Mental illness has been part of human society throughout recorded history, but how we care for people with mental disorders has changed radically, and not always for the better.

In Colonial days, settlers lived in sparsely populated rural communities where sanctuary and community support enabled the tradition of family care brought from England. “Distracted persons” were acknowledged, but erratic behavior wasn’t associated with disease.

Records indicate unusual tolerance of bizarre behavior. When 18th century Pastor Joseph Moody of York, Maine, unable to face crowds, delivered sermons with a handkerchief covering his face, his behavior was tolerated for three years before he was relieved of his duties.

As urban areas grew in size and number, a transient poor population with no access to family support led to almshouses, the first form of institutionalization, inspired by 18th century reforms in Europe.

A Philadelphia Quaker who had visited an English retreat brought the idea to this country and in 1817 founded the Friends Asylum, a self-sufficient farm that offered a stress-free environment known as “moral treatment.” Other private asylums followed, but they soon became overcrowded. By the late 19th century, this was addressed with larger state hospitals, which soon became overcrowded as well.

People with mental disorders are more likely to be stigmatized owing to fear and misunderstanding when they aren’t part of the community. And stigmatization can discourage those with a mental disorder from seeking or complying with treatment. It also can lead to people being institutionalized against their will, more to protect the public than to provide compassionate care for those with mental illness.

In the mid-1950s, new antipsychotic medications offered relief from some of the most disabling symptoms of schizophrenia and other major disorders, such as psychosis and hallucinations. And in 1963, President John F. Kennedy’s Community Mental Health Act shifted funding from large state hospitals, which had been plagued by scandal, to small-scale community-based mental health centers. With deinstitutionalization, the inpatient population dropped from over half a million in 1955 to about 60,000 by the end of the century.

By 1977, federally funded centers were serving close to 2 million people a year in 60 community mental health facilities. But the law was never adequately funded, and a national standardized system of community care did not emerge. As a result, people began to associate mental illness with homelessness or acts of violence, though the vast majority of people with mental illness pose no threat.

That raises the question of whether it’s possible to reduce stigma so that those with a mental disorder are not feared and shunned. Patrick Corrigan, director of the National Consortium on Stigma and Empowerment, has investigated three approaches to reducing stigma: protest, education and contact.

In one study, subjects received information regarding mental illness in the context of the three approaches. Statements meant to induce a sense of moral outrage protest produced no stigma reduction. Both education and contact with someone known to have a mental illness did produce significant changes in attitude — less blame toward persons with mental illness and greater confidence in their chance of recovery — and encouraged future contact with those known to have mental illness. Previous contact mitigated lingering stereotypes more than education.

To get a sense of how it is possible for community members to have contact with those with mental illness without inciting stigma and fear, it helps to take a look at present-day communities where that happens. For centuries, in Geel, Belgium, community contact has been an everyday event for those with mental illness, with the state paying families to care for “boarders” in their homes. Modern-day Geel combines community care with medical care and psychotherapy, as well as hospitalization if needed. (For more modern-day Geel, see Invisibilia‘s story here.)

In the United States, variations in state funding affect the quality of public mental health care. But dozens of programs offer evidence that it is possible to build sustainable fostering communities.

Gould Farm, a working farm established in Monterey, Mass., in 1913, was the first modern-day residential therapeutic community in the U.S. Here patients are referred to as guests, and all staff — and their families — live on the farm. Daily work, on the farm or at its bakery or cafe, is a key aspect of the therapy.

Today Gould Farm is one of more than 30 members, in 15 states, of the American Residential Treatment Association. These programs are not covered by Medicare or Medicaid, but some ARTA members help families secure financing; health insurance may cover part of the cost. For example, more than 50 percent of Gould Farm “guests” receive financial assistance. But, for the most part, people must assume the expense of a six- to 12-month stay, ranging from $400 to $900 per day.

In Chicago, the Thresholds organization offers services to people with mental illness in more than 100 locations in the city and surrounding counties. It was founded in 1959, by women from Chicago’s National Council of Jewish Women who attended a mental health educational conference and learned that people who had spent years in mental hospitals were often left to fend for themselves upon release. It started as a small volunteer organization that offered social activities, then grew to include residential programs, supported employment, housing-first, and treatment for people with both mental diagnoses and substance disorders. Last year, 75 percent of its services were delivered in the community.

Thresholds is one of 15 programs I’ve visited across the United States in decades of researching models of community care in mental health. Those 15 are a small sample of programs of varying sizes that offer affordable housing or help in finding such housing; occupational training and placement; recreational opportunities and more.

