Psychiatric community care: Belgian town sets gold standard

In the obscure little Flemish town of Geel in Belgium, Dis and Luc sit at the dinner table squabbling. Luc is going to camp for 10 days, Dis for only five.

Dis’s voice gets more and more shrill. Toni Smit, their foster mother, says quietly, “Dis gets jealous.” But after a few minutes they get up and together they clear the supper table.

Luc is 48 and suffers from obsessive compulsive disorder. He was shunted off into a  psychiatric hospital after his father died. 

“He hated it,” she says, but Luc eventually wound up in Geel, where he has lived with Smit and her husband for the past seven years. 

Dis is 89, and no one even labels his psychiatric disorder. He came to Geel in 1938 and lived with one family through three generations. Then he came to live with Smit.                                                    

​“They are part of the family – we love them,” she says.

Hundreds of families in Geel take in psychiatric patients; people who suffer from schizophrenia, from obsessive compulsive disorder, serious mental illnesses. About half  of  “the boarders” as they are known, also have what is described as “a mild mental handicap.” 

Families in Geel have been looking after mentally ill people for centuries. When the numbers were at their highest in the late 1930s, there were 3,800 psychiatric patients living with families in Geel, a town at the time of only 15,000. A quarter of the town was noticeably mentally ill.

The tradition continues today. A young woman dressed like some sort of ragged angel scurries past on the street; a few minutes later a man with a vacant gaze wanders by muttering to himself. No one bats an eye.

“We are known all over the country as the place where there are insane people.” says tour guide Alex Martens. “There’s also an expression instead of saying you’re crazy. You can say you belong in Geel.”

There really is nowhere on Earth quite like it. Geel has become the gold standard of community care of psychiatric patients, and it's a model that others are starting to adopt.

The legend of Dimpna

It all started, legend has it, in the 7th century with a fair-haired Irish princess named Dimpna who fled the incestuous advances of her father. He chased her to Geel, and when she resisted he murdered her.                      

​Her legend flowered and she was canonized, becoming St. Dimpna, patron saint of  the mentally ill. Geel became a religious shrine.          

“Here in Geel they thought they were chosen by God to help people with mental illness,” says Frieda van Ravensteyn, curator of the Dimpna museum, as she unlocks the side door of the  church.

The door opens onto the sick room where in the middle ages the rich brought their mad children, and institutions for the poor brought cart loads of men, shackled and bound. They came from France, from the Netherlands and from Germany, and they were crammed, screaming and moaning, into four small cells in the sick room. They were made to crawl under the bones of Dimpna, considered religious relics with healing power, and when they were not  “cured”  they went back to the sick room.

“In the middle ages the only remedy they had was to be close to God,” says Martens, “and perhaps you will be cured.”

In time the church was overwhelmed and local families began to take in the afflicted.

“It is 14th, 15th century that family care started,” says van Ravensteyn, adding that some did it for less than altruistic reasons. “There was a lot of  agriculture here, it was cheap labour.”

The Geel question

In the 19th century, medical treatment of the mentally ill trumped religious devotion. Belgian  law required “mad people” to live under lock and key in an asylum. But Geel, with its history of community care of psychiatric patients, was exempted  for economic as much as humanitarian reasons.

Patients worked  on the farms, in bicycle shops, in houses. They were part of the Geel soccer team, the Geel band. They were not locked away, and Geel became an object of medical curiosity.   

Doctors came from all over the world to study the town. Debate raged. Some argued Geel was “a paradise  for the insane,” while one critic wrote that he had  never in his life seen “something as despicable as Geel - a place where sick people live together with normal people and the normal people could become sick.”

But, as the modern mantra of  psychiatric patients goes, mentally ill people in Geel had “a home, a job, a friend.”

"And when we see them we know how to react - so do all the shopkeepers, bartenders, the bus drivers,” says Toni Smit. "No one really notices them. Not in a negative way.”

Bert Buchs, social historian and hospital archivist, sees that as key today. 

“Knowing that you are accepted not only by doctors, not only by your foster family, but accepted by the whole of the community - that also has a healing effect.”

Luc and Dis

After 700 years, there is a still a steady stream of international visitors, doctors, social workers - particularly North Americans who can’t quite believe that a town can live so comfortably with mentally ill people. 

“We had journalists from Milwaukee here last month,” says hospital spokesman Johann Claeys. "The first thing  they asked was how many time have police intervened in a family. In 10 years they had three interventions and it had nothing to do with violence, not at all.”

And in Geel, there are no labels.

“No one tells us what the  problem is,” says Toni Smit. “Nobody says oh this person has schizophrenia or anything. The only thing we know about Luc is what he told us himself.”

All of the patients with foster families are officially wards of the local psychiatric hospital. A treatment team comes by unannounced every couple of weeks, has a chat and drops off any medication. The rest is left up to the families.

“We do not ask the families to do special things. We only say be as normal as possible. That’s the heart of the system,” Claeys says.

The people eat together, they share a bathroom, they are just member of the family.

“There are no great goals set by the professionals, saying try to do this or that, not at all. You don’t focus on illness you focus on the qualities and the strengths of those people and you try to do something with that.”                    

The families receive a stipend. They  provide individual rooms for their boarders, and if things do not work out there is a parting of the ways and the hospital looks for another family.  

“We take time to let it grow,” says Claeys, “we do not expect in the next week or next month that they [the patient will] become another person. In some families they stay for the rest of lives.”

No NIMBYism

Belgium is questioning the reliance on drug therapy these days, and psychiatric foster care is not the only alternative. The Geel psychiatric hospital provides sport therapy, work therapy, cooking and even gardening therapy for mental illness, as well as foster family care.

There have been foster family programs springing from the Geel model all over the world, often after considerable community resistance.

But in Geel there has never been a question of Not-In-My-Backyard. No one in Geel, Toni Smit maintains, has ever said they don’t want mentally ill people around.                                            

“They’re just people. They need caring for too.”