User:JannaLefevere/Psychiatric Foster Family Care (Geel, Belgium)

Psychiatric Foster Family Care in Geel is a community-based psychiatric care program. The model has its origins in the worship of St. Dymphna, patron saint of Geel and patron saint of mental illness.

Foster Family Care is a form of foster care in which a family cares for a person with a mental illness or vulnerability in their home. Many consider this a successful treatment method for patients because it promotes integration into society. The Family Foster Care program in Geel rests on three pillars: the foster guest or patient who experiences a safety net in a foster home, the Geel community which is open and tolerant, and the Public Psychiatric Care Center (OPZ Geel) which guarantees a professional, medical framework.

Geel is referred to by the term "merciful city" of "compassionate city" because of these pillars.

Origins
Foster Family Care in Geel evolved from the legend and cult of St. Dymphna. According to tradition, Dymphna was a 7th-century Irish princess who fled to continental Europe with the priest Gerebernus after refusing several marriage proposals from her father. She ended up in the Geel parish of Zammel where she helped the poor and needy until her father found her and beheaded her in a fit of madness. Dymphna was canonized because she resisted her father while he was "possessed by the devil." Thus, she became the patron saint of epileptics and the mentally ill.

Middle Ages
In the 12th century, Bishop Guy I of Laon ordered that the legend of Saint Dymphna be written down in a vita. During this period, pilgrims also began to visit Geel to pray to Saint Dymphna. Initially, the saint was invoked for all sorts of ailments, but over time, especially for mental disorders. During the Middle Ages, mental disorders were considered a punishment from God for engaging with the devil. Pilgrims hoped that through prolonged prayer and following a nine-day ritual, the novena, evil would disappear. This took place at St. Dymphna's Church, built in the 15th century. After nine days, it was verified that the devil had disappeared. If not, the nine-day cycle was repeated once more. In the meantime, the pilgrims stayed in the so-called "siec-caemer" or sick room. This infirmary consisted of four beds and was built between 1458 and 1483 on the south side of the church tower. Staying in the sick room was mandatory because it provided the patient with rest.

Healings were noted in the Liber Innocentium (or the Book of the Innocents) in which the personal details of the patient were recorded. The book recorded healings attributed to St. Dymphna, but it had primarily a legal function.

Until 1795
Due to a large influx of pilgrims, there was not enough room in the church to accommodate all of them. Staying in the church was also often too expensive for them. Another solution had to be found for these pilgrims. The pilgrims could stay with the citizens who lived around the church for a fee or performing household chores. When the persons with mental disorders were cured after their novena, they could go home with their families. But when this was not the case, the family sometimes requested that the person could stay with the foster family for a fee. This way the pilgrims could still repeat their rituals to hopefully achieve healing. This is how the foster family system in Geel developed.

The determination of which pilgrim went to which family was done by the clergy of the church. The pastor and the dean of the church laid this down by contract in 1548. In assigning the sick to the families, they looked mainly at behavior, testimonies from the surroundings and the extent to which the sick person should be tied up. The reception of a mentally ill person should not disrupt ordinary family life too harshly. In the 15th and 16th centuries, 200 people were taken care of in this system. Starting in the 17th century, other neighborhoods in Geel also began to receive and take care of pilgrims.

From then, all pilgrims were recorded in the Liber Innocentium. This reads that four thousand pilgrims traveled to Geel between 1687 and 1797.

The reasons that the people of Geel at that time took in the pilgrims were mainly so that they could receive a papal indulgence and because it provided them with extra labor. It was believed that this would have a positive impact on the welfare of the mentally ill and the Geel economy. The Geel model was a precursor to occupational therapy.

Until 1800, the care of the mentally ill had a religious motivation. The canons of St. Dymphna's Church were responsible for the organization of family nursing. This ranged from the organization of rituals to the assignment of boarders to families and the payment of boarding fees. Medicine did not yet exist at that point. Mistreatment of the mentally ill were common, but there were also "dangerous" patients. In 1676, a local regulation was issued that made the boarders of dangerous patients responsible for the damage their boarder could cause. These regulations required foster families to shackle these persons in a way so that they could do no harm. From 1747 they refused these patients in the church although their severe illness was the reason why they came to Geel. One was primarily concerned with the welfare of the people of Geel. Back then, the consequences for the patient were not a priority.

In the 18th century, a more humane approach emerged. The government began to care more about the welfare of the mentally ill.

After 1795
Starting in 1795, Geel fell under French rule as a result of the French Revolutionary wars. The French wanted to abolish the foster family care system in Geel and replace it with closed institutions and asylums. In 1797, they closed the St. Dymphna church, reducing the number of boarders. They replaced the novena with another ceremony where the boarder could pray in the church upon arrival in the community. The canons were no longer in charge of organizing care. Directors took over. The directors were Geel citizens who searched for a suitable family for the patient, paid boarding fees and kept the administration in order. However, due to a lack of control, abuses arose. Some withheld part of the family's boarding money.

