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The story of Geel, a model of community-based mental health care for centuries

The Belgian town welcomes people with mental disabilities and illnesses into their homes as “boarders.”

Chronic Crisis: A look at Geel and its centuries-old tradition of caring for those with mental illness

The remarkable story of Geel, the Belgian town that for more than 700 years has welcomed people with mental disabilities and illnesses into their homes as “boarders,” is the focus of an article in the September issue of The Psychologist, the monthly publication of the British Psychological Society.

Geel has been featured in the press repeatedly over the years, but its story is worth telling again for those who may not have heard it before.

The town is believed by many to be a model of community-based care.

“Among the people of Geel, the term ‘mentally ill’ is never heard: even words such as ‘psychiatric’ and ‘patient’ are carefully hedged with finger-waggling and scare quotes,” writes journalist and cultural historian Mike Jay (with British spellings and punctuation). “The family care system, as it’s known, is resolute non-medical. When boarders meet their new families, they do so, as they always have, without a backstory or clinical diagnosis. If a word is needed to describe them, it’s often a positive one such as ‘special’, or at worst, ‘different’. … But the most common collective term is simply ‘boarders’, which defines them at the most pragmatic level by their social, not mental, condition. These are people who, whatever their diagnosis, have come here because they’re unable to cope on their own, and because they have no family or friends who can look after them.” 

A legendary beginning

Geel’s history as a welcoming place for people with mental disabilities and illnesses can be traced back to a legend — that of the 7th-century Irish princess Dymphna, who fled to Geel to escape the incestuous advances of her father. Once there, she built a refuge for the poor and sick. But Dymphna’s father tracked her down, and, when she continued to refuse him, beheaded her.

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“Over time, she became revered as a saint with powers of intercession for the mentally afflicted, and her shrine [in Geel] attracted pilgrims and tales of miraculous cures,” writes Jay. A church was built near the shrine, and, in 1480, a building was added to house the steady stream of pilgrims who came to visit the site. 

“During the Renaissance, Geel became famous as a place of sanctuary for the mad, who arrived and stayed for reasons both spiritual and opportunistic,” says Jay. “Some pilgrims came in hope of a cure. In other cases, it seems that families from local villages took the chance to abandon troublesome relatives whom they couldn’t afford to keep. The people of Geel absorbed them all as an act of charity and Christian piety, but also put them to work as free labour on their farms.” 

The system today is much the same, although without the heavy farm work. Writes Jay:

A boarder is treated as a member of the family: involved in everything, and particularly encouraged to form a strong bond with the children, a relationship that is seen as beneficial to both parties. The boarder’s conduct is expected to meet the same basic standards as everybody else’s though it’s also understood that he or she might not have the same coping resources as others. Odd behaviour is ignored where possible, and when necessary dealt with discreetly.

Those who meet these standards are ‘good’; others can be described as ‘difficult’, but never ‘bad’, ‘dumb’ or ‘crazy’. Boarders who are unable to cope on this basis will be readmitted to the hospital [built in the 1800s]: this is inevitably seen as a punishment, and everyone hopes the stay ‘inside’ will be as brief as possible.

The people of Geel don’t regard any of this as therapy; it’s simply ‘family care’.

The government steps in

Not that there haven’t been problems over the years with this system, including the mistreatment of boarders. In fact, reports of boarders being chained and beaten caused the Belgium government to take over the program from the church in 1850.

“Families got a modest state payment [today it’s about $55 a day], in return for which they had to submit to inspection and regulation by the medical authorities,” explains Jay. And in 1861, government authorities built a special hospital in Geel, where boarders could be assessed before being placed with families in the town.

“The reformed system became a source of great professional and local pride,” Jay says. “Doctors and psychiatrists from across Europe and American came on fact-finding missions. Dozens of town in Belgium, France and Germany established their own versions of the ‘Geel system’, some of which still survive.”

By the late 1930s, Jay reports, the town had about 4,000 boarders among its native population of 16,000.

A fading tradition

“In recent decades,” writes Jay, “the ‘two-layered system’ — family care supported by a medical safety net — has been constantly recalibrated to reflect developments in psychiatry.”

“Today,” he says, “there are around 300 boarders in Geel; less than a tenth of its pre-war peak and fading fast. While many locals believe family care will endure, it has become a markedly smaller part of town life, and others suspect that this generation will be the last to maintain it.”

The reasons for this change “is not demand but supply,” Jay explains. “Few families are now able to willing to take on a boarder. Few now work the land or need help with manual labour; these days most are employed in the thriving business parks outside town, working for mulinationals such as Estee Lauder and BP. [And] dual-income households and apartment-living mean that most families can no longer offer care in the old-fashioned way.”

The decline of Geel’s centuries-old system of community care for people with mental illnesses and disabilities can be seen in a positive light, “as a reflection of modern improvements,” Jay suggests. “Psychiatry has met the town halfway; the choice is no longer limited to the stark alternative of Geel or the horrors of the asylum. Care in the community, of which the town was once the leading example, has become the norm.”

Yet, if Geel’s remarkable system of community care disappears, it’s difficult not to view that outcome as a great loss.

“People remain proud of the tradition, and credit it with giving Geel a broad-minded and tolerant ethos, one that has made it attractive to international businesses and visitor,” writes Jay. “But the town is no exception of the march of modernity and the irreversibly loosening social ties that come in its wake.”

You can read Jay’s article on The Psychologist’s website or on the website of the online magazine Aeon, where it first appeared. The Milwaukee Journal Sentinel also ran a piece on Geel in 2013. It includes a very moving five-minute video that profiles one middle-aged couple and their two boarders.