A Visit to Gfaeel Colony, Belgium
- Author:
Clement Brown
The history of the care of the insane is one of special fascination to those who are interested in the social anomalies arising where human relationships move the emotions most deeply. In the formation and growth of social institu- tions controlling these relationships, there often appears little or no consistency with the knowledge and philosophical theories of the time. Practice may out- run scientific analysis and ethical thought, and be later explained by the one and justified by the other; or, conversely, social habits of action may persist long after the judgment of individuals has shown that the means used have little relation to the end in view.
The tools of social research which make it possible for the Blue Book to shape for us maps of social problems, sometimes beguile us into thinking that to plan the route of the journey is to accomplish our purpose. Such a project, for instance, as Community Care of the defective, or the mentally ill, where the private family shares the responsibility of the socially irresponsible with the institution or with the hospital, is not always considered from the standpoint of the slow growth of social attitudes and integrity. Gheel Colony, in which there has been continuity of family care of mental patients for at
least seven centuries, and which has already an honourable name in the history of psychiatry, justifies, therefore, a more intimate appreciation from the stand- point of the sociologist.
The market town of Gheel lies inland from the city of Antwerp about an hour’s journey, and a little further from Brussels. It is a scattered com- munity, with a population of eighteen thousand, covering an area of about 27,000 acres. Its long history is told in the homes, which range from fourteenth century two-roomed thatched cottages, to modern red-brick, slate-roofed, three- storey villas. The surrounding country is typical Flemish flat agricultural land, and the men of Gheel are mainly occupied locally, in the fields, or in the marketing of produce.
The central buildings of the Colony, which include a reception block, an observation department for men and for women, and facilities for special therapy, was opened only in 1925, and appears pleasantly hospitable, and adequately equipped. An older central building, previously used as an infirm- ary, now provides ample space for administrative offices. To the Colony also belongs a special school for mental defective children, opened in 1922. In each of the four districts, into which, for purposes of medical care, the area of the town is divided, there is a central bath house, for which patients are given special tickets. These are made very necessary by the fact that water is not laid on in the majority of the houses.
The medical staff consists of the Director, Dr Sano,1 well known to members of the International Council of Mental Hygiene and a leader of this movement in his own country, and six assistants: one for general charge, one pediatrician, and one for supervision of each of the four geographical districts. Thus the average number of patients to each physician is six hundred, a propor- tion considerably higher than that in most of the mental hospitals in this country. One must bear in mind, however, that a proportion of the patients are defectives, for whom less medical attention is necessary.
Although at one time a service founded by the Church, and conducted as a religious charity, the Colony is now the property of the State, and is used for rate-aided patients from any province in the country.2 Private patients are also welcomed, and, owing presumably to the exceptional kind of care provided, there has always been a number of foreign patients at Gheel. During a morn- ing spent in visiting foster homes, an American woman, brought over specially from the United States by her husband, and a Londoner who had been at Gheel since before the War, were as pleased as the visitor to have a talk in their 1 To Dr Sano’s kind hospitality I am indebted for this visit and for all the information and opportunities for observation of which this account is a result.
2 The Province pays the Institution about 10/6 a week per patient. The rates paid to the foster homes vary from 6/- to 8/- in accordance with the capacities of the patient. There is thus a small balance for overhead expenditure. These expenses, however, seem mainly to be met by the fees of private patients who pay about ?250 a year, of which 15% goeS to the administrative side of the Institution. The Colony provides clothes for rate-aided patients.
own language. While, rather surprisingly, both private and rate-aided adult patients are at Gheel under judicial certificate, no difference of procedure seems to arise until the patients arrive at the Institution, when it is generally arranged for private patients to go direct to their foster homes, whereas rate-aided patients must be examined at the Reception building before they are placed.
