Restrains on a bed in a seclusion room in Lopača Psychiatric Hospital, in southwest Croatia. There are no official guidelines on the use of restraints in Croatia, allowing for broad discretion on the use of physical and chemical restraints and seclusion by healthcare staff in psychiatric hospitals.

© 2014 Emina Ćerimović/Human Rights Watch

(ジュネーブ)— クロアチアでは8,200人超の知的障がい者及び心理社会的障がい者が隔離された施設や精神病院に収容されており、生活に関わる選択の自由をほとんど持てないでいる、とヒューマン・ライツ・ウォッチは本日述べた。今週国連は、障がい者の権利に関する条約を実施しているかどうか、クロアチアの取組み状況を審査する予定だ。

クロアチアにおける障がい者の権利保護は一部進展もみられるが、ヒューマン・ライツ・ウォッチによる調査は、人びとを施設からコミュニティー基盤の生活環境へ復帰させる動きは遅々として進んでおらず、また限定的なものであることを明らかにしている。障がい者の一部は、いまだ自らの生活に関する選択の自由を法的にはく奪された状態にあるのだ。政府の「脱・施設収容制度」計画には、障がい者たちが暮らす国営・私営すべての施設が含まれるべきだ。加えて政府は、障がい者の法的能力をめぐる国内法を改正し、障がい者自身の意思決定を容認・推奨すべきである。

ヒューマン・ライツ・ウォッチのケーニッヒ・フェロー、エミナ・チェリモビッチは、「障がいをもつ人びとは生涯幽閉され、就学や就職、果ては起床時間を自分で決めるといった、私たちの多くが当たり前のように思っている日々のことを奪われている」と述べる。「クロアチア政府は、地域社会に根ざした住居施設や医療、支援を確立するために更なる努力を払う必要がある。そうすれば、障がい者も自らの人生を選ぶことができるようになるのだ。」

2014年4月〜8月にヒューマン・ライツ・ウォッチは、クロアチアの3地方で87人に聞き取り調査を行った。調査対象となったのは知的・心理社会的障がい者とその家族、施設職員、障がい者支援団体を含むNGO関係者、政府関係者、障がい者のためのオンブズ(ウー)マン。施設で暮らす人びとは何らかの人権侵害、たとえばコミュニティーからの隔離、言葉による虐待、強制治療、プライバシーの欠如、移動の自由の制限などを経験していることが明らかになった。

本日ヒューマン・ライツ・ウォッチが発表したビデオでは、心理社会的障がいを持つ人びとが、隔離された施設からコミュニティーに復帰したことのプラス面について語っている。これらの人びとの一部は、生まれてすぐに施設に収容された。

2012年に17年間の施設暮らしを経てコミュニティー内のアパートに移ったジェリカさん(58歳)は言う。「尊厳を取り戻して、人間らしくなれた気がします。家[施設]では…刑務所にいるような、罰を受けているような気がしていました…。でも今は人間としての尊厳を取り返しました。また自分のことを自分で決められるようになったのですから。」

46の国営施設のうち11が「脱・施設収容制度」手続きを開始しており、2014年7月の時点で知的障害者458人、心理社会的障がい者96人がコミュニティー復帰を果たしている。

しかしながら、クロアチアにある様々な形態の施設には未だ8,200人超の知的あるいは心理社会的障がい者がおり、コミュニティーで生きる権利を否定されている。

クロアチア政府が2011年に採択した「社会福祉ホームの脱施設および変革計画(マスター・プラン)」は、国の援助を受けた24の私営施設に暮らす1,800人超の知的あるいは心理社会的障がい者をその対象から外すもの。加えてマスター・プランは、いわゆるファミリー・ホームや里親家族も適用対象外だ。こうした施設は個人が運営しているものの、最大で20人の知的あるいは心理社会的障がい者を受け入れている。こうした中、障がいをもつ成人は本人の同意もなしに里親家族と同居させられ、コミュニティーとの交流も限定されている。

クロアチア政府は、これらのカテゴリーを非施設型のコミュニティー居住例とみなす。しかしこのたびの調査で明らかになったのは、ファミリー・ホームも実際は小規模なだけで施設には変わりないことだ。また、本人の意思を問わずに障がい者を受け入れる里親家族制は、地元コミュニティーとの交流が制限されており、「施設」に該当する可能性がある。

