Geel family foster care

1. Introduction

Version followed: psychiatric family care (psychiatrische gezinsverpleging) as run today by OPZ Geel (Openbaar Psychiatrisch Zorgcentrum, the public psychiatric care centre in Geel, Belgium). It is described in OPZ's brochure Gezinsverpleging: zorg van velen (L. Van de Walle, director of the Rehabilitation division; undated) and in OPZ's reform text Een nieuwe toekomst voor psychiatrische gezinsverpleging (target-group teams from spring 2011, F-ACT mobile teams). The 2022 Psyche interview with OPZ psychologist Wilfried Bogaerts fills some gaps. Older accounts (Bradshaw 2009; NPR 2016) are used only for details the OPZ texts leave out, and are dated where used.

What it is. Geel family care is a service model and a community tradition, not a psychotherapy. People with long-term psychiatric illness, often with intellectual disability, live as paid guests in ordinary local households. Older English texts call them "boarders"; OPZ now says "client" or pleeggast. A multidisciplinary psychiatric team supports each placement, with a 24-hour on-call service and inpatient beds behind it. NPR (2016) reports that the programme does not present itself as a treatment or therapy. [source: Van de Walle, Zorg van velen; Chen 2016, NPR]

History in brief. The practice grew out of the medieval pilgrimage to the shrine of St Dymphna, which involved a nine-day ritual (noveen). When the church was full, townspeople were asked to take pilgrims into their homes. Guests who stayed became part of the family, and hosting passed down through the generations. In 1851 the State Colony of Geel for free family care was founded, and the whole municipality was recognised as a "hospital" under the Lunacy Act. In 2023 UNESCO selected the safeguarding of this practice for its Register of Good Safeguarding Practices. [source: Van de Vel 2022, Psyche; UNESCO 2023]

Scale. There were about 3,000–4,000 guests in the 1930s, about 516 in 2003, about 400 in 2009 and about 250 in 2016. A recent Belga report gives about 135 adult guests and about 12 children and adolescents. [source: Bradshaw 2009; Chen 2016; Belga News Agency] [uncertain: the Belga article's date was not shown]

How change is thought to happen. Recovery is understood as a return to ordinary life: shopping, hobbies, friends. Several things are thought to drive it:

• a stable home and daily routine;
• household members who act as role models;
• neighbours and a social network;
• daily contact between the town and its guests, which also counters stigma.

The family is not asked to treat. It provides normal living conditions, and the team provides the professional care, as little as possible and as much as necessary. In a 1968–74 cohort of long-stay patients, social functioning improved in most cases even though clinical state hardly changed. [source: Van de Walle, Zorg van velen; Van de Vel 2022; Bradshaw 2009; Pierloot & Demarsin, Tijdschrift voor Psychiatrie]

Who this guide is for. Clinicians who refer to Geel, work in a Geel-type team, or adapt the model as host-family or adult-foster-care schemes elsewhere. Adaptations outside Geel are marked [synthesis].

2. Framework

There are no therapy sessions or session counts. The unit of work is a placement, which can last a few months or several decades. OPZ describes four forms of stay [source: OPZ, Een nieuwe toekomst]:

• long-term stay for stable clients, the most common form, seven days a week;
• temporary stay, for example as a bridge to independent living after a long hospital stay, or while waiting for a nursing-home place;
• part-time stay;
• supportive and treatment-oriented stay, already used with young people and planned for adults and older adults.

Day foster care and assisted-living arrangements next to a family's home have been proposed as extensions. [source: Van de Vel 2022]

Since spring 2011, care has been organised by target group (doelgroepenwerking): children and young people under 18, adults aged about 18–65, and older adults over 65. Each group has its own mobile team. OPZ planned to extend the catchment from Geel and the surrounding municipalities to the whole Turnhout district. [source: OPZ, Een nieuwe toekomst]

Phases. The phases below are reconstructed from the sources; OPZ does not publish a numbered protocol. [synthesis, built from the cited components]

