Beyond Hospital By Guardianship Officer,
Gates
LUCY E. BEACH
Central Association
for Mental Welfare
This paper is an attempt to pass on to others the encouragement gained visit by recently paid to selected places in Belgium and Holland to see some of the methods there employed for the care of mental patients boarded out in the community. a
The expenses of the
a donor, whose for mental welfare aware, anonymity concealed, work, who thus enabled Miss Burdett, Secretary of the Suffolk Mental Welfare Association and Miss MacMichael, Secretary of the Devon Mental Welfare Association and myself, to obtain some idea of what can be accomplished for mental patients by treatment carried out extra-murally. We are very grateful for this opportunity, and should like here to express our thanks also to the many workers in Belgium and Holland and also in England, who readily gave us all possible information. Exchange visits are insufficiently frequent between mental health workers on the Continent and in this country, and the general trend towards international co-operation should surely be more evident in this sphere as in others. Be that as it may, we return from our visit with admiration for the way in which certain methods have been tested and have been shown to triumph over the difficulties which appear to many in this country to be insuperable.
journey
we are
were a
generously
very active
met
concern
by
MENTAL WELFARE
50
originally planned as a short visit to the Colonie de Gheel of Gheel, but was extended to include as a modern follower Belgium, in where boardBeilen and other Beilerood at Holland, Stichting hospitals in with treatment. the usual out has been conjunction hospital ing adopted " Etablissement central To be at Gheel, and not to visit the near-by d'observation at Moll-Huttes would have been to miss the chance of seeing that most interesting example of the psychological study and treatment of delinquent behaviour. Some general view of work in Holland we gained by visits to: The large Hospital at Santpoort, already so well-known to many in this country for its outstanding success in organising occupation for its patients: the Willem van den Bergh Stichting at Nordwijk-Binnen, where the small group system is carried out in ideal surroundings for 330 feeble-minded patients, boys and girls of special school and lower grade type, and some adults: a Special Day School at Amsterdam: Child Guidance Clinics at Amsterdam and the Hague: After-Care workrooms for mental patients at Amsterdam. We saw the conditions of boarding out from the main hospitals, as already practised in England, at Vught, and at Franeker?Vught, where the Roman Catholic Psychiatrische Inrichting Voorburg is an example of modern equipment, excellent workrooms, beautiful grounds, and sunny gardens for each ward and a markedly high standard of care given by the Nuns and Brothers; Franeker, with its main building on the site of the 14th century University abolished by Napoleon, and its excellently equipped new two-storied crescentshaped building, and its intensive land cultivation. In our brief survey of community-care certain points struck us in both countries. Our
tour was
"
in
"
"
1.
The attitude
of the -public towards those suffering from mental disorder.
greater tolerance, a recognition of how thin is the line between normal and subnormal or abnormal, a rather amazing absence of fear, and readiness to trust the patient, make the reception of mental patients in the coma matter of remark than in this less country. munity
A
2.
Deficiency Acts and Lunacy Acts. England activities under the Mental Deficiency Act have made the care of the defective in the community more complete perhaps than in any other country. In Belgium and in Holland there is no separate legislation for adult defectives as such; they are alienes just as the mentally disordered the Acts dealing with the dealt with under and can be are alienes," only
Mental In
"
"
"
insane. to see that this has tended to leave many defectives without and attention, but on the other hand it has obviated that deep cleavage in the public mind between mentally defective and mentally disordered patients. Workers in this country are aware that there is considerable fear in the minds of many of receiving into the home anyone who
It is easy
needed
care
MENTAL WELFARE
51
has been in a mental hospital where no such fear is aroused by a patient from a mental defective institution. Until this fear can be lessened it will be difficult to extend the Boarding Out of Mental Hospital patients. 3-
Boarding out as a condition of treatment. Living in the community instead of in hospital
is definitely accepted as the better way in cases where the mental trouble can be dealt with under fairly free conditions. The doctor's sphere of work is not only in the hospital, it is equally in the home, and nothing struck us as more remarkable than the acceptance of this by the doctors. At Gheel, five out of the seven doctors have duties only outside the hospital; at Beileroord, the two doctors work both outside and inside the hospital. These two schemes are, of course, definitely extra-mural, but at other places where boarding out is only part of the general activity of the hospital, the doctor undertakes supervision. Much of this side of the work would be undertaken in this country by the social worker, but it should be emphasised that boarding out is definitely an alternative to hospital conditions for treatment, and the doctors look upon it as such. We were assured that many patients who were most unmanageable in hospital gave no trouble when boarded out. The patient remains a unit of the hospital, and may be coming in and out for work, or for recreation or medical attention. Visits to the home are frequent, to an extent unknown, surely, in this country: by the doctor once a month, by the nurse once or twice weekly. Here such frequent visits would probably be felt excessive both by the guardian and the patient. "
4.
"
boarded out. of visits is probably partly acc6unted for by the degree of illness of boarded out patients. A feeling of confidence must be given to those having difficult patients when they know that the doctor is watching closely over the case and noting any change for the worse, and one cannot help thinking that it is the part played by the doctor that makes it possible to board out patients who in this country would be regarded as unsafe." At present in England boarding out is confined almost entirely, one may say, to those who have become chronic or have almost recovered? for whom treatment has already done all that is possible. One would like to see the Medical Superintendent of one of our hospitals boarding out certain patients (after a period of observation) near to the hospital and being able to visit them as he does patients in the wards.
Type of patient This frequency
"
Some details of the
Colonie
de
This
places
we
visited may be of interest.