精神病院に本人の同意なしに長期間収容されている心理社会的障がい者も、マスター・プランの適用対象外となっている。

心理社会的障がいをもつ20代後半のイワンさんは、16年間も精神病院に収容されている。彼はヒューマン・ライツ・ウォッチに、「ここで僕は悲しみに打ちのめされています。一刻も早く出ていきたい」と語った。

おおよそ1万8,000人の知的あるいは心理社会的障がい者が、現在も後見制度下に置かれており、その法的能力や基本的な権利をめぐる決定権限を奪われている。具体的には、結婚および家族を形成する権利や雇用契約に署名する権利、そして財産保有の権利など。こうした障がい者の大多数は完全後見制度下に暮らすが、これは後見人(しばしば国が選出)が代わりにすべての決定を下すことを意味する。

2008年にクロアチアは、障がい者の権利に関する国連条約を批准。この人権条約は施設入所制度および後見人制度から脱し、代わりに障がい者がコミュニティーに復帰して、必要な支援を受けつつ人生の選択を自らできる機会を提供する義務を、加盟国政府に課している。

前出のチェリモビッチ フェローは、「私たちのほとんどは、好きな場所で好きなように生きる権利を享受していて、これを政府に奪われるかもしれないなどとは考えもしない」と述べる。「最新のEU加盟国であるクロアチアは、障がい者が自分のことを自分で決めるのは不可能だという考えを捨て、干渉的な態度・実践から脱するべきだ。」

国営あるいは私営の施設や、長期間精神病院に収容された障がい者、そして本人の同意もなしにファミリー・ホームや里親家族暮らしをしている障がい者を、確実に「脱・施設収容」手続きに含む措置を、クロアチア政府はとるべきだ。そして、コミュニティー内での住居を自由に選べる生活支援を提供する援助プログラムに投資すべきだろう。援助プログラムは障がい者の生活形態に関係なく、誰にでも利用可能である必要がある。

クロアチア政府は現行の後見人制度を廃止し、これに代わって障がい者の自主性、意志、好みを尊重する意思決定をめぐり支援体制を確立すべきだ。

加えて、障がい者支援団体ほかコミュニティー単位で社会サービスを提供・支援する団体を経済的に支援すべきだ。

ヒューマン・ライツ・ウォッチによる今回の調査で、障がい者関連プログラムの関係者の間で、施設収容の問題点に対する認識が高まってきていることが明らかになった。オシエクにある精神障がいの成人ホーム(心理社会的障がいをもつ成人のための社会福祉施設)のラディスラフ・ラムザ代表は、ヒューマン・ライツ・ウォッチに次のように述べている。「長期滞在の場所として、施設は間違っていると我々は気がつきました。施設は障がい者に必要なすべてを提供しているようにみえます。が、実際はもっとも大切なものを奪っているのです―生きる目的を。」

調査の詳細
Human Rights Watch first documented conditions for people with intellectual or psychosocial disabilities living in institutions in Croatia in a 2010 report, “‘Once You Enter, You Never Leave’: Deinstitutionalization of Persons with Intellectual or Mental Disabilities in Croatia”. Human Rights Watch found more than 9,000 people with intellectual or psychosocial disabilities living in institutions, without access to community-based programs for housing and support. The 2014 follow-up research, in addition to the interviews, included visits to four social welfare homes, one psychiatric hospital, and seven community-based living arrangements in three regions in Croatia: Slavonija, Central Croatia, and Kvarner. Researchers also spoke to staff and former residents of two social welfare homes for people with psychosocial disabilities and one psychiatric hospital. One privately run but state-funded institution, Center for Rehabilitation Nada in Karlovac, refused permission to visit. Most of those interviewed are not identified by their real name to protect their privacy.

In August 2014, Human Rights Watch submitted a Memorandum to the United Nations Committee on the Rights of Persons with Disabilities, ahead of its upcoming adoption of list of issues on Croatia.