An effort is made to adapt the type of home: to the social status and other needs of the patient. Obviously, the paying patient receives better care, if ” better ” is interpreted in absolute rather than in relative terms. Within certain limits, however, it would probably be agreed that in a family circle the social demands made upon the patient should correspond with those of his own home. Each district physician is well aware of the family resources of his own area, and in medical conference, after examination of the patient, the home is chosen, or adjustments are made, in accordance with individual and social diagnosis. Fortnightly medical conferences are held for the purpose of reviewing these decisions, and when changes are made, the Medical Director himself often pays a visit. Where emergencies arise, an ambulance can be sent immediately from the central building, and the patient detained there. Patients unsuitable for the Colony may be transferred to other State Mental Hospitals.
So much our Blue Book might have mapped for us in planning the care of three thousand patients. The point which really concerns us here is, how has this become possible in terms of community life ? Why are the inhabitants of Gheel willing, and indeed anxious, to have patients for a sum of money which can hardly raise their own standard of living?3 What difference does the fact that every sixth inhabitant is suffering from mental disorder or defect make to individual attitudes and social relationships? How effective in the healing of his condition is this acceptance of the patient as a member of society within the limits of his social capacities ?
It would be presumptuous to suppose that a twenty-four hour visit to Gheel could supply us with an answer to these questions. To solve the prob- lem of the difference between a community of this sort and a Welsh border country town where the inhabitants recently protested against the local estab- lishment of a colony for epileptics, would require all the resources of the histor- ian, the sociologist and the philosopher. Yet it is in the analysis of such subtle problems of social psychology that the success or failure of schemes for the care ?f the abnormal individual lie. The social psychiatrist, and, in a somewhat different way, the criminologist, must be concerned almost as much with the meaning of these conditions to society, and with the attitudes of individuals towards them, as he is with the mentally disordered patient or with the criminal himself.
One of the conditions of the acceptance of foster parents as such is that they should have an adequate independent income. There has never been a time in the recorded history of Oheel when there are not more applications from foster homes than can be accepted. In ^pril, 1932, the number of applications on the waiting list was thirty, and there were over vacancies in homes already approved.
Perhaps the first thing that is apparent to the visitor is that every section of the community is absorbed into the scheme, from the stationmaster who welcomes die patient and the relatives on arrival, to the village inn-keeper who supplies them with innocuous drinks. Gheel, in fact, exists for the Colony, and all the inhabitants apparently accept part of the responsibility as their own. For the patients were under no general rules of supervision. They went about their business with the purposefulness or the aimlessness appropriate to their con- dition. The village seemed to be theirs. The feeble-minded boy went for his foster family to purchase the daily paper, and greeted the Director with a smile.
He had been entrusted with a simple money transaction which he was unable to explain, but which, it was found, involved no loss to his guardians. The imbecile spent his time babbling by the village pump in the traditional manner of the village idiot, but apparently without attracting either the reverence or the ridicule which has sometimes been his heritage. An elderly woman, suffering from dementia praecox, soliloquised her way down the village street without regard to the rights of the traffic; indeed, these were waived in her favour, for the pedestrians of Gheel have a right of way which often makes a round-about course for vehicles. A paranoid patient who had exceeded his function of amateur traffic inspector by making personal enquiries from the drivers, is said to have desisted when he was given a special message from the Ministry of Justice to the effect that, though he was in his rights to make notes of the make and registration of cars, he must not take any steps which involved obstruction. The policeman entered into both the positive and negative aspects of this form of social” therapy. He had a patient in his own home, and understood the peculiar needs of this condition from a practical standpoint. He did not expect a response to argument. Another patient, skilled in clerical work, assisted with zest in the tracing of his own heredity in the administrative building. The clues to his possible descent from Napoleon were followed up, even to the obtaining of birdi certificates.