1. Referral and indication.
   • Goal: decide whether family living suits this person.
   • Typical candidate: someone with severe or long-term illness who needs more safety than group housing offers but is not ready to live alone after treatment.
   • Exclusion: people with a history of violent behaviour are usually not admitted.
   • Move on when: the indication is agreed and the client consents. [source: Van de Vel 2022; Chen 2016]
2. Observation and preparation.
   • The client is admitted to the intramural living unit (leefeenheid Intramurale Zorg) and follows a targeted observation and preparation programme (gericht observatie- en voorbereidingsprogramma), in some cases in an observation house.
   • In 2009 this lasted "a couple of months". It consisted of daily-living tasks (cooking, laundry, gardening, looking after chickens) while staff judged the client's abilities and whether they interact safely with others.
   • Move on when: the client's profile is clear enough to match. [source: Van de Walle; Bradshaw 2009]
3. Matching and introduction.
   • The team weighs the client's character, background, difficulties and expectations against the family's expectations, care capacity and the personalities of its members.
   • A day visit usually comes before moving in.
   • Move on when: client and family both agree after the trial contact. [source: Van de Walle]
4. Settling-in.
   • The district nurse (wijkverpleegkundige) may be in contact daily at the start.
   • The team draws up a weekly schedule with the client and the family.
   • Move on when: the household routine is stable and contact can be reduced. [source: Van de Walle; Van de Vel 2022] [uncertain: no formal criteria published]
5. Maintenance.
   • Regular nurse visits: at least monthly per patient in 2009, more often when problems arise.
   • Psychiatrist appointments, for example monthly, plus day activities or work and network building.
   • A key person of trust (vertrouwenspersoon) follows the client throughout. [source: Van de Walle; Bradshaw 2009; OPZ, Een nieuwe toekomst]
6. Crisis or time-out (as needed).
   • 24/7 on-call service; a short admission (time-out); or a temporary return to the living unit.
   • Return when: the client's mental state has settled and the family is ready. [source: Van de Walle; Van de Vel 2022]
7. Transition or end.
   • Possible routes: rematching to a new family, a move to independent living or a nursing home, or the placement passing to the next generation when a host dies or grows old. [source: Van de Walle; Bradshaw 2009; Belga]

Format and capacity. Each family usually has one to three guests; in 2009 the maximum was three. In 2009 one nurse's caseload was 36 patients in 30 families. Families receive a monthly, tax-free payment for costs and care: about €450 per patient per month in 2009. In 2016 the state paid about €40 per guest per day, and less than half of this went to the family. [source: OPZ, Een nieuwe toekomst; Bradshaw 2009; Chen 2016] [uncertain: current amounts not found]

3. Guiding principles

• Care in and by the community (zorg in de gemeenschap, door de gemeenschap): the family, the neighbourhood and local clubs are the main care setting, and the team supports them rather than replacing them. [source: Van de Walle]
• As little as possible, as much as necessary ("zo weinig mogelijk, zoveel als nodig"): set support levels for each person and step them up or down as needs change. [source: Van de Walle]
• Care made to measure: "Ze krijgen die zorg die ze nodig hebben, niet meer, niet minder" (they get the care they need, no more, no less). Review intensity regularly rather than keeping it fixed. [source: OPZ, Een nieuwe toekomst]
• Normalisation: aim for ordinary roles such as household tasks, mainstream clubs, work or volunteering, and use specialised day activities only where mainstream options fail. [source: Van de Vel 2022; Van de Walle]
• Acceptance as a household member: hosts treat the guest as one of the family and accept odd behaviour as part of the person, not as a target to correct. Coach families toward tolerance, not treatment. [source: Bradshaw 2009; Chen 2016; Van de Vel 2022]
• The family is not the therapist: treatment, medication decisions and crisis work stay with the professional team. Do not hand clinical tasks to hosts, apart from agreed supervision of medication. [source: Van de Walle; Pierloot & Demarsin]
• Client participation and self-direction: involve clients in treatment decisions and in decisions about their own life course, and work on independence and social skills. [source: OPZ, Een nieuwe toekomst]
• Continuity of the relationship: each client keeps one key person of trust through admissions and moves, and OPZ guarantees that it will take back care when needed. Never leave a family or client without an agreed fallback. [source: OPZ, Een nieuwe toekomst]
• Back up the family around the clock: 24/7 on-call service, with the team on site within about half an hour; a family that knows help comes fast tolerates more. [source: Van de Walle; Van de Vel 2022]
• Careful matching, acknowledged uncertainty: match thoroughly, and still expect some placements to fail and plan for rematching without blame. [source: Van de Walle]
• A diverse pool of families: recruit varied households because guests' needs vary widely. [source: Van de Vel 2022; Bradshaw 2009]
• Strengths focus: in reviews, attend to what is going well, not only to problems. [source: Van de Vel 2022]
• Contact against stigma: everyday contact between town and client is treated as the best anti-stigma strategy, so place clients visibly in community life. [source: Van de Walle]
• Social network as treatment: build the client's ties with their family of origin, the foster family, neighbours, fellow clients and services, as deliberate work. [source: Van de Walle]
• Safety by selection: screen out people with a history of violence and assess safe interaction before placement. [source: Chen 2016; Bradshaw 2009]
• Respect for the family's limits [synthesis]: hosts are paid carers, not staff. Their capacity, holidays and need for rest are part of the care plan; the brochure describes the pause after a failed placement as a rest period for the family. [source: Van de Walle]