Those with a mental disorder can live a meaningful life, if their community facilitates community contact. It’s been happening in Geel for centuries. It is happening in the U.S. today. The voice of stigma originates in the community, but so does the voice of hope.

Jackie Goldstein is a professor emeritus of psychology at Samford University and author of the 2016 book Voices of Hope for Mental Illness: Not Against, With.

This story is part of Invisibilia‘s episode on solutions, including a report on how residents of the town of Geel, Belgium, have been taking in strangers with mental illness as boarders for centuries. We also talked with Mr. Kitt, who found sobriety and his calling as an artist after he moved off the streets into a Broadway Housing Communities apartment in New York. And NPR reporters Pam Fessler and Nate Rott visit community housing sites on the East and West coasts that aim to provide sanctuary, not just shelter.

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Lisa Lynn Kotnik has been a singer on the New Orleans club circuit for more than 15 years.

“I sang at Fritzel’s for eight years,” she says. “I sang at the Bombay Club for 15 years, I sang at Margaritaville — the list could go on and on and on.”

While Kotnik sings to revelers at night under the stage name Lisa Lynn, in the daytime she’s battled health problems — fibroids, ovarian cysts, a hysterectomy and even a brain aneurysm.

“So, I’ve had a lot of surgeries,” she says. She counts at least five.

And like many of her fellow musicians, Kotnik has never really had health insurance. Her income as a singer is tenuous and fluctuates with the seasons, so insurance has always just been too expensive, she says.

But not anymore.

Kotnik was at the New Orleans Musicians Clinic recently signing up for Medicaid.

Hundreds of thousands of Louisiana’s working poor have health insurance as of July 1 because the state has expanded its Medicaid program, as allowed under the Affordable Care Act. The new insurance benefits Kotnik and many of the other performers and workers who serve the millions of tourists visiting New Orleans every year.

That’s also good news for the New Orleans Musicians Clinic, which has provided health care to the city’s musicians and artists for decades, mostly for free.

The clinic, decorated with vintage Jazz Fest posters and signed photos of musicians like Harry Connick Junior and James Booker, is located on historic St. Charles Street in a building that also hosts doctors and clinics affiliated with Louisiana State University.

But it’s funded mostly by philanthropists, and its services, until now, have been limited.

In the past, Kotnik could see doctors at the clinic; but if she needed a blood test or ultrasound scan, she had to go across town to University Hospital, and potentially wait hours for what in Louisiana is called charity care.

“We have all that in this facility, but it wasn’t covered,” explains Megan McStravick, a social worker at the musicians clinic who helps people like Kotnik get the care they need.

Prescriptions also weren’t covered, so McStravick would spend hours working with drug companies to get her low-income patients the medications they need for free.

Medicaid changes the terms of coverage — and that’s a big deal for the state’s health secretary, Dr. Rebekah Gee.

“These are our heroes,” Gee tells Shots. “These are our local New Orleans heroes — our musicians are the fabric of our community.”

Musicians, restaurant workers and hotel workers are the backbone of much of Louisiana’s tourist economy, she says.

“People love to come to Louisiana, they love to eat our food, hear our music and stay in our hotels,” she says. “Because those jobs are not high income, we have a huge workforce that was uninsured.”

Moving all those people into the Medicaid program has been a huge task.

The poorest and least healthy state in the U.S., Louisiana is now the 31st state to join the Medicaid expansion, and the first in the Deep South to embrace this sliver of Obamacare.

It’s a big turnaround for this Republican state. Bobby Jindal, the former governor, loudly opposed expanding the government program and the state’s Republican-dominated legislature went along with him.

But last fall, a new Democratic governor, John Bel Edwards, was elected after campaigning specifically on expanding Medicaid.

His election, combined with a huge budget crisis, convinced many state officials to embrace the program because Edwards made the case that it would save money by handing over health care costs to the federal government.

“The Medicaid expansion was something that I believed in and I knew it would save money,” Edwards says. “It no longer was optional, because we had to implement every cost saving measure that we could.”

Still, Gee faced a big challenge because the state legislature refused to allocate any money to hire people to sign people up for Medicaid.

“The idea of having more state employees at a time when we were cutting the budget by $3 billion — there just was not an appetite for it,” she says.

It fell to Gee to figure out, without any new help, how to sign up the estimated 375,000 people who were eligible.

“I said to my husband, ‘Gosh, we can maybe get a couple of cards into people’s hands by July, but I have no idea how we’re going to get this done,” she recalls.

So Gee turned to other programs that work with the poor. Anyone who gets food stamps was automatically qualified for Medicaid. And anyone who had been in earlier state health plans for the poor was automatically signed up.