Obviously, not all the patients could be trusted at large. But the degree of freedom possible under these circumstances seemed astonishing. In the middle of the market-place in the early morning, while a funeral procession collected outside the church, a young man stood with fixed gaze, carrying out bizarre, stereotyped movements. The visitor watching through the window of the village inn, was apparently the only person interested in this phenome- non. Certainly, later on in the day, the children coming home from school, stopped to regard with interest the hoisting of a cretin on to the shoulders of the Director, as he introduced her on the door step of her foster home to the large group of social students from Strasbourg; but one felt that it was the crowd that amused them more than the patient. The medical staff themselves have doubted the advisability of placing epileptic patients in families with children; but even this concession to accepted theories has been abandoned. ” The children take over the same attitude as their parents,” says Dr Sano.
Along with this acceptance of different degrees of responsibility goes, apparently, a willingness to accept guidance in their homes in a friendly, informal way. One can hardly imagine, in England, the visiting physician wandering through the garden and opening the back door, without a knock, upon the mid-day meal of a family. Still more is it difficult to picture a farm- house family in this country tolerating a group of about thirty students tramp- ing from the mud of their yard through the kitchen in order to see the con- ditions under which patients are living. Yet these kindly people seem, as a matter of course, to accept the needs of the student as well as of the patient.
Many of the homes are extremely simple; none are probably up to the standard of cleanliness and ventilation of our mental hospitals. But appreciation and criticism alike seem to be taken in good humour, and from the patients one got the impression of a certain underlying self-respect which, from the social standpoint, must be a valuable foundation for readjustment.
The fact of social acceptance which is such an important one in the con- sideration of Community Care, may be largely accounted for by sheer familiar- ity. Does this familiarity alter the standards of hnman conduct for the people of Gheel ? At Moll, some six miles distant, where the Ministry of Justice main- tains its famous Observation Centre and training scheme for delinquent boys, it was suggested in reference to Gheel ” Ceux qui demeurent chex fous devixendront fous.” The more sceptical of critics might suggest that even if the arrangement was not disastrous from the standpoint of contagion, it might be so from that of eugenics. It is claimed by the Director, however, that only once in the history of family care since he has known it, have the authorities been acknowledged responsible for the support of an illegitimate child, and that sexual irregularities do not present an insurmountable problem. In con- nection with this it must be remembered that there always exists the remedy of transfer, and that the central building obviates the difficulties of delay. Each year a certain number of incurable wanderers who cannot be persuaded to stay even within the wide confines of the Colony, are dealt with in this way.4 But M. Sano writes: ” the tendency to escape is equal to so many other small diffi- culties which must be overcome by patience and training in discipline. It is a minor difficulty in the system of family care.”
Perhaps the solution to many of the subtle problems of the social life of the village is to be found with the patron saint of the people?the prematurely wise, serene little figure of St. Dimphne, who stands silently presiding over community life in her shrine in the wall, and whose dramatic history is recorded in the magnificent sixteenth century altar carving of the church. St. Dimphne During the year 1931, about 450 new patients were admitted and 3,000 were constantly present. 176 times patients who wandered into neighbouring villages, escaped wilfully, ?r broke their parole, had to be returned. Only once a patient was not found, and it is Presumed that she went to France. Some of the patients go over the nearby Dutch border, but by special arrangement the authorities return them to the frontier.
herself?by legend an Irish princess of the seventh century?had been the victim of the uncontrolled passions of her father, from whose incestuous desires she fled with her priest, St. Gerebernus, across the stormy channel into the port of Antwerp, where they took refuge in the village of Gheel. Here their hiding place was discovered by the enraged king, and, in the words of the local history: ” Dimphne and Gerebernus are martyrs of the chastity.”5
The peculiar potency of the tomb of St. Dimphne for the healing of dis- orders of the mind is not elaborated in the story. But the graphic portrayal in the carving of types of mental disturbance?the manic, whose wrists are chained, and whose relative is obviously anxious of the effects of delay upon his patient; the hysteric, with taut posture, a devil passing visibly from the back of her head, who seems to enjoy the attentions of the group of priests, while protesting dramatically against them; the senile dement, with his detached, vacant stare?all these are unmistakable. It is, says the local account, the ” unhappies ” who are kneeling before the relic; and we are told that ” St. Dimphne secured a great number of sicks.”