4. Intervention inventory

The items below are the service procedures named in OPZ and related sources. None of them is a talking-therapy technique, and Geel's sources do not publish step-by-step protocols for them. The steps under each item therefore turn the described components into concrete actions. Steps not stated in a source are marked [synthesis]. All example wording is illustrative.

4.1 Referral and indication assessment

• Purpose: decide whether a person would benefit from living in a family.
• When to use:
  • The person has severe, long-term illness (in the sources, mostly stabilised schizophrenia, severe depression, Korsakoff syndrome, or illness combined with intellectual disability).
  • They have no suitable home of their own to return to.
  • They need more safety than group housing gives but are not ready to live alone.
  • [source: Bradshaw 2009; Van de Vel 2022; Pierloot & Demarsin]
• Steps:
  1. Confirm that a return to the person's own family or independent housing is not realistic now.
  2. Screen for a history of violent behaviour, which usually excludes admission [source: Chen 2016].
  3. Review current suicide and self-harm risk in line with standard practice and document it [synthesis]. In an older non-Geel scheme of individual foster families for younger patients with personality disorders, 2 of 16 placed patients died by suicide, and the authors called for stricter selection [source: Pierloot & Demarsin].
  4. Ask about the person's wishes: duration (short or permanent), and preferences such as rural or urban, a family with children, pets, religion [synthesis; duration-by-wish from Van de Walle].
  5. Obtain informed consent and involve any legal representative, such as the voorlopig bewindvoerder (court-appointed administrator) [source: Van de Walle, network list; consent step: synthesis].
• Example language (illustrative): "This isn't a ward or a group home. You'd live in an ordinary house with a family, and our team stays in touch with you. Does that sound like something you'd want to try?"
• Watch for:
  • The person agreeing passively, without real interest.
  • Unmanaged risk of violence or suicide.
  • Needs beyond what a household can carry, such as heavy nursing care.
  • Working if: the client can say what they hope for from family life.

4.2 Observation and preparation programme

• Purpose: learn what the client can do in daily life and how they get on with others, and give them practice in household living before matching.
• When to use: after admission to the intramural living unit and before matching [source: Van de Walle; Bradshaw 2009].
• Steps:
  1. Admit the client to the living unit or observation house.
  2. Run a daily programme of practical tasks: cooking, laundry, social contact, gardening, looking after animals (2009 description).
  3. Staff record the client's abilities, need for prompting, tolerance of noise and closeness, sleep and habits, any wandering or leaving the house, and how safely they interact [source: Bradshaw 2009; items beyond abilities/safety: synthesis].
  4. Continue for as long as the profile needs; in 2009 this was "a couple of months".
  5. Write a short profile for matching: abilities, support needs, triggers, likes, and the family features that would and would not suit [synthesis].
• Example language (illustrative): "These weeks are about getting to know how you like to live: what you're good at in a house, and what's hard. Nothing here is a test you can fail."
• Watch for: institutional habits that will clash with family life (fixed meal times, being looked after for everything). Working if the client takes part in household tasks with less prompting.