Gheel
colony
is
already
well-known
to
many in this country and
a
descrip-
MENTAL WELFARE
52
tion of it was given by Miss Clement Brown in the Mental Welfare Magazine for January, 1933, to which readers are referred for detailed information and
interesting comment. The unique religious origins of the Colony dating from the Dymphne have invested the whole work with a devotional aspect. inhabitants of Gheel
are so
accustomed
to
time of St. The 18,000
the presence of the 3,000
(3,233,
in their midst that their appearance and behaviour
January
1st, 1935) patients excite little remark. It has become almost a hall-mark of respectability to have one or as a rule two, patients living in the home. All guardians must be married couples, and as the number of children per family in Belgium is usually seven or eight, a very large proportion of the households are concerned in the work. Such is the eagerness of die inhabitants to be guardians, that no newcomers to the town are accepted on the waiting list. At the time of our visit there were already about 100 approved applicants on the list, and had additional been received between the first of January applications 148 and April, 1935. The growth of the Colony may be studied on an interesting chart. In the middle ages the number of patients appears to have been about 300. In 1805 there were known to be about 600; and from 1875 exact records have been kept (it may be of interest to mention that in that year Charles Dickens his admiration of the Colony in an article entitled The crazy expressed " In in All round there were the "). year 1908 1,291 patients and colony with the exception of a heavy decline about 1915 owing to the death-rate from influenza the numbers have steadily increased, and of late years have been round about 3,000. The Colony was under the Church up to 1789, when it was taken over by the Province of Antwerp up to i860, at which date it was transferred to the State under the Ministere de la Justice. Many private cases (some foreigners) are admitted: they pay higher rates to the guardians and a percentage to the Hospital. There are about 600 Dutch patients (sent by public authorities) admitted at a rate slightly lower than the It was interesting to note that the reason rate of the ordinary private case. for so many Dutch patients was said to be that the standard of Dutch Hospitals had become so high: a certain number of authorities therefore sent their patients to Gheel, where the cost of maintenance was about one-third. Not infrequently, we were told, Belgian, Dutch or German patients are placed in a foreign hospital as their relatives are glad to have the frontier between them! The minimum charge to private patients is about 13 francs a day (one American pays nearly three times that amount) to the guardian, plus 16% to the hospital. The general rate is 7.50 a day. Of this, 5.50 goes to the guardian for a patient who can work for him, 6.40 for a patient who cannot work but is easy to manage, and 7.75 for a difficult patient (which represents a loss of 25c. to the hospital). Clothes and medicine are provided by the hospital. A normal person who required accommodation would pay about 10 to 20 francs a day (the agricultural wage being from 25-30 francs a day), so that it will be noted that as in England, people are found to accept patients at a somewhat lower rate than they would the ordinary lodger. The accommodation selected "
"
MENTAL WELFARE far
53
possible in accordance with the usual style of living of the patient. Every patient must have a bedroom alone. There are no baths in the houses, and at present it is only possible to arrange a bath a month for each patient at the bath houses established in the four districts of the Colony. The Colony has a certain number of cases under 21 (usually about 50) and the rate for those who can work is 8 francs a day (of which 6.50 goes to the guardian, 1.25 to the Hospital and 25c. is set aside to be given to the patient on attaining 21 years). For other children the rate is 7 francs a day, of which 25c. goes to the hospital. There is a small school for the children managed by the hospital where they are taught until 14 (the general school leaving age in Belgium is 12). Figures taken out in 1922 showed that out of 446 children, 148 had returned to the community and were self-supporting. Patients come to the hospital on the certification of one doctor, and after observation in hospital for five days, the certificate must be confirmed. During the last seven or eight years, a certain number of uncertified private cases have been received but certification is general. Dr. Sano accepts all patients but is as
as
after observation has to return some and it appears there is a certain amount of wasted effort, as people will not realise the necessary limitations for such conditions of freedom, and we understood that, except at Brussels and Antwerp, there are no observation wards for previous selection. Patients find their occupation where they are placed, on the land or in the house or in the shop. There is very little recreation or entertainment organised by the hospital. Under the charge of a Committee some handicraft is being encouraged?patients may obtain material for basket work, embroidery, etc., and there is an exhibition of work annually, each patient being allowed to keep the proceeds of the sale. For the Dutch patients there is a Protestant Church; and a special Club Room attached to the Hotel l'Agneau. The supervision of the patients is carried out by the doctors, each of whom has two nurses attached to his district. The number of patients to each doctor is in accordance with conditions of access, etc.?two of the doctors have 700 patients each, while one doctor is responsible for the children. Bicycles, not motor cars, are used, and each patient is visited by the doctor every month and by the nurse every week. There is a trained social worker but her time is almost entirely taken up with after-care work outside the Gheel area. One doctor is in charge of the hospital, and here there is accommodation for too patients, but in practice there are seldom more than 50; of these, some are under observation, some recalled temporarily to hospital, some requiring some transfer as unsuitable, a few who have treatment, physical awaiting become chronic or are nearing the end.. At the time of our visit a powerful man who had become violently maniacal had been brought to hospital, was deemed unfit to be placed out again, and would be transferred to an ordinary mental Hospital. A feeble-minded girl living in one of the outlying hamlets of Gheel was brought into hospital for physical treatment. Dr. Sano had warned the guardian that she would be fetched some day: when he arrived at the farm with the ambulance the girl was sorting potatoes in the potatoto was and and then. A man about 30 was in there brought hospital heap,
MENTAL WELFARE
54
for a temporary period. He was a remarkably clever maker of he had strong obsessions which changed about every three months?he imagined himself to be Christ and cut stigmata on his body?or a Russian officer and made himself the complete uniform. At the present time while with his guardian he had become obsessed by the idea that his guardian's little girl was his sister and he wished to take her about with him everywhere. When this obsession had passed, another guardian would be again found for him. Typical cases in the homes were the following:
hospital mats:
(a) (b)
feeble-minded girls working at a small farm in an outGheel. of hamlet lying A painter (private patient) who had two rooms?one as a studio where he painted not very pleasing pictures for which he would only ask exorbitant prices: and in the same house, a mentally defective boy about 18.