Further evidence that the church was originally the centre of the work of mental healing at Gheel is to be found in the annexe to the church, dating from the 17th century, and containing rooms in which the patients were cared for while they were waiting to attend religious services. The unlit cells with indirect ventilation and barred gratings show that the church of St. Dimphne had not altogether discarded the methods current at the time.
It is understandable enough that the hospitality of the church might often be too much in demand by the relatives of the ” unhappies,” and that the local inhabitants, eager to have a part in the dramatic events at the tomb, would offer to take to their own homes those who had made long pilgrimages. In this way the Colony of Gheel is said to have grown up.
Without the background of this story as the traditional heritage of the people, it seems doubtful whether anything comparable to the community integrity which has been described could ever have been brought about. The Colony of Gheel, by special arrangement with the combatants, to whom it was well known, even survived the devastations of the War. Psycho-analysts might find interesting significance in the fact that it was this particular form of Electra theme which proved the social magnet. Be that as it may, the conscious use of psycho-analytic, or indeed other direct psycho-therapeutic measures does not play an important part in the present methods of the Colony ?for, as the Director remarked : ” The priests do our analysis.”
Social psychiatry at Gheel is, however, a recognised, well-considered service. An ” assistant social psychiatrique ” has been employed since 1923, and there is a trained social worker occupied on, the task of social readaptation 5 This and other quotations are from a locally translated account of the story which is recorded in Flemish and French and accompanied by excellent photographs.
of Gheel patients throughout the country.6 Limitations of time determine the fact that the social worker is occupied mainly in social readjustment rather than on the side of social diagnosis, but that this is inconsistent with general outlook is evident by the stress laid upon the aetiological significance of social circum- stances in a publication which has the official approval of the staff. Here it is maintained that, just as a healthy mind is dependent upon a healthy body, so mental hygiene waits upon social hygiene. As a result of experience at Gheel the first social psychiatric assistant recommended a scheme for widely increased local out-patient facilities staffed with trained social workers?a plan which has already been partly adopted since he wrote in 1924. About sixty cases are under the care of the social worker at any one time, the rate of discharge from the Colony being about three hundred a year. One has the impression that a considerable amount of very careful personal work is carried out by her, both with the patient himself, after discharge, and also with the relatives, and M. Borgers has made a most useful analysis of the social application of psychia- tric methods.
The Colony of Gheel stands as a demonstration of the effectiveness of slow unconscious growth in social situations where studied, imposed plans often seem to present insuperable difficulties. The obvious danger of such undirected growth is the inevitable tendency to slowness in adaptation to discoveries and methods which come from other fields of experience. But the eagerness with which members of the staff at Gheel take part in and make use of the attempts to analyse more closely the objectives and methods of mental hygiene, particu- larly on the social side, seems to show that they are aware of this danger, and, therefore, perhaps, proof from it.
The fact that different forms of Community Care are now discussed upon a basis of recent knowledge, and with recognition of the fact that to some extent social control is learned through social responsibility, seems to show that there is something basically true in the inspiration of St. Dimphne. And if the same truth, learned at her shrine, is more effective than when it is delivered from the platform of the most enlightened Societies, these are facts which the sociologist may offer for the consideration of psychiatrists and social workers.
This service was started by M. Adolphe Borgers, from whose posthumously published reprint, ” L’Hygiene Mentale et ses Applications,” information is obtained. This has been supplemented by Madame Borgers, who now carries out her late husband’s work. The present tra’ining for psychiatric social workers in Belgium is three years for the general social science certificate, of which eighteen months is spent on probation, occasion- ally with salary, at a mental hospital. It is more usual for this probationary service to be non-residential.
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