The possibilities for therapy in psychiatric institutions in Bulgaria continue to be deficient, the staff is insufficient, and the use of restraints does not comply with international standards. These are findings in a new report by the Council of Europe's Committee Against Torture following their latest visit to Bulgaria in March 2023.
Physical violence against patients by staff in these closed institutions continues. The Committee regards it as a serious failure of the Ministry of Health that it has not managed to stop these unacceptable practices.
The Committee acknowledges some progress in social care institutions for people with mental disorders and expresses hope that real deinstitutionalization will be achieved.
Last March, the Committee's delegation visited for the first time the state psychiatric hospital Tserova Koria, as well as the one in Byala (the second largest psychiatric hospital had previously been visited by the Committee in 2020). European representatives also visited social care homes for people with intellectual disabilities in Draganovo and Tri Kladenets. The purpose of the visits was to determine whether the recommendations of the Committee from the November 2021 visit had been taken into account.
ABUSE
At the Byala hospital, the delegation received numerous claims from patients – in three out of four male wards – that staff shout at patients, and orderlies slap them, hit them on the head, punch them in the kidneys, and push them (including in the lower back). Similar complaints are found at the Tserova Koria psychiatric hospital, where it is somewhat common for staff to shout at patients, and sometimes orderlies also hit them, including with a restraining belt.
In addition, patients have complained that orderlies use swear words, call them offensive names, and threaten them. Some of the orderlies, mentioned by name by patients, are the same individuals identified during the previous visit in 2020. At that time, their names were given to the director of the institution by the delegation with a request for immediate action. In both hospitals, it is claimed that the orderlies sometimes carry a stick for 'authority'.
At the Byala hospital, in the closed ward for long-term and adult patients (Ward 4) and in the closed ward for long-term patients at the Tserova Koria hospital (Ward 3), the delegation found wooden sticks easily accessible in the staff offices at the places indicated by the patients.
Nurses and doctors at the Byala hospital were aware of the unacceptable behavior of the orderlies but chose to turn a blind eye, even when a patient turned to them for help.
Regarding the evidence of physical violence in the visited closed institutions, the Committee states: 'Such findings once again show that there is a serious omission on the part of the Ministry of Health to prevent all forms of patient abuse. There is a lack of a clear and unambiguous message from the department to the staff of psychiatric hospitals that cases of abuse will not be tolerated and will be subject to sanctions...'.
Other direct observations in Byala
During their visit to the psychiatric hospital in Byala, the delegation found that 20 percent of the patients no longer need hospitalization but remain in the hospital because they do not have an alternative place to live, nor suitable facilities to provide care outside of it.
The director explained that the hospital, in addition to providing psychiatric treatment, acts as a home for social care for people with mental disorders, a shelter for the homeless, and a hospice for the terminally ill. The Committee once again expresses its view that the continued presence of individuals in psychiatric hospitals only due to the lack of a suitable public or health facility is 'very regrettable'.
RECOMMENDATIONS
In this regard, the Committee again calls on the Ministry of Health to take decisive action to stop the abuse of patients by staff by improving hiring, training, and supervision, as well as by promptly and independently investigating complaints of abuse. The Committee also calls on the Bulgarian authorities to significantly increase their efforts to develop and organize diverse and appropriate alternatives to home, day, and outpatient psychiatric care in the community, including the development of functional and responsive community mental health teams. This is part of the country's obligations under the UN Convention on the Rights of Persons with Disabilities.
For patients without family support, social care should be provided in small residential buildings, preferably in urban areas, with all necessary facilities and services. The Committee emphasizes once again that the Ministry of Health and the Ministry of Labor and Social Policy should work closely together to implement these recommendations.
You can read the full report in English here.
You can read the response from the Bulgarian authorities at this link.