4.3 Matching client and family

• Purpose: find the household with the best fit [source: Van de Walle].
• Steps:
  1. List the client's character, background, difficulties and expectations.
  2. List each candidate family's expectations, care capacity and the personalities of its members, including children, grandchildren and frequent visitors.
  3. Take relevant family experience into account; the brochure gives the example of a host with a nursing background [source: Van de Walle].
  4. Draw on as varied a pool of families as possible [source: Van de Vel 2022; Bradshaw 2009].
  5. Make the family's existing guests part of the fit check (in 2009, up to three per family) [synthesis].
  6. Choose a match and plan the introduction (4.4).
• Example language (illustrative), to a family: "He's quiet and likes routine and gardening. Loud evenings unsettle him. How does that fit with how your house runs?"
• Watch for: matching only on who has a free room; a family whose expectations (company, help in the house) the client cannot meet. Working if both sides describe the other in realistic terms before moving in.

4.4 Introduction visit and trial move

• Purpose: let client and family test the fit before committing [source: Van de Walle, case of Victor: one day visit, then a stay in the observation house, then moving in].
• Steps:
  1. Arrange a day visit with a known staff member present at first [staff presence: synthesis].
  2. Debrief the client and the family separately afterwards [synthesis].
  3. Repeat the visit or extend it (overnight, weekend) if either side is unsure [synthesis].
  4. Agree a moving date, what the client brings, and the first-week contact plan.
• Example language (illustrative): "How was the day for you? What would you need to feel at home there?"
• Watch for: the client masking discomfort to please staff. The brochure warns that clients with traumatic childhoods often start without problems, and difficulties come later, so a smooth first visit is not proof of fit [source: Van de Walle].

4.5 Translating the diagnosis into everyday behaviour for the family

• Purpose: give hosts a practical understanding of the client, without jargon. Families want to know whether the person will fit into their household. The team translates the client's problems into concrete behaviour and gives tips for living together [source: Van de Vel 2022].
• Steps:
  1. With the client's consent, share what is needed for daily life: typical behaviours, early signs of relapse, what helps, what to avoid, and medication routines [consent and content list: synthesis].
  2. Describe behaviour, not labels. For example, say "may talk back to voices in the evening" rather than a diagnosis [synthesis].
  3. Give two or three concrete tips for each problem behaviour.
  4. Tell the family when and how to call the team.
• Example language (illustrative): "When she starts pacing and checking the doors, that usually means she's getting anxious. A cup of tea together and a calm voice help more than questions."
• Watch for: sharing more than the client agreed to; families treating the information as rules to enforce. Working if hosts describe their responses in their own words.

4.6 Recruiting, screening and preparing foster families

• Purpose: keep a diverse pool of capable households.
• Steps:
  1. Recruit through public campaigns and an informal no-commitment first conversation (vrijblijvend gesprek) [source: OPZ, Een nieuwe toekomst; Belga, recruitment campaign].
  2. Explain the payment (monthly, tax-free), the on-call service, team support, the guarantee that OPZ will take back care, and possible day activities [source: OPZ, Een nieuwe toekomst].
  3. Assess the household: motivation, space, who lives there and visits, health, availability during the day, and safeguarding checks according to local rules [synthesis].
  4. Prepare the family. NPR reports that hosts receive training and support from psychiatric professionals [source: Chen 2016]. [uncertain: no OPZ training curriculum was found; the brochure describes ongoing support, not a course]
• Example language (illustrative): "You don't need to be a nurse. You need to be willing to share your home and your routines, and to call us early when something worries you."
• Watch for:
  • Purely financial motivation [synthesis].
  • Families who cannot tolerate odd behaviour.
  • A recruitment pool that is getting older: candidate families are now mostly older people, because in younger families both partners usually work [source: Van de Vel 2022].