She says she hopes other states in the region will follow Louisiana’s lead.

“We are an island amongst a sea of states that haven’t expanded,” she says. “We are hoping to lead the charge here.”

But insurance is only the start, Gee says.

“Our major challenge is to transform this state from the most unhealthy state in the nation to a state that has a healthy future,” she says.

For people like Lisa Lynn Kotnik, the Medicaid card is at least a start.

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At the center of Geel, a charming Belgian town less than an hour’s drive from of Antwerp, is a church dedicated to Dymphna, a saint believed to have the power to cure mental disorders. It’s a medieval church with stone arches, spires and a half-built bell tower, and it has inspired an unusual centuries-old practice: For over 700 years, residents of Geel have been accepting people with mental disorders, often very severe mental disorders, into their homes and caring for them.

It isn’t meant to be a treatment or therapy. The people are not called patients, but guests or boarders. They go to Geel and join households to share a life with people who can watch over them. Today, there are about 250 boarders in Geel. One of them is a Flemish man named Luc Ennekans. He’s slim and has green eyes, and he’s 51 years old. NPR’s Lulu Miller went to Geel and met him and his host family there and reported this story for Invisibilia.

Like all of the guests in the town today, Ennekans first went to a public psychiatric hospital in Geel that manages the boarder program. Ennekans saw medical professionals and received treatment and an evaluation. Then he was paired with a household. His hosts, Toni Smit and Arthur Shouten, say that living with Ennekans was rough at the start.

Ennekans became deeply attached to Smit. “If it were up to Luc, he would be hugging and kissing me all day,” Smit says. He showered her with such affection, bringing her flowers, little kisses, linking arms with her on walks, that it began to interfere with Smit and Shouten’s marriage. “You couldn’t even give each other a hug or Luc is standing behind us,” Shouten says. Wrinkles like this are common, according to the couple. They’ve had six boarders over the years, each with a unique set of challenges.

One boarder used to lock Smit and Shouten out of the bathroom to furiously wash his hands, and another used to struggle to sleep because he saw lions coming out of the walls. “He was really dementing,” Smit says. But that doesn’t affect the way they see their boarders. Like many hosts in Geel, they accept that this is simply who their boarders are. It’s not abnormal or something they need to change. “It’s just normal life,” Shouten says.

That acceptance of mental differences has become something of a tradition in Geel. It’s at the heart of the boarder program, and some observers think it’s also responsible for the system’s success. Around the world, many different experiments have been attempted over the centuries to provide humane care for people with mental illness and mental disabilities. Geel is one that has endured.

Residents of Geel have not only accepted the eccentric or disruptive behaviors of the boarders but have come up with creative ways to help boarders and residents manage them, says Ellen Baxter, the founder of Broadway Housing Communities, a nonprofit in New York City. It is partially inspired by Geel, which Baxter visited as a young woman.

For example, when Ennekans became too jealous or attached to Smit, Shouten and Smit encouraged him to find a girlfriend or other companionship. When their former boarder hallucinated lions coming through the walls, Smit would pretend to chase the lions away. “And that would work every time,” Smit says.

Shouten and Smit receive a stipend from the Belgian government for taking care of Ennekans, as well as training and support from psychiatric professionals. Hospitalization is available if needed. Several studies have found that the incidence of violence by boarders is low; people who have previously exhibited violent behavior are usually not admitted to the program.

The integration of people with mental disorders into Geel society has fascinated scholars for centuries. In 1862, Dr. Louiseau, a visiting French doctor, described it as “the extraordinary phenomenon presented at Geel of 400 insane persons moving freely about in the midst of a population which tolerates them without fear and without emotion.” Nearly 100 years after that, an American psychiatrist named Charles D. Aring wrote in the journal JAMA, “The remarkable aspect of the Gheel experience, for the uninitiated[,] is the attitude of the citizenry.”

Early psychiatrists who observed Geel noticed that the treatment prescribed for mental patients was, in fact, no treatment at all. “To them, treating the insane, meant to simply live with them, share their work, their distractions,” Jacques-Joseph Moreau wrote in 1845. He and others advocated for that communion. “In a colony, like in Geel, the crazy people … have not completely lost their dignity as reasonable human beings.” In the next half-century, many would uphold Geel’s model as the best standard of practice for mental disorders.

How Geel came to be this way begins with the town’s devotion to St. Dymphna, whose church stands in the center of town. According to legend, Dymphna was a 7th-century Irish princess who fled to Geel from a maddened father and devoted her life to serving the mentally disabled. But she became a martyr when her father discovered her location and traveled to Geel to behead her.