Two
low-grade
A feeble-minded
girl about 20 who had been born to a patient who arrived confusional state. The mother died, and the guardian brought up the child, who proved to be mentally defective and was educated at the Hospital School and had become fairly useful, able to help in the house and small shop. (d) A strong-looking man about 32 who chose to spend his time chiefly in taking walks of about 10 miles a day. While we sat in the inn in the main square one evening, a man about 30 walked up and down beneath the window monotonously for about two hours, even though it was already dark. No one took any notice of him. The recovery rate is not high, as many of the patients sent to Gheel are chronic. A natural question is, do the patients abuse such freedom? It is admitted that many mental patients would be totally unsuitable. But for those at Gheel, where the whole community is friendly towards them, the records show that on the whole it is justified. Violence there has been, and injury inflicted, but in all the years since 1875 there has been no fatal result and it is claimed that on the average there has not been more than one illegitimate child born a Some patients abscond but are frequently returned, and on the whole year. this does not present a great problem. (c)
at
Gheel in
a
Beileroord Some have thought it would not be possible to establish a colony on the lines of Gheel if there were no long tradition behind it. But the same principles have been carried out for some fifty years in France at Dun-sur-Auron and Ainay-le Chateau, some descriptions of which have already been given by Sir Lawrence Brock and Miss Fox, and we understand that at Lierneux, the province of Liege established a Colony about 1895 for some 800 patients, but this has developed on somewhat different lines,
MENTAL WELFARE
55
Beileroord is a modern example, with excellent hospital accommodation adjunct to the boarding out of some 338 patients. The present Medical Superintendent (Dr. Hemmes) inclines to think that 400?450 is perhaps the ideal limit. Stichting Beileroord belongs to the three provinces of Friesland, Groningen and Drenthe, but patients are received from any part of Holland. It is situated in the small town of Beilen with a population of about 8,000, most of whom are engaged in the cultivation of the land. The work began in 1922, when eight patients were placed in a house no longer required for the Burgomaster, with three nurses responsible for their care. From these small beginnings has grown the present boarding out organisation. The hospital has two separate buildings, one for certified, and the other for uncertified patients built four years ago?long low buildings of delightful architecture, with excellent gardens and fields and small sunny wards and work rooms. There is accommodation for 78 patients. The observation period may be two to three weeks or even six months, and a few patients are permanently in hospital, having become too infirm, such as an old woman of ninety who had been in family care for ten years. The principle of freedom is the same as at Gheel, but the hospital stands for the centre of activity as well as for the reception of patients. For whereas at Gheel patients work in and around the house they are living-in, at Beileroord the great majority of them work at the hospital, either on the land or in the workrooms busy at mattress-making (with alpen grass), bookbinding, weaving, tailoring repairs, and the usual occupations. A splendidly built garage, and sun-parlours for two of the wards were the work of patients. One man? a mental defective, who had threatened his family with an axe?had as his particular occupation the chopping of logs for the hospital fires, and very proud he was to show the really enormous pile of wood he had prepared. Organised activity is dius the linch-pin of the whole. Only about a dozen patients boarded out are unable to do anydiing. The Medical Superintendent and his assistant see most of the patients daily, and the advantages of this arrangement are apparent. There are some patients working away from hospital for their guardians and seven men have their own little businesses, selling flowers and potatoes and vegetables from door to door. The general attitude to the hospital is the same as at Gheel: there are always keen applicants for patients and at the time of our visit there were 50 approved homes but no patients on the waiting list. (We were told that the boarding out idea had not yet been fully accepted by all public bodies in Holland.) Even troublesome cases could be placed without difficulty. One girl had recurring maniacal periods. She had been in 20 different homes, and after a stay in hospital had just been placed out again?this time with fresh applicants who were most anxious to be on the books of the hospital. The guardian of two old women about seventy-five needing pretty constant care and attention to habits had recently died and they were placed without delay with a young woman who had just lost her husband?one had obsessions, the other was an epileptic. Their home was a sunny newly-built house with gay colours and the lovely flowering plants one sees in almost every Dutch house. as an
56
MENTAL WELFARE
Just as at Gheel, a new house is scarcely saleable if it has not the two rooms available for patients. The cost per patient is about 600 guilders a year (which may be compared with other hospitals in Holland, such as Franeker, circ. 760 guilders, and Voorburg, circ. 650 guilders, though the cost at Santpoort is over 1,000 guilders per patient). The guardians are paid 1.25 guilders a day for the first patient, 1.10 for the second and .90 for the third. Furniture, bed and bedding are tobacco and sweets and 5c. provided by the hospital?clothes, pocket money (usually). Paying patients are of two classes and get better accommodation? the first class (10-12 patients) has two rooms, the second class (50-60 patients) An excellent Bath-house is at the hospital (for there are no baths one room. in Beilen) and the patients have weekly baths. During the week-ends the patients are with their guardians?they can go to the church in the village, to the pictures, etc. For the girls there is basket ball, for the men football. There is a pleasing sense of activity and friendliness everywhere and the exceptionally high standard of Dutch homes was observed in every case we visited. In a measure the householders have become part of the staff and they are encouraged to take part in discussions of the principles of care at die hospital. They receive the unannounced visit of doctor and nurse in a way that would surprise the social workers in England who have sometimes to exercise their supervision with marked tact. The staff consists of the Medical Superintendent and an assistant, 25 nurses (only 5 of whom are men), 18 servants and 4 men in charge of the work. There is one nurse who lives at the hospital but works entirely outside and is also responsible for after-care. Dr. Hemmes selects the home, and visits frequently?a weekly visit is paid either by one of the doctors or by the nurse. The type of patient seems to be similar to that of Gheel. The older schizophrenic is considered particularly suitable for this form of care. There are only four children at Beileroord?one a pathological liar attending the village school, two feeble-minded aged 15 and 14, one a recent encephalitis case who had been under observation three weeks and was about to be placed. Among those we were taken to visit were three male patients at a baker's ?one was a psychopath who assisted in the bakery and was paid two or three Three women in a week, one a hysteric, one inclined to be violent. guilders another house were occupied, one at the hospital, one working in the house for the guardian and the other mending stockings for people in the village, for which she earned about half a guilder a week. It is to be observed that the feeble-minded and mentally disordered are frequently placed in the same home?indeed it is claimed that this is a positive advantage as the quieter feeble-minded is a counteracting influence to the more excitable type. Beilen is proud of the hospital in its midst, and the villagers co-operate in helping to protect the patients by informing Dr. Hemmes if they see them wandering away or behaving in an undesirable manner. Vigilance has triumphed over difficulties, and the results have been admirable. It is a proud boast that no illegitimate child has been born during all these twelve years.
