Geel, Belgium: A History of Community Mental Healthcare
In 1977, Powers of Ten, which would become one of the most famous short films ever made, was introduced to the world. The film zooms out from the original frame of a young couple’s picnic ten times every ten seconds until we can see the entirety of our known universe. The frame then collapses inwards until we see the man’s hand on a submicroscopic level. The premise was compelling because instead of relying on a dynamic plot, it showed how the story of a single moment changed with perspective. The message is clear: reframing your perspective provides infinite ways to view the same thing. The power of reframing has also been used by many problem solvers to unlock creative solutions. For example, instead of asking what number equals five plus five, asking what two numbers add up to ten provides a reframing that causes the number of potential solutions to jump from one to infinity.
One problem that our society has been struggling with for decades is how best to care for patients with a severe mental illness. The traditional solution involves attempting to alleviate symptoms in order to allow patient recovery. However, in attempting to treat one problem, therapies can often create new problems, such as medications that can cause severe side effects.
But what if you could reframe the problem of treating mental disorders so that you no longer viewed it as a problem at all? That’s exactly what the town of Geel, Belgium has done with people suffering from severe mental illnesses like schizophrenia or bipolar disorder since the Middle Ages. Around two hundred families from the 39,535 person town currently accept these people into their homes, not as patients, but as guests referred to as boarders. This boarder program is not meant to treat mental illness and Geel residents never find out the official diagnosis of their boarders. Instead, the hosts simply integrate their boarders into their lives, providing them with food, care, and work. Boarders often stay with hosts long-term, with over a third of boarders staying in their foster home for over fifty years.
Of course, adjusting to life with Geel boarders is not necessarily easy. One host couple, Toni Smit and Arthur Shouten, describe some of the challenges they’ve faced living with boarders in an interview with NPR. For example, “one boarder used to lock Smit and Shouten out of the bathroom to furiously wash his hands, and another used to struggle to sleep because he saw lions coming out of the walls.” They dealt with these situations first by accepting that for the boarders, these quirks are simply a part of normal life. In Geel, mental illness has been reframed as mental differences that should be accepted. Their community care for the mentally ill provides the boarders the opportunity to be integrated into a social circle rather than isolated in a hospital facility, allowing them to regain an identity that is often lost in traditional mental health care.
Families of mental illness patients in more traditional facilities often describe their frustration with over-bureaucratization that leads to a mindset that, “the care given only counts when it is written down” and “the presumption that all patients will get better following predetermined pathways and time frames.” Geel instead relies on individualized care with fewer regulations, depending on the hosts who get to know their boarders the best to make decisions regarding their care.
However, some severe symptoms of mental illness are more than just “quirks” and could cause harm to the boarder or the hosts. Geel has a team of 12 district nurses that are assigned to border-host pairs in order to mediate between them and provide professional psychological counseling or medication if deemed necessary. In most cases, instead of seeking professional help, the hosts help provide tools for the residents to manage their disruptive behaviors rather than treating them. Shouten talks about how he would frequently pretend to chase away the imaginary lions that prevented his former boarder from sleeping. “That would work every time,” he recalls. Concerns for the safety of the hosts, especially since violence and mental illness are commonly associated in popular culture, have resulted in studies on the rates of violence among the boarders in Geel. The correlation between severe mental illness and increased violence does appear to exist for patients with certain diagnoses, but that relationship is not clear and seems to rely heavily on environment.
Despite the lack of expert agreement on how severe mental illness and violence correlate, the stigma that the mentally ill are violent has been publicly accepted based on news headlines rather than a statistically significant correlation. Studies have identified that there are some specific environmental factors that contribute to violence from mentally ill patients. These environment factors are only exacerbated by the public stigma against them. For example, patients are slightly more likely to exhibit violence right after hospitalization, when they feel personally threatened, or when they perceive hostility from both known and unknown others. As a place where the mentally ill are accepted and allowed to function in a natural social environment, Geel provides a unique case study. The town has been studied to help researchers and mental health professionals understand how the public stigma against patients with severe mental illness, in combination with their frequent social isolation, contributes to their likelihood to be violent. These studies found no significant difference between the pattern of violence from Geel’s boarders and other members of its community. The authors suggest that the success of Geel’s boarder program might come from the fact that community members, whether or not they themselves function as hosts, have been exposed consistently to the realities of mental illness rather than the stereotypes associated with it.
The curious case of Geel, Belgium and its approach to mental illness provides the world with a reframing on mental healthcare. Psychologist Dr. Henck van Bilsen from New Zealand describes the differences between traditional mental health care and Geel’s boarder program as the difference between a pressure cooker and a slow cooker. Traditional pathways for treatment of severe mental illness demand change as quickly as possible in order to recover from symptoms of a mental disorder. Meanwhile, Geel asks its boarders not to change, but to simply “be and discover their mutual road to understanding and recovery.” Both methods have their merits, but Geel has certainly provided a window into another possibility for community mental health care.
- Eames, Charles. (2010, August 26). Powers of Ten. [Video file]. Retrieved from https://youtu.be/0fKBhvDjuy0
- Seelig, T. L. (2012). InGenius: A crash course on creativity. New York: HarperOne.
- Goldstein, J.L. & Godemont, M.M.L. Community Ment Health J (2003) 39: 441. https://doi.org/10.1023/A:1025813003347
- Chen, Angus. “For Centuries, A Small Town Has Embraced Strangers With Mental Illness.” NPR Public Health, NPR, 1 July 2016, http://www.npr.org/sections/health-shots/2016/07/01/484083305/for-centuries-a-small-town-has-embraced-strangers-with-mental-illness.
- Van Bilsen, H. P. J. G. (2016). Lessons to be learned from the oldest community psychiatric service in the world: Geel in Belgium. BJPsych Bulletin, 40(4), 207–211. http://doi.org/10.1192/pb.bp.115.051631