ETHICAL LIVING | SOCIETY

Geel, Belgium has a radical approach to mental illness

The city pioneered revolutionary health care — and it all started with a teenaged saint
By Anne Thériault | September 5, 2019

Luc Ennekens (left) gives Toni Smit a kiss at their home in 2013. Eight years before, Ennekens, who has a mental illness, moved in with Smit as a boarder in Geel,
Belgium. (Photo: Gary Porter)

I bought my St. Dymphna medallion in New Orleans on a muggy August afternoon in 2016, the kind of day when high summer begins to tip
over into the peak of hurricane season. Beads of moisture dotted my hairline, not sweat but water pulled from the oversaturated air. The
cathedral gift shop had bins and bins of medallions, a saint for every need — Jude for lost causes, Anthony for lost objects, Joan of Arc for lost
wars. I ran my hands through them, making the metal shift and clink in a satisfying way, before picking one out, paying for it and sliding it
onto a thin silver chain.
As I fixed the clasp at the back of my neck, I offered up a silent prayer to the patron saint of mental illness: “Please, Dymphna, fix my brain.”

Outside, the atmosphere crackled with coming storms and peculiar magic.

That magic came back to me again three years later, on a train rattling across the Belgian countryside. Travelling can sometimes feel like
falling in love — there’s the same sense of giddiness, the same wild curiosity — and everything around me made me feel like I was waking up
from a long stupor. The view from my window looked like a landscape painted by a Flemish master, and the spring air was strangely sweet in
a way I’d never smelled before. I kept pausing to take in big lungfuls, trying to print the scent on my memory.

But the magic was more than just the thrill of being somewhere new; it was knowing that with every mile of track that passed, I was getting
closer to Geel. This city, 50 kilometres southeast of Antwerp and small enough that it didn’t even warrant a dot on the map in my guidebook,
was the site of Dymphna’s martyrdom. It is also home to a remarkable social psychiatry program that sprung up in the wake of her death.

I dreamed of a place like Geel long before I knew it was real. Through all the time I’d spent in Canada’s psychiatric system — years of white-
knuckling it through months-long wait-lists just to get an intake appointment, late nights in the ER with panic attacks that wouldn’t stop,
wards with doors that lock behind you with a gut-wrenching click — I’d tried to imagine how it might be different. I fantasized about a
system where care is ongoing and mental health isn’t treated as a binary of “fine” and “crisis;” where patients are considered complex
individuals rather than a list of dysfunctions; where clinicians understand the difference between staying alive and actually living.

The stigma against mental illness permeates well past the medical system into all aspects of society, from the hushed tones we use when we
talk about it, to the looks we exchange when a dishevelled man is being too chatty on the subway, to the way we casually pepper our
conversations with words like crazy, insane, psychotic. Managing the distress caused by mental illness is hard enough, and that difficulty
increases exponentially when you have to exist in a world that fears and hates your illness. To fix all that, you would have to change society
entirely, but that’s exactly what Geel has done. And it all started with St. Dymphna.

According to her legend, Dymphna was born in the small Irish kingdom of Oriel sometime in the seventh century. Her father, Damon, was
the king; he was also a pagan. Her mother was a Christian, and like so many mothers in these types of stories, she’s rarely accorded the
dignity of a name. All we get are a few nebulous adjectives: beautiful, loving, virtuous.

The interfaith nature of Dymphna’s parents’ marriage was reflective of the changing religious landscape in Ireland at the time. It had been
200 years since a Romano-British bishop named Patricius allegedly drove out all the snakes, helping to popularize Christianity. By the time
Dymphna came along, the faith was spreading rapidly across the island. It was still very new though, and, like Damon, many continued to
worship the old gods of the Celts.

Dymphna, however, was raised Christian, and at the age of 14, she took a vow of chastity and dedicated her life to Christ. The timing of these
particular solemn promises might have been influenced by a decline in her mother’s health — a bargain for her recovery — since shortly
afterwards, Dymphna’s mother died.

More on Broadview: Anne Thériault on her spiritual journey to Geel, Belgium

Damon and his daughter were distraught. As months went by and his grief deepened, his counsellors began to worry. They urged him to
move on and remarry. Eventually, he agreed, but only on the condition that his new wife would be as beautiful and accomplished as his last.
His men travelled all over the country to find a woman good enough for Damon, but they failed. His mental state continued to deteriorate,
and he developed a frightening new fixation: marrying Dymphna.

