Just imagine a place where foster families take people with a serious mental illness into their homes instead of putting them in hospital. Just imagine that in these foster homes those individuals become functioning members of the family, and that very few of them ever return to a psychiatric institution. And just imagine this system has been operating successfully for more than 600 years. There are many lessons to be learned from the oldest community psychiatric service in the world.
For generations a small city in Belgium has been practising a radical system of community mental health care. It all started with a shocking story of sexual assault from the sixth century. When the pagan Irish king Damon was widowed, losing his beautiful Christian wife, his grief was so overwhelming that it tipped over into madness. The only person who resembled his lost beloved was his daughter Dymphna and in his delusion he pursued her as a replacement. Dymphna escaped her father’s incestuous desires, fleeing across the channel, to the town of Geel in Belgium. There, having had experience caring for her demented father, she began caring for the locally mentally unwell. Damon, however, tracked her down and, possibly while in a psychotic state, killed her.
Over the years that followed, the site became a destination of pilgrimage for those suffering from mental illness. The influx of pilgrims seeking alleviation from their psychological and psychiatric torments culminated in stories of miraculous cures, which in turn led to Dymphna’s canonisation in 1247, when she became the patron saint of lunatics.
Mental illness in the middle ages was attributed to demonic possession, an idea that still holds currency to this day.
While in Geel the “possessed pilgrims” received nine days of religious treatment in the local church.
By the mid-1400s the church was overflowing with pilgrims and while waiting for their turn for treatment, a practice developed whereby the Geel villagers took the visitors into their homes, just as nowadays many locals on the popular Camino de Santiago take in pilgrims en-route.
The difference in Geel was that many of the seekers of sanity often stayed on after their treatment and became permanent local residents. At one point it became such a sanctuary for the mentally afflicted that it was said that “half of Geel is crazy and all of Geel is half crazy”. The result was that an open-house policy developed into a system that we would now call integrated community residential care, as radical and rare now as it was 700 years ago.
By the 20th century, the International Congress of Psychiatry had declared Geel an example of best practice to be copied elsewhere. The people who were once pilgrims became known as “boarders”, not patients because they were essentially billeted to local homes. Families with generations of experience took in mentally ill strangers and, in most cases, assimilated them successfully into the family structure.
By the 1930s, the numbers reached their peak at about 3,500 in a town of approximately 20,000 residents. Without any formal training or medical knowledge – or even awareness of their houseguest’s particular diagnosis – Geel families became mental health providers, and that tradition continues to this day as part of what is now referred to as the Family Care Program, an integral part of the public psychiatric hospital system.
Between 1968 and 1977, during a 10-year Geel Family Research Project, the nearby city of Kortenberg took the decision to transfer 78 chronic patients from the local psychiatric hospital, a group composed largely of people with schizophrenia and personality disorders, into the Geel family care system, despite resistance from nursing staff, patients and relatives. At the end of the study, only nine patients had returned to the hospital.
In Geel, as of 2003, 516 boarders lived in the homes of 423 care-taking families, 20% of whom were diagnosed with schizophrenia or psychotic disorders, an undertaking that would fill many Australian families with terror. This is because the majority of people in Australia only ever hear about serious mental illness when it becomes a headline.
The take-home message from this centuries-old tradition for our modern and much beleaguered mental health system in Australia is that no matter what change we make in the treatment of people with mental illness, it will be short-lived as long as there is no change in the social treatment from the community. A sense of belonging, of having a role, of being accepted by the broader community – what is otherwise called social health – is equally, if not more important, than medication.
We used to keep physically disabled people out of sight because we found them disturbing. Fortunately, attitudes are changing in that regard. Perhaps the next frontier is the visibility of people with serious mental illness. Maybe we need a chain of Dymphna cafes staffed only by people with serious mental illness. Work is one of the most important ways that Geel integrates their boarders into society. In contrast, in Australia, the vast majority of people with serious mental illness are locked out of employment for life. It is as if a decision has been made that we’ll leave them to scrape by on welfare. But if in the light of the Productivity Commission’s report into the effect of mental illness on the Australian economy, we decided that employment was a priority, the problem of impoverished social and economic health among people with serious mental illness would be well on the way to being resolved. And those customers coming in to order their lattes from a Dymphna cafe might just learn to enjoy meeting people who are, as one anthropologist put it, “altogether human, only more so”.
Australia was one of the first countries to embark on a national mental health strategy, with the first National Mental Health Policy published in 1992 declaring that wherever possible, people with mental illness should be able to live with dignity in the community. It is time that we took that intention and put it into practice.
Gabrielle Carey is an Australian writer