Establishment of the Colony of Geel
In the 19th century psychiatry advanced and this changed the treatment of persons with mental illness. By introducing "moral treatment," taking care of a person rather than treating an illness became more important. The premise was that the mentally ill should experience as little coercion as possible while residing in an institution. These institutions or asylums were usually located in rural areas. From the moral treatment of patients arose different types of therapies, such as bath therapy. This consisted of placing the patient, primarily as a sedative, in a lukewarm bath for several days. The Belgian supporters of moral treatment, such as Doctor Jozef Guislain, expressed negative opinions about the conditions that occurred in the institutions. In Geel, a medical service had been established in 1838 but due to its poor functioning, the first psychiatrist, Doctor Parigot, came to the community in 1848. The abuses in the closed institutions led to the enactment of the Insane Asylum Act in 1850. This emphasized the importance of personal freedom and care and protection of people with mental disorders. In 1851, special regulations were issued that officially recognized the model in Geel. The regulations described the establishment of an infirmary with observation cells, the duties of the foster families, the placement of the mentally ill and so on. This building was build in 1861. This led to the establishment of "the State Colony of Geel for the Foster Care of Mentally Ill" in 1852. Doctor Parigot was assigned the role of medical director. The colony consisted of an inner and an outer department. The inner department was responsible for the allocation of boarders and medical-psychiatric treatment. The outside service were the foster families.

Between 1850 and 1950
The care of persons with mental disorders was now regulated by law. This brought more structure and organization to the Geel foster family system. In 1861, Adolphe Pauli built an institution for the mentally ill in the center of Geel. This is now known as the Public Psychiatric Center. Originally, it served as a temporary residence for patients before they were placed with families. The new psychiatric hospital was built according to the contemporary moral views on how to treat mentally ill people. It was symmetrically designed and contains many courtyards and gardens. Pauli wanted to create a peaceful environment for the patients.

The central hospital was responsible for the 'Colony of Geel' and thus the community-based foster family system. The territory of Geel was divided into several sections, with a doctor at the head of each section. The doctor kept a watchful eye, assisted by guards. They were responsible for transporting the patients who were 'hospitalized' within the community and they tracked down patients who escaped their family. Patients who stayed with boarders could receive medical and therapeutic guidance from the institution. In the 19th century the local government was given a greater say in family foster care man. Patients were divided into three categories: the non-hygienic (gateaux), the demi-gateaux and the sanitary. As patients required more care, the boarding fees families received increased. The families were divided into two types: the hôtes, which took in the wealthier patients, and the nourriciers, which took in patients dependent on the municipalities of origin.

In the 19th century, psychiatric care was primarily based on bloodletting and the insertion of leeches. Except for tranquilizers, medication and therapy didn't really exist yet. In Geel, they used few medication or controversial treatment methods. The basis of the Geel model was that people could stay in a homely environment and via the foster family integrate into society. The only form of therapy that was integrated in Geel was occupational therapy.

In the 19th century, the Geel model gained fame throughout the world. Proponents of the phenomenon cited that it was positive that patients were introduced to a domestic environment and could participate in society. Opponents expressed that there was extensive use of restraints and a lack of medical supervision. Some even said that patients could be a bad influence on the Gelenians. Psychiatrists, other doctors and sociologists started to describe and critically examine the family foster care system and tradition in Geel. These studies were important to better inform the foster families and improve the care of boarders. In 174 places they tried to imitate the Geel model, but as a copy it was only in a few places successful. Other places were inspired by and adapted the Geel model and its ethics.

Due to overcrowding in closed asylums, there was a large influx of persons with mental disorders in Geel. By the end of the 1930s there were around 3,700 patients in the foster family system. Many of the patients came from other countries because Geel had now acquired an international reputation.

For the Geel economy, foster family care was a positive thing. Families received boarding fees. Patients could be employed cheaply and the people from Geel themselves could work 'in the colony' (psychiatric hospital. The municipality received grants from the government.

Doctor Frits Sano remodeled the colony in 1920. A large complex was built, with residential houses for the doctors and nurses, a mortuary and a school to help children with mental problems integrate into society as well as possible. Several pavilions were built which were connected by glass corridors. This brought patients close to nature and gave them peace and light. Patients who stayed in the central hospital could work in the gardens of the pavilions. This labor system was necessary to keep the colony running, but it was also seen as therapeutic since patients were occupied in significant activities. Psychiatry as a science gained new insights which allowed patients to be better classified according to their needs.

Second World War
During World War II, Geel was under siege and the psychiatric hospital was occupied by the nazi-regime and its soldiers. The board of the hospital had to improvise emergency rooms for the patients. These could be located on the hospital grounds, but also in the general hospital and schools. During the Liberation of Geel in 1944 around 30 patients died. During wartime the number of international patients declined. Several patients fled or moved closer to their families. A few were left alone in the homes of their boarders who had fled. Some patients stayed in the central hospital. This created overcrowding, which was a difficult situation in times of food shortage. The Colony tried to house as many patients as possible with farmers since they had more food. At the beginning of the 21st century, there were around 300 people in family nursing care. The number of patients declined but the quality of psychiatric care became better and professional.

