public officials and legislators in Hungary about the actions and legal reforms that the government must take to ensure full enforcement of the rights of people with mental disabilities under international law. This report is also directed to the international community, which can play a much greater role providing oversight of human rights conditions in psychiatric systems and supporting mental health reform. 

The identification of human rights violations and deficiencies in the operation of the current mental health system is an essential first step, but reform will not succeed without the participation of concerned citizens and governments. In that spirit, MDRI has provided detailed recommendations to service providers, activists, the Government of Hungary, and the international community. This report is the product of numerous fact-finding missions to Hungary, conducted primarily in March 1995, November 1995, and March 1996.6 Members of the MDRI teams interviewed representatives of the Legal Department of the Ministry of Welfare, judges and court-appointed medical experts involved in the psychiatric commitment process in Budapest, members of the Guardianship Authority for Budapest, and a professional public guardian who works closely with the Guardianship Authority. MDRI also met with the director of the National Psychiatric Institute and a number of psychiatrists and department directors at the Lipot psychiatric institution in Budapest. 

In March 1995, a MDRI team toured one of the psychiatric wards at Nyirö Gyula hospital, three wards at the National Psychiatric Institute (also known as Lipot) in Budapest, and a new psychiatric institution for children on the grounds of Lipot. MDRI also visited the Szentgotthárd social care home. In November 1995, an MDRI team interviewed the directors of two psychiatric departments at Dr. Kenessay Albert Hospital, Balassagyarmat, the deputy director of a psychiatric department at Nyirö Gyula Hospital in Budapest, and the Director of the psychiatric department at Bajcsy Zsilinsky hospital. MDRI teams interviewed medical school authorities at the Semmelweis Medical School, and toured the psychiatric wards of Semmelweis, Kenessay Hospital and Nyirö Gyula hospital. In September 1995, MDRI associate Judith Klein toured a locked ward at Lipot. The November 1995 team also toured the Ludányhalászi social care home near Balassagyarmat. MDRI teams visited the AAwakenings@ community mental health program of Semmelweis medical school, and met with staff seeking to establish a community-based home in Budapest. In March and November 1995, the MDRI teams met with mental health system consumers and family members, including representatives of two consumer organizations. In March 1996, MDRI investigators observed a civil commitment hearing at Semmelweis medical school and visited three out-patient clinics in Budapest. On visits to psychiatric programs, team members toured facilities, visited therapeutic and residential wards, and interviewed administrative authorities, staff, and consumers. 

At most locations, MDRI teams received full access to facilities, staff and clients without restrictions.7 MDRI was met with great openness and candor, and many people gave generously of their time. Almost without exception, they expressed concern about the need to improve services and the protection of rights of people with mental disabilities. This report - and the difficult reform process that lies ahead - would not have been possible without their support. The observations published in this report and the conclusions reached are those of the authors alone. 

The findings of this report represent the views of its authors and of Mental Disability Rights International. Affiliations of the authors are listed for purposes of identification only. This report does not represent any position on the part of the Washington College of Law or American University.