MENTAL WELFARE
57
If in this country it were possible to find the right district for such an experiment, and it were begun on a small scale there seems to be no reason to doubt that it would be equally successful, and would prove an excellent of treatment for way many patients who would do less well under hospital restraint. Here again, one would like to emphasise what appears to be a greater willingness to take risks, in regard to mentally disordered patients. It is true that the examples to be quoted are not in connection with boarded out patients but they illustrate this contention. At Santpoort there are two separate wings accommodating respectively 18 men and 18 women, where the patients live practically without supervision and manage their own house," and have their meals sent there, with no nurse in attendance, and being visited once only at night. Somewhat similar arrangements are made, it is true, at Brentry Colony, for some of the mental defectives, but have they been adopted anywhere in this country for mental hospital patients? An even more surprising example was at Franeker (in the hospital there is also a free ward for about twelve men) where a large house about a quarter of a mile away from the hospital on the main road is occupied by about ten women. One is responsible for the housekeeping and for telephoning to the hospital in any emergency; a nurse is in attendance in the morning and at night, but the patients are It was delightful to see the moderateand alone all afternoon evening. entirely sized rooms and two dining rooms with small tables, flowering plants, easy chairs, and a general atmosphere of home. "
"
"
"
Other
Boarding Out Schemes
The
lines
over
country.
out which we were introduced to in other areas was on familiar to us in this country. It was developed however, in close to the parent-hospital and had the advantage which such proximity the more scattered boarding out which is the usual method in this
boarding
more
proximity
gives
"
It may be noted in passing that at Moll-Huttes no less than six hundred had, seven years, been placed out in the surrounding district. We were not in a position really to judge whether the cases we saw boarded out from the mental hospitals were of a different type from those at Gheel and Beileroord, but we incline to think that they approximated more closely to those for whom boarding out is developing in England under the supervision of social workers. At Franeker there was an attempt made some fifty years ago to start boarding out on the lines of Gheel, but the inhabitants objected and the project was dropped. But of recent years, boarding out from the mental hospital has become acceptable, partly owing to the economic difficulties of the inhabitants, who are chiefly occupied in land cultivation or in connection with the canal which intersects the town. There are 512 patients in the hospital; in 1929 there were only six patients boarded out (a beginning being made by placing patients in the homes of some of the nurses) and by 1934 there were 38 (28 of in
MENTAL WELFARE
58
whom were male) and there are many householders awaiting patients. The Medical Superintendent, Dr. Piebenga (who is about to go to another hospital), selects the home, and visits from time to time, and one of the two other doctors gives one afternoon a week to visiting. The payment to guardians is i guilder 25c. for the first patient, 1.10c. for the second, 90c. for the third. Furniture and bedding (clean sheets weekly) are provided by the hospital. The patients have from 5c. to 40c. pocket money weekly. We visited the home of one of the attendants?a beautifully kept house where there lived two women (working at the hospital) and another, where two men lived and had just finished their mid-day meal after working all morning at the Hospital. Their guardian was a chairmaker, but trade was bad and he and his wife were depending for the time on the payments from the hospital. A third man who had been with them had had to be returned to hospital, and they were hoping he would soon be replaced. As at Beileroord, during the week-end the patients remained with their
guardians.
Voorburg
Voorburg in Vught, the methods were reversed. The guardians responsible for giving the patients suitable occupation but they came to the hospital for their weekly baths, and for church and recreation on Sundays. A fine large room was set aside at the hospital entirely for these boarded out men where meals were brought to them, and they played billiards or received their friends. By either method, at Franeker and at Vught contact with the hospital was constant. The costs are about the same as for patients inside the hospital (600 guilders men and a thirty-two women are boarded out: year instead of 650). Fifty the from receive (30c. for men and 25c. for money hospital pocket they women): furniture for the bedroom is provided by the Institution. At
were
The doctor visits once a month, a nurse twice a week. This nurse is not under the control of the Nuns at the Hospital but is appointed by the 's Hertogenbosch town authority to whom Voorburg now belongs. She has to draw a plan of the house of each applicant and give very full details, and the Authority send a visitor before the recommendation is accepted. Two patients were boarded out on a farm?one man aged 55 was feeble-minded, obviously very proud of the cows which he helped to look after, the other was a young man about 26, a dementia praecox patient. One man (also a dementia praecox case) was an inveterate wanderer: his guardian works at the Hospital and the wife was alone with the patient who helps on a small piece of land?as there was another man (also suffering from dementia praecox) in a house not far off who had no desire to run away, they were sent together to the hospital for their Sundays. There was a pleasant girl who had been two years in the home where we visited her: her guardian paid her a little additional pocket money, as she This girl had been was useful to her?there was seven sons in the family.
MENTAL WELFARE
hysterical out
and very troublesome in
patient.
hospital
but gave
59 no
trouble
as a
boarded-
After-Care A word may be said about after-care. At Gheel, the social worker was cases, mostly in Antwerp. At Franeker we had the of some of die cases with one of the doctors who visits opportunity visiting about two hundred patients (15-20 a day, one day a week)?some of whom " " were on trial for one year, and others discharged but kept under some supervision for five years. Nearly all were living with relatives who were cultivating land. It was said at Santpoort that earlier discharge from hospital was definitely possible because of the excellent system of after-care in Amsterdam both for men and women. We visited the workrooms at Amsterdam for men discharged from mental hospitals and the weaving rooms for the women. The standard of work done is very high, and the goods are saleable. Orders are obtained for large quantities?such as five hundred reed mats for one firm. About forty women a day are thus employed, mostly in weaving, and one hundred and five men. They are paid small wages, and the workrooms are
responsible for after-care
self-supporting. To
sum
up the main
impressions
of
our
visit?the
hospitals
were more
cheerful and less formalised than most of those we had visited in this country. Bright curtains, dainty tablecloths, gay paint, growing plants catch the eye. But these are externals?what more than anything impressed us was the
general attitude towards the mental hospital patient who
was not so isolated and cut off from the community as in this country. One can only hope that in England the fuller use of the Mental Treatment Act will encourage a more tolerant attitude and that boarding out will develop.