Last decades
Up until 1983, mental health care in Geel consisted only of psychiatric foster family care. This gradually changed. The institution started to hospitalize patients for a short-term. These new activities led to the establishment of a psychiatric regional clinic, the Sano Clinic.

Changes in demography and economical systems triggered an evolution in the Foster Family Care system. Also medical knowledge influenced this evolution. Medical research and development of new therapies gave people a better understanding of persons with mental disorders. In Geel, a psychiatric hospital, the Sano clinic, arose alongside the colony (Foster Family system). This clinic is now known as the Public Psychiatric Center Geel (OPZ). Nowadays Foster Family Care is part of the Rehabilitation division of the OPZ.

The last decades Foster Family Care has changed and evolved, having a great impact on the lives of the boarders. The typical foster care elements remain, but now patients are even more a part of Geel society. They are full members of the town and participate in cultural activities and sports. Citizens in Geel are known to be very tolerant towards the 130 boarders living in Geel with foster families.

Novena for Saint Dymphna
The novena consisted of seven activities the pilgrims performed during the time they stayed in Geel.

The first ritual when a pilgrim arrived in the church consisted of confession. This applied only to the ill who were able to communicate. The clergy attached great importance to this first step toward healing.

The second ritual required the ill person to crawl barefoot under the reliquary three times a day while praying the Our Father and Hail Mary thirty times. If the ill pilgrim could not do this himself, they engaged a substitute. At first people viewed this step as a "rebirth," then as a humiliation of the devil.

The ill performing the novena attended daily Mass. After Mass, they drank the water from the ablution vessel. The priest pronounced an exorcism over them. This was the same for all the sick and served to exorcise the devil. During their stay, they had to keep their clothes on while sleeping. This was seen as a kind of medical treatment and penance.

The ill person had to offer his weight in corn to Saint Dymphna. This was to prove his loyalty and gratitude to the saint. For this he/she or his relatives had to go begging at the neighboring houses. Later they were allowed to buy the wheat or take it from their own stock. Still later, they replaced the wheat with 32 pennies. The significance of this came from Christian humility.

Boarders
The people who come to Geel to enter the foster family care system are mostly people with chronic and/or multiple psychiatric problems. First, the Public Psychiatric Center places them under observation. After this, they come into contact with the family they are going to live in. When placing a person in a family, particular attention is payed to the patient's abilities and interests. The clinical picture or diagnosis itself is not decisive. In earlier days patients who stayed in the Foster Family Care system were mostly people with a mental disability. These patients are now often treated in other care systems. Patients who live with foster families nowadays are often people who cannot live completely independently or cannot be cared for in their own environment.

Among the boarders there used to be many people from other countries, especially the Netherlands. This was because the Geel model was cheaper than staying in a Dutch asylum. The international appeal of Geel to these patients has diminished.

Boarders came from all walks of life. The distinction used to consist mainly of the richer, self-paying people who lived with families in the center of Geel and poor people that ended up outside the center, in the more rural parishes.

Foster Family
The foster families were originally families living in Geel. The boarders used to call their family members "mom" and "dad." Demographic changes and industrialization changed this. Now most foster families consist of single widows/widowers or people who have space because their children are out of the house. Still, there are younger families taking in patients.

In the past, foster mothers<w or fathers were often craftsmen or farmers, allowing the boarders to work with them. Nowadays the OPZ provides sheltered or adapated employment. Foster Family Care is often passed on from parents to children, generation to generation, so boarders stay with different generations in the same family. Some families take in several boarders.

International
Throughout history, the model of care that originated in Geel has been applied in other communities. Within Belgium, for example, there is Lierneux near Malmedy. Outside the country, there is the example of Xanten, Iwakura and the Broadway Housing Communites in Manhattan, New York.

Intangible Cultural Heritage
The cult and veneration of Sint-Dymphna and the Psychiatric Foster Family Care System in Geel was one of the first elements to be included on the Inventory of Intangible Cultural Heritage Flanders in 2009. In 2017, the heritage community of Foster Family Care in Geel received the Flemish Ultima Culture Award for Intangible Heritage. On May 15, 2021, Flemish-Minister President Jan Jambon announced that the Flemish Government is nominating the Foster Family Care system to be included in the Unesco Register of Good Safeguarding Practices.

The city of Geel and OPZ Geel are strongly committed to maintaining the foster care model and passing on the tradition. Every year on May 15, the feast day of St. Dymphna, the foster families are celebrated. Every five years, Geel hosts the Dymphna Days, an urban festival where the people of Geel celebrate their patron saint, the tradition of psychiatric foster family care and the community's inclusive care giving culture. During the Dymphna Days, the St. Dymphna Procession passes through the streets. Since 2015, there has also been the musical spectacle GheelaMania in which a contemporary interpretation is given to the legend of St. Dymphna and Geel's title of "Merciful City". The legend of Dympna and the foster family tradition are also featured in the local hospital museum and in the visitor center of the OPZ Geel.