These days, Damon’s breakdown might be called brief reactive psychosis, an extreme break from reality triggered by a stressful life event; in
the 600s, it was termed “madness.” But a mad king is still a king, and Damon wielded a huge amount of power. His pursuit of his daughter
intensified, her refusals unacceptable in his eyes. As a last entreaty, she begged him to give her 40 days to decide, which she used to secretly
prepare to leave. Once everything was in place, she fled with her priest, Father Gerebernus, first on a ship to the port city of Antwerp, then
on to Geel.

It must have been a terrifying journey. Travelling over water was dangerous in those days, and a trip through the Irish Sea and across the
English Channel would have been perilous. Dymphna also probably experienced the same mix of feelings many women do when they make
it out of an abusive situation: relief, of course, but also a profound sadness. Damon, after all, was her only living parent. All of this must have
been compounded by guilt, since disobeying her father went directly against one of the core values of Christianity: honour thy father and thy
mother.

Maybe it was those complicated feelings that led Dymphna to what she did next: use her considerable resources to build a hospice for the
poor and sick. According to some versions of her legend, this hospice particularly served those with mental or neurological illnesses. If this is
true, Dymphna would have been centuries ahead of the rest of Europe. Most medieval hospices turned away people with mental illness,
believing them to be contagious or possessed or both. But Dymphna seemed determined to help others who suffered the way her father did.

It wasn’t long before Damon’s scouts heard stories about a young woman spending Irish gold in the Flemish countryside. Damon
immediately went to Geel, where the owner of a local inn pointed him in his daughter’s direction. After finding her, Damon had her priest
executed in front of her. But even that didn’t convince Dymphna to marry him, so Damon beheaded her with his own sword.

It’s hard to imagine a lonelier or more frightening death — in a foreign land, at the hands of her father, at just 15 years old. Damon’s soldiers,
who probably teased and played with Dymphna when she was a little girl, looked on and did nothing. Maybe that was the worst part. Or
maybe it was all so awful that there was no one single part that could be called the worst.

Some traditions hold that mentally ill patients from her hospice also witnessed Dymphna’s death, and they were immediately, miraculously
cured. As this story spread, Geel became a place of pilgrimage for the “mad” — anyone with mental illness, epilepsy, neurological disorders
and cognitive differences. Pilgrims flocked to Dymphna’s burial site, and more cures were recorded. At some point, she began to be
venerated as a local saint.

St. Dymphna’s remains are on display at the St. Dymphna Church in Geel (left). Across the street, she lives on in art, including this painting in Geel’s Gasthuis
museum (right). (Photos: Judith Jockel, Gary Porter)

A statue in St. Dymphna’s likeness (left) at the St. Dymphna Church in Geel (right). (Photos: Judith Jockel, Gary Porter)

More than a dozen centuries after Dymphna’s death, Geel is filled with statues and paintings made in her likeness. The camera roll on my
phone is filled with various depictions of her, each of them unique but with common elements: a crown to show her royal status; green robes
to show her Irish heritage; a Bible to show religious devotion; a sword to show how she died; and a demon representing madness crushed
beneath one foot. Many of her statues are adorned with candles and pots of fresh flowers. Always her face holds the same impassive look, one
that seems to say: you don’t understand, but I forgive you anyway.

The first church dedicated to St. Dymphna was built in 1349, about 100 years after her legend was recorded by Petrus van Kamerijk, a canon
of Cambrai. The influx of pilgrims hoping to be healed of mental health issues increased dramatically, and in the mid-15th century, the
church decided to add a dormitory to house them. There, women from the town cared for the pilgrims as they underwent a nine-day healing
ritual. A key part of this “treatment” involved crawling on the ground beneath Dymphna’s remains, which had been disinterred and placed in
an elaborate shrine.

As time went by, these remains slowly diminished. Her skull was lost at some point — bricked up in a church pillar, according to some
stories — and then there was the all-too-generous 17th-century prior who apparently gave away pieces of her without consulting his
colleagues. The more the myth of Dymphna grew, the more the real Dymphna shrank.

Those who travelled to Geel and weren’t immediately cured might stay for years, or even the rest of their lives. Sometimes this was their
choice, but some were abandoned by family members. When the dormitory became inadequate to house everyone, the people of Geel took
pilgrims into their homes. This was partly religiously motivated (charity is a virtue, after all), but it was also practical. In exchange for room
and board, families expected help around the house or in the fields.