Gates
LUCY E. BEACH
Central Association
for Mental Welfare
This paper is an attempt to pass on to others the encouragement gained visit by recently paid to selected places in Belgium and Holland to see some of the methods there employed for the care of mental patients boarded out in the community. a
The expenses of the
a donor, whose for mental welfare aware, anonymity concealed, work, who thus enabled Miss Burdett, Secretary of the Suffolk Mental Welfare Association and Miss MacMichael, Secretary of the Devon Mental Welfare Association and myself, to obtain some idea of what can be accomplished for mental patients by treatment carried out extra-murally. We are very grateful for this opportunity, and should like here to express our thanks also to the many workers in Belgium and Holland and also in England, who readily gave us all possible information. Exchange visits are insufficiently frequent between mental health workers on the Continent and in this country, and the general trend towards international co-operation should surely be more evident in this sphere as in others. Be that as it may, we return from our visit with admiration for the way in which certain methods have been tested and have been shown to triumph over the difficulties which appear to many in this country to be insuperable.
journey
we are
were a
generously
very active
met
concern
by
MENTAL WELFARE
50
originally planned as a short visit to the Colonie de Gheel of Gheel, but was extended to include as a modern follower Belgium, in where boardBeilen and other Beilerood at Holland, Stichting hospitals in with treatment. the usual out has been conjunction hospital ing adopted " Etablissement central To be at Gheel, and not to visit the near-by d'observation at Moll-Huttes would have been to miss the chance of seeing that most interesting example of the psychological study and treatment of delinquent behaviour. Some general view of work in Holland we gained by visits to: The large Hospital at Santpoort, already so well-known to many in this country for its outstanding success in organising occupation for its patients: the Willem van den Bergh Stichting at Nordwijk-Binnen, where the small group system is carried out in ideal surroundings for 330 feeble-minded patients, boys and girls of special school and lower grade type, and some adults: a Special Day School at Amsterdam: Child Guidance Clinics at Amsterdam and the Hague: After-Care workrooms for mental patients at Amsterdam. We saw the conditions of boarding out from the main hospitals, as already practised in England, at Vught, and at Franeker?Vught, where the Roman Catholic Psychiatrische Inrichting Voorburg is an example of modern equipment, excellent workrooms, beautiful grounds, and sunny gardens for each ward and a markedly high standard of care given by the Nuns and Brothers; Franeker, with its main building on the site of the 14th century University abolished by Napoleon, and its excellently equipped new two-storied crescentshaped building, and its intensive land cultivation. In our brief survey of community-care certain points struck us in both countries. Our
tour was
"
in
"
"
1.
The attitude
of the -public towards those suffering from mental disorder.
greater tolerance, a recognition of how thin is the line between normal and subnormal or abnormal, a rather amazing absence of fear, and readiness to trust the patient, make the reception of mental patients in the coma matter of remark than in this less country. munity
A
2.
Deficiency Acts and Lunacy Acts. England activities under the Mental Deficiency Act have made the care of the defective in the community more complete perhaps than in any other country. In Belgium and in Holland there is no separate legislation for adult defectives as such; they are alienes just as the mentally disordered the Acts dealing with the dealt with under and can be are alienes," only
Mental In
"
"
"
insane. to see that this has tended to leave many defectives without and attention, but on the other hand it has obviated that deep cleavage in the public mind between mentally defective and mentally disordered patients. Workers in this country are aware that there is considerable fear in the minds of many of receiving into the home anyone who
It is easy
needed
care
MENTAL WELFARE
51
has been in a mental hospital where no such fear is aroused by a patient from a mental defective institution. Until this fear can be lessened it will be difficult to extend the Boarding Out of Mental Hospital patients. 3-
Boarding out as a condition of treatment. Living in the community instead of in hospital
is definitely accepted as the better way in cases where the mental trouble can be dealt with under fairly free conditions. The doctor's sphere of work is not only in the hospital, it is equally in the home, and nothing struck us as more remarkable than the acceptance of this by the doctors. At Gheel, five out of the seven doctors have duties only outside the hospital; at Beileroord, the two doctors work both outside and inside the hospital. These two schemes are, of course, definitely extra-mural, but at other places where boarding out is only part of the general activity of the hospital, the doctor undertakes supervision. Much of this side of the work would be undertaken in this country by the social worker, but it should be emphasised that boarding out is definitely an alternative to hospital conditions for treatment, and the doctors look upon it as such. We were assured that many patients who were most unmanageable in hospital gave no trouble when boarded out. The patient remains a unit of the hospital, and may be coming in and out for work, or for recreation or medical attention. Visits to the home are frequent, to an extent unknown, surely, in this country: by the doctor once a month, by the nurse once or twice weekly. Here such frequent visits would probably be felt excessive both by the guardian and the patient. "
4.
"
boarded out. of visits is probably partly acc6unted for by the degree of illness of boarded out patients. A feeling of confidence must be given to those having difficult patients when they know that the doctor is watching closely over the case and noting any change for the worse, and one cannot help thinking that it is the part played by the doctor that makes it possible to board out patients who in this country would be regarded as unsafe." At present in England boarding out is confined almost entirely, one may say, to those who have become chronic or have almost recovered? for whom treatment has already done all that is possible. One would like to see the Medical Superintendent of one of our hospitals boarding out certain patients (after a period of observation) near to the hospital and being able to visit them as he does patients in the wards.
Type of patient This frequency
"
Some details of the
Colonie
de
This
places
we
visited may be of interest.