Life Beyond an Institution
Josip, 34, has a mild intellectual disability and has lived in an institution since he was a baby. He does not know his family, and has never spent a weekend or a holiday outside of the institution, attended school, held a job, or cooked his own food. He has never decided when to eat or what to wear, and has shared his bedroom with up to 10 other people.

Josip moved to an apartment in the community in September. Now, for the first time he is surrounded everyday by people outside the institution, and by people who do not have a disability. Now, for the first time  he is  be able to move freely.

“In Zorkovac [a branch of the institution], we can only walk to a sign and then we have to walk back,” he told us while he was still living in the institution. “In Karlovac [the city he has moved to], I will be able to move [about] as much as I want.”  

Dijana Borović, director of the Center for Rehabilitation in Ozalj where Josip lived, told Human Rights Watch, “It was like a prison. We make them depend on us. We do everything for them. Even if they do something on their own, it is done under our supervision.”

In September 2014, Zorkovac was closed and 57 people in addition to Josip have moved out and are now living in apartments.

People with disabilities confined in institutions have not only been deprived of the choice about where and how to live, but have very limited access to education, work, and health care. For instance, people in the institutions Human Rights Watch visited had very poor dental hygiene. Staff said residents had limited, if any, access to dental care. Jovan, 54, said that during the eight years he spent in the Džakovička Breznica institution, he never had a check-up, a filling, or a dental cleaning.

Most people Human Rights Watch interviewed said they have no privacy and are obliged to follow strict, unchanged daily routines. Ivan, a man in his late twenties with a psychosocial disability, said residents have to wake up every morning before 8 a.m. to get breakfast: “Breakfast is served from 8 until 8:15. In case you miss it, you have to wait for the next scheduled meal [at midday].”

Some people who have lived in institutions were forced to work. Ognjen, 51, who has paranoid schizophrenia, has spent 12 years in various institutions. “We were forced to work,” he said. “We were forced to spend the entire day outside in the field. They would lock the home in the morning until late at night. In the middle of summer, the sun is burning, and you have to be in the field working.”

Most expressed a new sense of confidence in being able to live in the community, even if they needed some support. Josip needs help with cooking and washing clothes. Iva, 43, who has an intellectual disability, said:

We cook, wash, do everything by ourselves. We have support. I prefer the apartment to the institution. No, no, no. I never want to come back to the institution. There is no turning back because this is my home now.

Adults who lived in foster homes told Human Rights Watch that life in independent apartments in the community was much different than life in a foster home. Marina, 42, who has paranoid schizophrenia, lived in five foster homes over several years. “Living in a foster home was not easy,” she said. “You had to wake up at 7 a.m. and work. You were forced to work, mostly on the farm. I planted and harvested potato plants from early morning until late at night.”

Marina, who now lives in a community living arrangement run by the Association Susret, an independent group, said of living in the community, “It is an advantage. You can buy the food you like to eat on your own. You can go out for a walk.” 

Barriers to Moving Into the Community
Human Rights Watch found that people with intellectual and psychosocial disabilities who live in institutions covered by the deinstitutionalization plan face a number of barriers to their right to independent living in the community. They are required to have an assessment by institution staff of whether they are “ready to live in the community” as a condition for moving out.

People with disabilities have the right to choose their place of residence and should not be obliged to pass a “readiness” test. Assessing a person’s needs and strengths should only help determine what kind of support and assistance should be made available to them.

Guardians still retain the right to make decisions on where and with whom people stripped of legal capacity may live. Under the Social Welfare Law, people with disabilities who have been deprived of their legal capacity can be placed in institutions – social welfare homes, foster homes and family homes – without their consent. Under this law, placement in an institution is considered a social benefit and a “right.”

A guardian’s consent for placement substitutes the person’s consent. The law neither provides for judicial oversight of placements nor any means to challenge the placements. Directors of four institutions told Human Rights Watch that a significant majority of people with disabilities in each of these institutions are deprived of legal capacity.

The guardianship system also limits the right of people with disabilities to leave institutions. “The guardian has the right to stop the process even though it is not in accordance with what the person wants,” said Mladen Mužak, manager of the housing unit at the Center for Rehabilitation Zagreb. “Without the consent of the guardian, we cannot do anything.”