As time went on, pilgrims became known as “guests” or “boarders” and a regular part of village life and culture. The result was that many of
the behaviours associated with serious mental illness were normalized in Geel, which meant that the boarders were able to navigate the
world without worrying about being harmed or stigmatized, alleviating a lot of their suffering.
While all of this was happening in Geel, attitudes toward mental illness were also radically shifting across the rest of Europe, although in a
much different direction. Madness had long been viewed as a domestic problem to be solved by families or parish priests, but by the late
medieval period it started to be seen as more of a public health issue. Hospitals like London’s Priory of St. Mary of Bethlehem (colloquially
known as Bedlam) were transformed into “madhouses” that specialized in caring for the mad — if filthy conditions and brutal restraints can
be called “care.”

In the 18th century, the Enlightenment touched off a wave of reforms in mental health treatment. Instead of viewing madness as an affliction
best handled by locking its sufferers away, a new school of doctors asserted that things like rest, fresh air and a generally humane approach
could vastly improve the prognoses of the mentally ill. The madhouse model fell out of favour, and progressive doctors began to promote the
idea of “asylums,” huge, sun-filled buildings where patients could escape the pressures of society and access various therapies.

These radical reformers began to take an interest in Geel, although their opinions of its so-called “Colony of the Mad” were divided. Some
thought that the boarder practice was backward, an archaic church system that left the mentally ill to languish without any kind of medical
care. “Treatment and freedom cannot go hand in hand. In Geel there is no treatment, and the alienated have nothing but freedom which is
harmful to them,” argued Dr. Ferrus, a French physician, quoted by Jules Duval in his 1867 text Gheel ou une colonie d’aliénés (Geel or a colony
of the alienated).

Many were deeply skeptical that illiterate farmers could know better than medical professionals. But others saw Geel as an outstanding
success. French doctor Philippe Pinel, sometimes referred to as the father of modern psychiatry, remarked that “the farmers of Geel are
arguably the most competent doctors; they are an example of what may turn out to be the only reasonable treatment of insanity and what
doctors from the outset should regard as ideal.” His student and successor, Jean-Étienne-Dominique Esquirol, visited Geel in 1821 and
marvelled over how calm and content the boarders seemed, especially in contrast to their institutionalized counterparts. The debate became
known as “The Geel Question”: was the boarder system more humane than that of the asylum, and was it something that could be replicated
elsewhere?

Some of the criticisms of the Geel system were valid. The church’s oversight was lax, and families who were abusive didn’t face
consequences. Residents who might be struggling with challenging behaviours from boarders lacked resources; some even resorted to using
physical restraints.

The family-care program isn’t miraculous; it is as profoundly human as Dymphna’s life story. It’s proof of how
well we can love each other when we practise radical acceptance.
When the Belgian state psychiatric system took over the management of the family-care program in 1850, it did its best to address all of these
issues while keeping the elements that made it unique and successful. The government outlawed the use of restraints on boarders and
introduced strong consequences for families who abused their charges. They also built a hospital at the edge of town along with large
bathhouses for the boarders’ use.

The hospital was a low, elegant red-brick building that looked more like a country retreat than a medical centre. Boarders were assessed there
before being placed with a family, and staff monitored individual cases. The beds were for those experiencing a crisis and in need of a higher
level of care than the families could provide. But this was viewed as a short-term coping mechanism rather than a long-term solution.

The bathhouses were deliberately separate from the hospital so they felt safe and non-threatening, especially to anyone who had experienced
institutionalization before coming to Geel. Boarders visited each week not only for hygiene and health reasons, but also so that doctors could
check in about their home life without the family overhearing. This, along with regular home checks, helped ensure boarders were safe and
thriving in their placements.

Sure, families who took in boarders received a small stipend, but the real incentive to participate in the program was a sense of pride in the
work they did. As the Brussels correspondent for London’s Pall Mall Gazette wrote in the 1870s, “It is the personal interest of the inhabitants
to do their duty well by the patients, as they are [e]ntrusted only to people whose moral fitness and means of existence are approved. In fact,
a family at [Geel] is not considered respectable if lunatics are not [e]ntrusted to it, and the withdrawal of them from care constitutes a heavy
punishment.”

The family-care system continued to gain international attention (Vincent van Gogh’s father even considered sending his son there). The
program saw incredible growth in the early 20th century. At its peak in 1938, nearly 4,000 boarders lived in a town of 16,000, and services had
expanded to include a school for children with mental illnesses and cognitive differences. But then the Second World War began, and Ger-
many soon occupied Belgium. Although family care continued throughout the war, numbers declined.