Gheel
colony
is
already
well-known
to
many in this country and
a
descrip-
MENTAL WELFARE
52
tion of it was given by Miss Clement Brown in the Mental Welfare Magazine for January, 1933, to which readers are referred for detailed information and
interesting comment. The unique religious origins of the Colony dating from the Dymphne have invested the whole work with a devotional aspect. inhabitants of Gheel
are so
accustomed
to
time of St. The 18,000
the presence of the 3,000
(3,233,
in their midst that their appearance and behaviour
January
1st, 1935) patients excite little remark. It has become almost a hall-mark of respectability to have one or as a rule two, patients living in the home. All guardians must be married couples, and as the number of children per family in Belgium is usually seven or eight, a very large proportion of the households are concerned in the work. Such is the eagerness of die inhabitants to be guardians, that no newcomers to the town are accepted on the waiting list. At the time of our visit there were already about 100 approved applicants on the list, and had additional been received between the first of January applications 148 and April, 1935. The growth of the Colony may be studied on an interesting chart. In the middle ages the number of patients appears to have been about 300. In 1805 there were known to be about 600; and from 1875 exact records have been kept (it may be of interest to mention that in that year Charles Dickens his admiration of the Colony in an article entitled The crazy expressed " In in All round there were the "). year 1908 1,291 patients and colony with the exception of a heavy decline about 1915 owing to the death-rate from influenza the numbers have steadily increased, and of late years have been round about 3,000. The Colony was under the Church up to 1789, when it was taken over by the Province of Antwerp up to i860, at which date it was transferred to the State under the Ministere de la Justice. Many private cases (some foreigners) are admitted: they pay higher rates to the guardians and a percentage to the Hospital. There are about 600 Dutch patients (sent by public authorities) admitted at a rate slightly lower than the It was interesting to note that the reason rate of the ordinary private case. for so many Dutch patients was said to be that the standard of Dutch Hospitals had become so high: a certain number of authorities therefore sent their patients to Gheel, where the cost of maintenance was about one-third. Not infrequently, we were told, Belgian, Dutch or German patients are placed in a foreign hospital as their relatives are glad to have the frontier between them! The minimum charge to private patients is about 13 francs a day (one American pays nearly three times that amount) to the guardian, plus 16% to the hospital. The general rate is 7.50 a day. Of this, 5.50 goes to the guardian for a patient who can work for him, 6.40 for a patient who cannot work but is easy to manage, and 7.75 for a difficult patient (which represents a loss of 25c. to the hospital). Clothes and medicine are provided by the hospital. A normal person who required accommodation would pay about 10 to 20 francs a day (the agricultural wage being from 25-30 francs a day), so that it will be noted that as in England, people are found to accept patients at a somewhat lower rate than they would the ordinary lodger. The accommodation selected "
"
MENTAL WELFARE far
53
possible in accordance with the usual style of living of the patient. Every patient must have a bedroom alone. There are no baths in the houses, and at present it is only possible to arrange a bath a month for each patient at the bath houses established in the four districts of the Colony. The Colony has a certain number of cases under 21 (usually about 50) and the rate for those who can work is 8 francs a day (of which 6.50 goes to the guardian, 1.25 to the Hospital and 25c. is set aside to be given to the patient on attaining 21 years). For other children the rate is 7 francs a day, of which 25c. goes to the hospital. There is a small school for the children managed by the hospital where they are taught until 14 (the general school leaving age in Belgium is 12). Figures taken out in 1922 showed that out of 446 children, 148 had returned to the community and were self-supporting. Patients come to the hospital on the certification of one doctor, and after observation in hospital for five days, the certificate must be confirmed. During the last seven or eight years, a certain number of uncertified private cases have been received but certification is general. Dr. Sano accepts all patients but is as
as
after observation has to return some and it appears there is a certain amount of wasted effort, as people will not realise the necessary limitations for such conditions of freedom, and we understood that, except at Brussels and Antwerp, there are no observation wards for previous selection. Patients find their occupation where they are placed, on the land or in the house or in the shop. There is very little recreation or entertainment organised by the hospital. Under the charge of a Committee some handicraft is being encouraged?patients may obtain material for basket work, embroidery, etc., and there is an exhibition of work annually, each patient being allowed to keep the proceeds of the sale. For the Dutch patients there is a Protestant Church; and a special Club Room attached to the Hotel l'Agneau. The supervision of the patients is carried out by the doctors, each of whom has two nurses attached to his district. The number of patients to each doctor is in accordance with conditions of access, etc.?two of the doctors have 700 patients each, while one doctor is responsible for the children. Bicycles, not motor cars, are used, and each patient is visited by the doctor every month and by the nurse every week. There is a trained social worker but her time is almost entirely taken up with after-care work outside the Gheel area. One doctor is in charge of the hospital, and here there is accommodation for too patients, but in practice there are seldom more than 50; of these, some are under observation, some recalled temporarily to hospital, some requiring some transfer as unsuitable, a few who have treatment, physical awaiting become chronic or are nearing the end.. At the time of our visit a powerful man who had become violently maniacal had been brought to hospital, was deemed unfit to be placed out again, and would be transferred to an ordinary mental Hospital. A feeble-minded girl living in one of the outlying hamlets of Gheel was brought into hospital for physical treatment. Dr. Sano had warned the guardian that she would be fetched some day: when he arrived at the farm with the ambulance the girl was sorting potatoes in the potatoto was and and then. A man about 30 was in there brought hospital heap,
MENTAL WELFARE
54
for a temporary period. He was a remarkably clever maker of he had strong obsessions which changed about every three months?he imagined himself to be Christ and cut stigmata on his body?or a Russian officer and made himself the complete uniform. At the present time while with his guardian he had become obsessed by the idea that his guardian's little girl was his sister and he wished to take her about with him everywhere. When this obsession had passed, another guardian would be again found for him. Typical cases in the homes were the following:
hospital mats:
(a) (b)
feeble-minded girls working at a small farm in an outGheel. of hamlet lying A painter (private patient) who had two rooms?one as a studio where he painted not very pleasing pictures for which he would only ask exorbitant prices: and in the same house, a mentally defective boy about 18.