In June 2014, parliament adopted a new Family Act, which abolishes full guardianship but retains the power of courts to place people under partial guardianship, restricting their ability to make decisions in some areas. Local disability advocates have raised concerns that this provision may result in the courts specifying activities that a person is not considered capable of undertaking independently and for which a guardian can make decisions, particularly with regard to health care, property, and where they will live. Such decisions, coupled with a lack of regular judicial review and other safeguards, may result in the de facto full deprivation of legal capacity and puts people at risk of being confined against their will in institutions or psychiatric hospitals.

In May, Vildana, 44, who has an intellectual disability and who has been living in the Center for Rehabilitation Zagreb, told Human Rights Watch:

At first my mother [also her guardian] said yes [to moving into the community], now she said “no” … I don’t want to live here. I want to live in a house on my own or with my mother. My mother does not allow me to live on my own.”

Staff at the institution expressed disappointment since they felt Vildana could manage living independently.

The head of the housing unit at one institution told Human Rights Watch, “Parents intervening in our [deinstitutionalization] program is a constant struggle.”

Tanja, 30, who has paranoid schizophrenia, is placed indefinitely in the Lopača Psychiatric Hospital. “I wanted to leave this place after the first four years, but I can’t because I have a guardian,” she said. “I told my sister and my doctor, but my guardian has a say.” Tanja added, “I can live on my own with support. I want to be as free as a bird!”

Tin, in his early thirties with a psychosocial disability, has lived in Lopača for more than seven years. “I am too young to be here all my life.”

Human Rights Watch research found that there is limited community housing and support for people with disabilities even if they are permitted to leave an institution. Many people with psychosocial or intellectual disabilities that Human Rights Watch interviewed said they have no real choice in deciding their living arrangements and from whom they get support once they leave an institution. To benefit from state assistance for housing and support services, they usually live in community-based living arrangements established and monitored by the institution and continue to receive assistance and service from the institution. Those who would prefer to live with friends or family or on their own are no longer entitled to government financial assistance for housing and support services.

Radmila Stojanović, president of the Association Susret, which provides housing and support to people with psychosocial disabilities, said, “People with psychosocial disabilities receive support from the state only if they are part of a program. If you exit the program, the money and support will not follow you. ”

Neda Memišević, legal expert with the Association for Promoting Inclusion, an independent group, said:

The problem with the Croatian system is that the person himself does not have any income or control over money. He does not have access to the financial support for housing. The system [housing-service provider] does.

Croatia’s personal assistance program, which is designed to help people with disabilities in their home, facilitate participation in the community, and provide some financial support, is available only to people with severe physical disabilities.

Senada, who has mild intellectual disabilities, lived in a community housing program run by the Association for Promoting Inclusion beginning in 2006, during which time she was receiving the support she needed. But after she left to live independently in Zagreb, she said:

I don’t have any kind of support. I could use support, someone who could help me maintain my home because of the difficulties I have in using my hands. But, the support is not provided to me and I can’t afford it myself. In order to get support, you need to enter a program.

Related Rights Denied
While physically moving from an institution to an apartment in the community is of enormous importance for people with disabilities, the right to live in the community involves having choice and control over their lives and should facilitate their enjoyment of many other rights. Under the international treaty, people with intellectual or psychosocial disabilities should be able to go to school, work, access health care in the community, and enjoy leisure activities on an equal basis with others.

Most of those interviewed by Human Rights Watch said one of their main unfulfilled desires was to have a job. Goran Karaš, president of a local self-advocacy group that works with people who have left institutions, said:

Employment is very important to them. They need the money, but also the independence it brings them. They feel more worthy. They are always offering their assistance; they like to help, to prove that they are worthy. When they lived in institutions, everything was done for them. They were never given a chance.

Work is also a way to overcome boredom and isolation. Luka, a 46-year-old man from Osijek who works part-time at a shop, said, “I am happy being able to work, being surrounded by people. When I leave the work for the day and am walking back home, I feel great. I am surrounded by people and I feel so good about it.”

However, people with intellectual or psychosocial disabilities who have been declared unfit to work by the Croatian Pension Fund on the basis of a medical assessment are legally prohibited from working.