Today, 232 boarders live in Geel with 187 families. The size of the program isn’t all that’s changed in the last 80 years. The shift from
agricultural to urban living means many families don’t have someone who can be home with a boarder during the day, and the rise of
psychiatric drugs means far fewer people require supported living. Many of the boarders in the 1930s had diagnoses like depression, anxiety
or obsessive-compulsive disorder that can be more easily managed now with medication. These days, boarders are more likely to live with
either serious cognitive disabilities or mental illnesses, like schizophrenia, that are more challenging to treat.

Incredibly, those diagnoses are not disclosed to the foster families. Instead, they approach their boarders as individuals with their own
behaviours and personality quirks rather than a list of symptoms. Instead of pathologizing the boarders, the aim is to highlight their abilities
and strengths. “[The] focus [is] no longer on cure, but on care,” says hospital spokesperson Johan Claeys. “The focus is on a normal daily life
in an average family, out of institutions.”

Most radically, the program works to reshape society to be fully inclusive instead of forcing people with mental illnesses to try to
accommodate an intolerant society. The end goal is for boarders to be able to live in a world that accepts them for who they are. Even the
term “boarder” is meaningful. It describes a social role within the community, unlike “patient,” which can indicate a dysfunctional state that
requires fixing.

Boarders often live with the same foster family through multiple generations; when the parents become too old to care for them, they will
move in with the adult children. These second-generation caregivers have an extra-close bond with the boarders, since they’ve often known
them for their entire lives. They also learned from a very young age not to view mental illness as strange or frightening. Kathleen Goovaerts,
who owns the Roosendaelhof Hotel in Geel, has a lot of fond memories of growing up next door to a family with three boarders. “They were
so different from the other adults,” says Goovaerts. “They were always ready to play with us, to be on our level. I didn’t realize then how
special it was, because it was just ordinary for us.”

Arthur Schouten (right) gives boarder Dis Simon, then 87, help with his hat after a day out in 2013. (Photo: Gary Porter)

Dis Simon (left) and Luc Ennekens, then 49, share a joke over a meal in 2013. The pair became close while boarding together in the same house. (Photo: Gary
Porter)

Many elements of the boarder program have remained unchanged over the centuries; and yet, some still feel like a modern departure from
the West’s approach to mental illness. It’s certainly a far cry from my own experiences. At best, I’ve found mental health care in Canada
difficult to navigate. At worst, it’s a system that has tried to “fix” me through coercion and threats. And I know that I’m one of the lucky
ones. Society considers my diagnoses non-threatening, so I can pass for “normal” for long stretches of time. Many others have it much
worse. Given all of that, Geel felt like a revelation to me.

The old hospital building is still there, on the large, leafy campus of Geel’s Openbaar Psychiatrisch Zorgcentrum, which is home to art
studios, a centre for teens and children, and a modern in-patient psychiatric unit. There is a café in one of the newer buildings staffed by
volunteers with a history of mental illness. The day I was there, a group of boarders and staff was assembling before leaving for a vacation in
Spain. Everyone seemed to know each other, and over the sounds of suitcase wheels and spoons clinking against coffee cups were shouts
wishing the travellers a good trip. If the scene was remarkable at all, it was only for its ordinariness.

Dymphna’s original church was destroyed in a 15th-century fire, but a new one was consecrated in 1532 and remains standing in spite of a
tumultuous history. During the French Revolution, it was ransacked and used as a stable by French troops. The Battle of Geel, one of the
bloodiest during the liberation of Belgium in the Second World War, destroyed its roof. But now it’s a peaceful place. What’s left of
Dymphna’s remains are held in an ornate silver reliquary. In 2002, a local university tested them, and radiocarbon dating showed that they
belong to a young woman who died between AD 700 and 800.

It’s tempting to view Dymphna through the lens of her saintly attributes — her piety, her self-sacrifice, her miracles. These are, after all,
what set her apart from everyone else. But if the person described in her legend ever existed, she was a young woman who experienced
horrors that young women are still confronting today. She was abused by someone she knew. Her abuser was protected by an imbalance of
power and people who were afraid to challenge the status quo. She died at the point in the abuse cycle when the risk of violence is highest:
the moment she gathered the courage to leave. Like so many other victims of abuse, Dymphna channelled her trauma into helping others.
Her brief life was an act of determination, bravery and resilience.

Dymphna was someone who understood what it meant to recognize the humanity of those who weren’t accorded that basic right by the
world around them. The family-care program isn’t miraculous; it is as profoundly human as Dymphna’s life story. It’s proof of how well we
can love each other when we practise radical acceptance.

I still have my Dymphna medallion. I wore it in the months after I was hospitalized for depression in 2017 because it reminded me of how
happy I’d been in New Orleans. It helped me believe in a future where I might feel that way again. I find comfort in rubbing it between my
fingers or running it along its chain; each movement a tiny, wordless prayer.