The town built St. Dymphna’s church in the 14th century to honor the saint and enshrine her supposed remains. It became a popular pilgrimage site for people across Europe, who would bring loved ones to the shrine in the hopes of finding relief from their mental distress.

By 1480, the town had built a small hospice on the side of the church to accommodate pilgrims, but the shrine became so popular that the pilgrims overwhelmed the annex’s capacity. “Sometimes the families would return home and leave their uncured relatives in the hospice,” says Mike Jay, a historian of psychiatry and curator for the Wellcome Collection in London, who has studied Geel. “So local people began taking them in as guests or boarders, as they call them.”

The early practice was often mutually beneficial for both the hosts and the boarders, Jay says. Many Geel residents were farmers, and boarders offered a source of labor. In exchange, the boarders got stable housing and a family life. But the integration was not always a happy one. There are stories of abuse, Jay says. “One of the laws was that if a boarder committed a crime, it was the fault of the family. If you had a boarder who was difficult, then some of the families would resort to keeping them chained or restrained.”

As medical treatment for the mentally ill evolved, so did Geel. In the 19th century, a central medical establishment was set up that provided standard medical and psychiatric care to boarders and other residents. But this was at the same time that large insane asylums were considered the most advanced, scientific form of care. Geel became the source of a great debate in psychiatry. “It was a polarizing example,” Jay says. “Some people regarded Geel as a sad remnant of old medieval culture where people were left to toil in the field and never given therapy and no chance of recovery.”

Other early observers noted the same things that Baxter and other more recent visitors have: By and large, people in Geel were happy. “One of the agreeable features is the general contentment manifested by the insane,” wrote John Sibbald, a Scottish psychiatrist, in 1861.

By the turn of the 20th century, the International Congress of Psychiatry had declared Geel an example of best practice to be copied elsewhere. The program continued to be a source of local pride, and it grew. At the program’s peak in 1930, about 4,000 boarders resided in Geel — a quarter of the town’s population.

Over time, Jay says, boarders had become such a part of life and society that distinctions between them and nonboarders blurred. And with that, “a lot of the problems we associate [with mental illness] kind of fade away,” Jay says. “Like trying to navigate a world full of kind of normal people who don’t understand what’s going on and aren’t tolerant towards it.”

There are a few important criteria for acceptance into the Geel program. The program typically selects patients with severe mental illness or cognitive disabilities who have difficulty living independently. In 2003, almost half of the town’s 516 boarders had a cognitive disability, and over 20 percent carry a diagnosis of schizophrenia or other psychotic disorder, according to research by Jackie Goldstein, a professor emeritus of psychology at Samford University. Some boarders have traditionally had other conditions such as learning disabilities or autism.

While scholarship of Geel is rich with observation, there remain few long-term, empirical studies on how these patients do in the system. “The successes and shortcomings of Geel’s system of foster family care had never been thoroughly or systematically examined,” Goldstein noted in a speech presented at the American Psychological Association Annual Convention in 1998. In the 1960s, researchers embarked on a 10-year project studying Geel that Goldstein took part in, but it never reached completion.

Goldstein continued studying Geel throughout her life, and some of her work shows that boarder life is stable. Boarders tend to stay in family care for years. In some cases, when boarders’ caretakers grow too old or die, they continue to live with their caretakers’ children. In 2005, nearly a third of boarders lived in a foster home for more than 50 years.

But the centuries-old custom has been shrinking. The number of boarders has fallen to roughly 250 today, less than 7 percent of its prewar peak. Eugeen Roosens, a Belgian psychiatrist, and Lieve Van De Walle, a former director for rehabilitation in Geel, write, “the time of extended farmer families, who could do with a helping hand, is gone,” in their book, Geel Revisited: After Centuries of Mental Rehabilitation.

There are possible reasons for the program’s decline besides the time and professional pressures of modern life. There may be fewer patients who need supported living thanks to improved psychiatric medication, which might contribute to fewer referrals to the program. Roosens and Van De Walle also note the program lacks enough funding to cover the cost of a boarder. The Belgian government pays 40 euros (less than $45) per boarder per day to support the practice, less than half of which goes to the foster family to cover living expenses.

Still, the tradition persists, in large part because Geelians are proud of it. In a 1962 survey of Geel foster families, American psychiatrist Matthew Dumont found that their main reason for accepting boarders was custom. Roosens and Van De Walle describe the program as part of Geel’s heritage. It’s part of the town’s identity. But, they write, that may not be enough to sustain the program.

With reporting by Lulu Miller.

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