In addition, the Croatian social protection system creates disincentives for people with disabilities to work; for example, those who work full-time are ineligible for community-based housing. Lack of formal education and access to education, stigmatization, and discrimination also make it very difficult for people with disabilities to obtain employment.

Access to health care in the community is also a challenge. People with intellectual or psychosocial disabilities who have moved out of institutions usually have to continue to see doctors at that institution. The situation is similar for people with psychosocial disabilities who have moved out of the Home for Mentally Ill Adults in Osijek.

Lamza, the Home’s director, said, “As a rule, Osijek’s general practitioners refer people with psychosocial disabilities who have left the Home to the Popovača Psychiatric Hospital,” an hour and half away.

In her 2014 report to the United Nations, Croatia’s Ombudswoman for Persons with Disabilities said that not even minimal progress has been made in the development of outpatient treatment for people with psychosocial disabilities or in improving the quality of health care available to them in communities, which leads to unnecessary hospitalization.

Way Forward: Promising Practices in Croatia
Despite these barriers, Human Rights Watch found a number of community-based living arrangements and support services provided by institutions themselves or by local non-governmental organizations.

For example, since 2012, the Home for Mentally Ill Adults in Osijek has actively involved its residents – some of whom have spent up to 20 years in the institution – in the deinstitutionalization process. The home developed a program called “I, Just Like You,” to eliminate the hierarchy in the institution and to promote collaboration among people with psychosocial disabilities who lived in the institution, service providers, and the community itself.

Each person spends about six months preparing for life in the community. Staff work with them to identify their needs, strengths, life goals, and plans, including how, where, and with whom they want to live and what support they need. This individual planning also involves building daily life skills such as cooking, housekeeping, personal hygiene, and even social interaction. For this purpose, the home built a mock apartment where people learn how to cook, do dishes, and wash and iron their clothes. Once the residents move to community-based housing, institution staff provide regular support services based on the individual’s needs, such as dealing with financial matters, helping with public transportation, and facilitating acess to community health services.

By October 2014, 33 people with psychosocial disabilities had left the institution and were living in several apartments in Osijek. All of those interviewed by Human Rights Watch said they live in adequate housing and feel included in the community, and some have part-time jobs and assistants who support and help them. Another 10 of the 150 people who remain in the home are expected move out by the end of 2014 into apartments provided by the Croatian government. Another 70 are expected to move out to community living arrangements under a grant from the Open Society Foundations.

In similar programs at the Center for Rehabilitiation in Ozalj, in southwest Croatia, and the Center for Rehabilitation Zagreb, Human Rights Watch found that residents with intellectual disabilities were given personal notebooks to record their needs and wants. With the help of personal assistants, they can share their goals and thoughts on who could provide them with the support they need to achieve what is important to them. This can include peer support groups as well as informal assistance from friends or neighbors.

Amorevera, a local group in Dugo Selo, near Zagreb, works in cooperation with the Association for Self-Advocacy to provide such support, with the aim of building confidence and skills of people with intellectual disabilities who have spent their entire lives in institutions where their opinions have rarely been considered. They organize weekly meetings with people with intellectual disabilities, encouraging them to talk about their rights, relationships, wishes, and other issues that are important to them. Personal assistants or caregivers are not present in order to allow people to speak freely and form their own opinions.

Goran Karaš, President of Amorevera, told Human Rights Watch:

We could see that when we asked about a certain thing, they would glance at the caretaker, expecting them to reply. You could feel how insecure they were. So we decided not to invite caregivers to meetings anymore and we observed that they dared to speak out more. We encourage them to make decisions about themselves.

Human Rights Watch found that people with intellectual disabilities who are members of self-advocacy organizations were also more aware of their rights and more empowered to make decisions about their own lives. For example, Iva attended self-advocacy meetings before moving into the community. When asked about her decision to move out, she said:

My mother didn’t want me to go, but is happy I moved to the apartment. I told her to sign. I told her if you don’t sign, I will not be your daughter, I will not look at you. Then she signed. I wanted to leave here because I wanted to see how other people live.… My apartment is great. I’ll die from happiness. What should I do? It’s beautiful that I have an apartment and roommate. I can make other decisions. Yes I can.