I reached for it often when I was in Geel, a way of grounding myself when everything around me was so surreal. I didn’t know what to feel —
sadness over the years of shame and stigmatization I’d felt over my mental health, frustration at the fact that the Geel model seems to be
largely ignored by much of the world, or gratitude that I got to be there. I settled on a combination of all three.

On my last morning in Geel, I decided to go to the church one more time. Even though it was Saturday, the doors were open and the pews
were full. It was, I realized, a confirmation ceremony for the congregation’s youth. I stood at the back and watched as a joyous priest doled
out blessings, parents took pictures, and children chased each other up and down the aisles.

After a while, I went out to the small graveyard and sat in the grass. I could still hear the children’s laughter from inside the church as a family
of rabbits started to come out, their noses twitching in my direction. I knew then that even if Dymphna’s death was brutal and lonely, her
legacy is certainly full of hope and joy.

Geel’s family-care program was run by the church until 1850 and is now run by OPZ Geel (left). It matched boarder Jefkae Harbant (right, middle) with Maria
Lenaerts and Jules Teunckens, who invited him into their lives and home. (Photos: Judith Jockel)

This feature was paid for through the David Wilson Broadview Fellowship, a reader-supported fund that honours this magazine’s former editor
David Wilson and supports high-calibre journalism.

Anne Thériault is a writer in Toronto.

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Giu Alonso says:

September 5, 2019

A touching read, and a beautiful story of acceptance and inclusiviness. Didn't know about Dymphna, but her story certainly sounds
familiar so many centuries after her death.

Reply

Sharon says:
September 5, 2019

Here in California, if you feel the need to go see a psychiatrist, neurologist or therapist—you call the office make an appointment and
pay for it. Seems much simpler than waiting for the government to approve.

Reply

William says:
September 6, 2019

Except what she's talking about has nothing to do with who pays for it. She's talking about how long it takes––in America, where I
live; in Canada, where she lives; in Abu Dhabi, where I have lived; anywhere--to receive care. If you had ever faced this problem
yourself you'd know that. Instead you take what could be an opportunity to learn something and turn it into your moment to make
some narrow-minded political statement-that isn't even relevant. I wonder...don't you have a bridge to go hide under and collect tolls
 from people?

Reply

C Save says:
September 9, 2019

Only if you have insurance, can find a provider in your network, hopefully they are accepting new patients or you don't have to make
an appointment with a gp first before you can get a referral, and then wait upwards of a month or more for your first appointment.
Much simpler.

Reply

Sandra Newman says:

September 17, 2019

Pretty obviously, if you can pay for it yourself, you can just call the office and make an appointment in any country of the world.
There isn't a law against paying for your own therapy in Canada or Europe or wherever. It's when you can't afford to pay that you
need either the government or your insurer—whoever is paying—to approve it. In both cases, that can take time. It's embarrassing
that you're expressing such ignorant opinions about this subject in public. Please don't speak about important subjects if you don't
know anything about them.

Reply

iquanyin says:
October 25, 2019

If you can afford it, or if you can find one that takes medicare. Single-payer means you need treatment, you get treatment. I guess
you haven’t noticed the many, many ill people living on the streets.

Reply

Anne Francis says:

September 6, 2019

What a truly extraordinary story. Kudos to Anne Theriault. It reminds me of Jean Vanier's L'Arche homes, which are, of course, much
better known, and for people with developmental disabilities rather than mental illnesses, but the concept of "radical acceptance" is
common to both models.

Reply

Danielle says:
December 14, 2019

Thank you for making that connection. It is a rare that we hear of places that practice radical acceptance of those with mental
illnesses whether they are considered minor or major. The issue is not one of payment but of the way people find their way back to
normalcy through a different model that is not pathologized. It is a shame that most readers missed that point. I am so happy to
have found this story. It is one of Hope at a time when it is in short supply.

Reply

LT says:
September 8, 2019

What a needless comment about the Canadian healthcare system. One only needs to look at California's homeless crisis to know that
good mental healthcare belongs only to those privileged with money or insurance. So many are left behind.

Reply
 Danielle says:
December 14, 2019

Lt, I don't understand how you can possibly defend the Canadian system of mental health. To compare it to what is happening in
the U.S. is like comparing apples and oranges. Our system is far from just and very inaccessible to many in need.

Reply

Fred Brailey says:

January 30, 2020

Seen as victims of a cruel disease, our "other-minded" friends await our attentive love and support. How little we know about
the mysteries of the mind.

Reply

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