Two
low-grade
A feeble-minded
girl about 20 who had been born to a patient who arrived confusional state. The mother died, and the guardian brought up the child, who proved to be mentally defective and was educated at the Hospital School and had become fairly useful, able to help in the house and small shop. (d) A strong-looking man about 32 who chose to spend his time chiefly in taking walks of about 10 miles a day. While we sat in the inn in the main square one evening, a man about 30 walked up and down beneath the window monotonously for about two hours, even though it was already dark. No one took any notice of him. The recovery rate is not high, as many of the patients sent to Gheel are chronic. A natural question is, do the patients abuse such freedom? It is admitted that many mental patients would be totally unsuitable. But for those at Gheel, where the whole community is friendly towards them, the records show that on the whole it is justified. Violence there has been, and injury inflicted, but in all the years since 1875 there has been no fatal result and it is claimed that on the average there has not been more than one illegitimate child born a Some patients abscond but are frequently returned, and on the whole year. this does not present a great problem. (c)
at
Gheel in
a
Beileroord Some have thought it would not be possible to establish a colony on the lines of Gheel if there were no long tradition behind it. But the same principles have been carried out for some fifty years in France at Dun-sur-Auron and Ainay-le Chateau, some descriptions of which have already been given by Sir Lawrence Brock and Miss Fox, and we understand that at Lierneux, the province of Liege established a Colony about 1895 for some 800 patients, but this has developed on somewhat different lines,
MENTAL WELFARE
55
Beileroord is a modern example, with excellent hospital accommodation adjunct to the boarding out of some 338 patients. The present Medical Superintendent (Dr. Hemmes) inclines to think that 400?450 is perhaps the ideal limit. Stichting Beileroord belongs to the three provinces of Friesland, Groningen and Drenthe, but patients are received from any part of Holland. It is situated in the small town of Beilen with a population of about 8,000, most of whom are engaged in the cultivation of the land. The work began in 1922, when eight patients were placed in a house no longer required for the Burgomaster, with three nurses responsible for their care. From these small beginnings has grown the present boarding out organisation. The hospital has two separate buildings, one for certified, and the other for uncertified patients built four years ago?long low buildings of delightful architecture, with excellent gardens and fields and small sunny wards and work rooms. There is accommodation for 78 patients. The observation period may be two to three weeks or even six months, and a few patients are permanently in hospital, having become too infirm, such as an old woman of ninety who had been in family care for ten years. The principle of freedom is the same as at Gheel, but the hospital stands for the centre of activity as well as for the reception of patients. For whereas at Gheel patients work in and around the house they are living-in, at Beileroord the great majority of them work at the hospital, either on the land or in the workrooms busy at mattress-making (with alpen grass), bookbinding, weaving, tailoring repairs, and the usual occupations. A splendidly built garage, and sun-parlours for two of the wards were the work of patients. One man? a mental defective, who had threatened his family with an axe?had as his particular occupation the chopping of logs for the hospital fires, and very proud he was to show the really enormous pile of wood he had prepared. Organised activity is dius the linch-pin of the whole. Only about a dozen patients boarded out are unable to do anydiing. The Medical Superintendent and his assistant see most of the patients daily, and the advantages of this arrangement are apparent. There are some patients working away from hospital for their guardians and seven men have their own little businesses, selling flowers and potatoes and vegetables from door to door. The general attitude to the hospital is the same as at Gheel: there are always keen applicants for patients and at the time of our visit there were 50 approved homes but no patients on the waiting list. (We were told that the boarding out idea had not yet been fully accepted by all public bodies in Holland.) Even troublesome cases could be placed without difficulty. One girl had recurring maniacal periods. She had been in 20 different homes, and after a stay in hospital had just been placed out again?this time with fresh applicants who were most anxious to be on the books of the hospital. The guardian of two old women about seventy-five needing pretty constant care and attention to habits had recently died and they were placed without delay with a young woman who had just lost her husband?one had obsessions, the other was an epileptic. Their home was a sunny newly-built house with gay colours and the lovely flowering plants one sees in almost every Dutch house. as an
56
MENTAL WELFARE
Just as at Gheel, a new house is scarcely saleable if it has not the two rooms available for patients. The cost per patient is about 600 guilders a year (which may be compared with other hospitals in Holland, such as Franeker, circ. 760 guilders, and Voorburg, circ. 650 guilders, though the cost at Santpoort is over 1,000 guilders per patient). The guardians are paid 1.25 guilders a day for the first patient, 1.10 for the second and .90 for the third. Furniture, bed and bedding are tobacco and sweets and 5c. provided by the hospital?clothes, pocket money (usually). Paying patients are of two classes and get better accommodation? the first class (10-12 patients) has two rooms, the second class (50-60 patients) An excellent Bath-house is at the hospital (for there are no baths one room. in Beilen) and the patients have weekly baths. During the week-ends the patients are with their guardians?they can go to the church in the village, to the pictures, etc. For the girls there is basket ball, for the men football. There is a pleasing sense of activity and friendliness everywhere and the exceptionally high standard of Dutch homes was observed in every case we visited. In a measure the householders have become part of the staff and they are encouraged to take part in discussions of the principles of care at die hospital. They receive the unannounced visit of doctor and nurse in a way that would surprise the social workers in England who have sometimes to exercise their supervision with marked tact. The staff consists of the Medical Superintendent and an assistant, 25 nurses (only 5 of whom are men), 18 servants and 4 men in charge of the work. There is one nurse who lives at the hospital but works entirely outside and is also responsible for after-care. Dr. Hemmes selects the home, and visits frequently?a weekly visit is paid either by one of the doctors or by the nurse. The type of patient seems to be similar to that of Gheel. The older schizophrenic is considered particularly suitable for this form of care. There are only four children at Beileroord?one a pathological liar attending the village school, two feeble-minded aged 15 and 14, one a recent encephalitis case who had been under observation three weeks and was about to be placed. Among those we were taken to visit were three male patients at a baker's ?one was a psychopath who assisted in the bakery and was paid two or three Three women in a week, one a hysteric, one inclined to be violent. guilders another house were occupied, one at the hospital, one working in the house for the guardian and the other mending stockings for people in the village, for which she earned about half a guilder a week. It is to be observed that the feeble-minded and mentally disordered are frequently placed in the same home?indeed it is claimed that this is a positive advantage as the quieter feeble-minded is a counteracting influence to the more excitable type. Beilen is proud of the hospital in its midst, and the villagers co-operate in helping to protect the patients by informing Dr. Hemmes if they see them wandering away or behaving in an undesirable manner. Vigilance has triumphed over difficulties, and the results have been admirable. It is a proud boast that no illegitimate child has been born during all these twelve years.
MENTAL WELFARE
57
If in this country it were possible to find the right district for such an experiment, and it were begun on a small scale there seems to be no reason to doubt that it would be equally successful, and would prove an excellent of treatment for way many patients who would do less well under hospital restraint. Here again, one would like to emphasise what appears to be a greater willingness to take risks, in regard to mentally disordered patients. It is true that the examples to be quoted are not in connection with boarded out patients but they illustrate this contention. At Santpoort there are two separate wings accommodating respectively 18 men and 18 women, where the patients live practically without supervision and manage their own house," and have their meals sent there, with no nurse in attendance, and being visited once only at night. Somewhat similar arrangements are made, it is true, at Brentry Colony, for some of the mental defectives, but have they been adopted anywhere in this country for mental hospital patients? An even more surprising example was at Franeker (in the hospital there is also a free ward for about twelve men) where a large house about a quarter of a mile away from the hospital on the main road is occupied by about ten women. One is responsible for the housekeeping and for telephoning to the hospital in any emergency; a nurse is in attendance in the morning and at night, but the patients are It was delightful to see the moderateand alone all afternoon evening. entirely sized rooms and two dining rooms with small tables, flowering plants, easy chairs, and a general atmosphere of home. "
"
"
"
Other
Boarding Out Schemes
The
lines
over
country.
out which we were introduced to in other areas was on familiar to us in this country. It was developed however, in close to the parent-hospital and had the advantage which such proximity the more scattered boarding out which is the usual method in this
boarding
more
proximity
gives
"
It may be noted in passing that at Moll-Huttes no less than six hundred had, seven years, been placed out in the surrounding district. We were not in a position really to judge whether the cases we saw boarded out from the mental hospitals were of a different type from those at Gheel and Beileroord, but we incline to think that they approximated more closely to those for whom boarding out is developing in England under the supervision of social workers. At Franeker there was an attempt made some fifty years ago to start boarding out on the lines of Gheel, but the inhabitants objected and the project was dropped. But of recent years, boarding out from the mental hospital has become acceptable, partly owing to the economic difficulties of the inhabitants, who are chiefly occupied in land cultivation or in connection with the canal which intersects the town. There are 512 patients in the hospital; in 1929 there were only six patients boarded out (a beginning being made by placing patients in the homes of some of the nurses) and by 1934 there were 38 (28 of in
MENTAL WELFARE
58
whom were male) and there are many householders awaiting patients. The Medical Superintendent, Dr. Piebenga (who is about to go to another hospital), selects the home, and visits from time to time, and one of the two other doctors gives one afternoon a week to visiting. The payment to guardians is i guilder 25c. for the first patient, 1.10c. for the second, 90c. for the third. Furniture and bedding (clean sheets weekly) are provided by the hospital. The patients have from 5c. to 40c. pocket money weekly. We visited the home of one of the attendants?a beautifully kept house where there lived two women (working at the hospital) and another, where two men lived and had just finished their mid-day meal after working all morning at the Hospital. Their guardian was a chairmaker, but trade was bad and he and his wife were depending for the time on the payments from the hospital. A third man who had been with them had had to be returned to hospital, and they were hoping he would soon be replaced. As at Beileroord, during the week-end the patients remained with their
guardians.
Voorburg
Voorburg in Vught, the methods were reversed. The guardians responsible for giving the patients suitable occupation but they came to the hospital for their weekly baths, and for church and recreation on Sundays. A fine large room was set aside at the hospital entirely for these boarded out men where meals were brought to them, and they played billiards or received their friends. By either method, at Franeker and at Vught contact with the hospital was constant. The costs are about the same as for patients inside the hospital (600 guilders men and a thirty-two women are boarded out: year instead of 650). Fifty the from receive (30c. for men and 25c. for money hospital pocket they women): furniture for the bedroom is provided by the Institution. At
were
The doctor visits once a month, a nurse twice a week. This nurse is not under the control of the Nuns at the Hospital but is appointed by the 's Hertogenbosch town authority to whom Voorburg now belongs. She has to draw a plan of the house of each applicant and give very full details, and the Authority send a visitor before the recommendation is accepted. Two patients were boarded out on a farm?one man aged 55 was feeble-minded, obviously very proud of the cows which he helped to look after, the other was a young man about 26, a dementia praecox patient. One man (also a dementia praecox case) was an inveterate wanderer: his guardian works at the Hospital and the wife was alone with the patient who helps on a small piece of land?as there was another man (also suffering from dementia praecox) in a house not far off who had no desire to run away, they were sent together to the hospital for their Sundays. There was a pleasant girl who had been two years in the home where we visited her: her guardian paid her a little additional pocket money, as she This girl had been was useful to her?there was seven sons in the family.
MENTAL WELFARE
hysterical out
and very troublesome in
patient.
hospital
but gave
59 no
trouble
as a
boarded-
After-Care A word may be said about after-care. At Gheel, the social worker was cases, mostly in Antwerp. At Franeker we had the of some of die cases with one of the doctors who visits opportunity visiting about two hundred patients (15-20 a day, one day a week)?some of whom " " were on trial for one year, and others discharged but kept under some supervision for five years. Nearly all were living with relatives who were cultivating land. It was said at Santpoort that earlier discharge from hospital was definitely possible because of the excellent system of after-care in Amsterdam both for men and women. We visited the workrooms at Amsterdam for men discharged from mental hospitals and the weaving rooms for the women. The standard of work done is very high, and the goods are saleable. Orders are obtained for large quantities?such as five hundred reed mats for one firm. About forty women a day are thus employed, mostly in weaving, and one hundred and five men. They are paid small wages, and the workrooms are
responsible for after-care
self-supporting. To
sum
up the main
impressions
of
our
visit?the
hospitals
were more
cheerful and less formalised than most of those we had visited in this country. Bright curtains, dainty tablecloths, gay paint, growing plants catch the eye. But these are externals?what more than anything impressed us was the
general attitude towards the mental hospital patient who
was not so isolated and cut off from the community as in this country. One can only hope that in England the fuller use of the Mental Treatment Act will encourage a more tolerant attitude and that boarding out will develop.