4.7 District nurse home visits

• Purpose: the wijkverpleegkundige knows every family, is their contact point and confidant, and is described as the institution's face ("het gezicht van de instelling") [source: Van de Walle].
• Frequency: regular visits, which may be daily at the start or in difficult periods [source: Van de Walle]; at least monthly per patient in 2009 [source: Bradshaw 2009].
• Steps:
  1. Visit the household and talk with the client and the hosts, separately when needed [separately: synthesis].
  2. Check how things are going: mood, sleep, behaviour, how the household is coping, and any new strains in the family.
  3. Deliver and check medication [source: Van de Walle].
  4. Note early relapse signs and pass them to the team.
  5. Agree what will happen before the next visit, and step frequency up or down.
• Example language (illustrative): to hosts, "What's been easier this month, and what's been wearing you down?" To the client, "Is there anything about living here you'd like to change?"
• Watch for:
  • Hosts minimising problems because they fear losing the placement. Bradshaw notes that families are strongly motivated to keep guests at home.
  • Clients who cannot speak freely in front of their hosts.
  • Working if: hosts call early rather than in crisis.

4.8 Medication supervision shared by nurse and family

• Purpose: keep treatment going without making the home a ward.
• Steps:
  1. The nurse supplies the medication and checks it [source: Van de Walle].
  2. The host checks daily intake. The brochure gives the example of a host who checks the guest's daily medication [source: Van de Walle].
  3. Agree in writing what the host does: hands over, watches the dose being taken, records it. Agree what the host never does: change doses or decide on extra doses [synthesis].
  4. The host reports refusals or side effects the same day [synthesis].
• Example language (illustrative): "Your part is just to see that the evening tablets are taken, and to ring us if they're refused twice in a row. Any change is our decision, not yours."
• Watch for:
  • Hosts drifting into prescribing roles.
  • Medication becoming a power struggle in the home.
  • Bradshaw notes that guests often need less medication in a stable routine. Any reduction is a decision for the prescriber [source: Bradshaw 2009; decision rule: synthesis].

4.9 Mobile multidisciplinary team (F-ACT) and key person of trust

• Purpose: provide flexible clinical care around the placement. Each target group has a mobile team of psychiatrist, nurse, social worker, therapist and psychologist, working with the F-ACT method for clients who depend on care over long periods. Each client is given a vertrouwenspersoon, who follows them through the whole recovery, including after an admission or a move [source: OPZ, Een nieuwe toekomst]. A general practitioner offers walk-in hours every day; the psychiatrist sees clients by appointment (one example: monthly) [source: Van de Walle].
• Steps:
  1. Name the key person of trust at the start and tell the client and the family who it is.
  2. Each team member assesses the client from their own discipline, and the team agrees the best care together [source: OPZ, Een nieuwe toekomst].
  3. Hold team discussions on each placement, involving the psychologist, occupational therapist and support workers [source: Van de Walle].
  4. Scale the intensity up or down following the F-ACT logic of flexible stepping [F-ACT detail: uncertain, as OPZ texts name the method but do not describe its board procedure].
• Example language (illustrative): "Whatever happens (hospital, a new family, your own flat), I stay your contact person."
• Watch for: the key person changing with every move, which undermines continuity. Working if the client names the key person as the one they would call.

4.10 Weekly schedule with client and family

• Purpose: structure the week with day activities and leisure. The psychologist draws up the schedule together with the client and the family [source: Van de Vel 2022].
• Steps:
  1. Sit down with the client and the hosts.
  2. Map fixed household routines: meals, chores the client shares (washing up, laying the table, shopping, putting out the rubbish, cooking, laundry) [source: Van de Walle].
  3. Add day activities or work, leisure, appointments, and time out of the house.
  4. Check the balance: enough structure, enough rest, and time when the hosts are free of care [balance and host respite: synthesis].
  5. Review the schedule at agreed intervals or when it stops working.
• Example language (illustrative): "Let's put the week on paper: what you do in the house, where you go during the day, and when everyone has their own time."
• Watch for: schedules that serve the household and not the client (the client used as unpaid labour) [synthesis]; empty days. Working if the client follows the routine without daily prompting.

4.11 Day activities, sheltered work and mainstream inclusion

• Purpose: give the client meaningful daytime roles outside the home.
• Options (OPZ):
  • District centres (wijkcentra) with day-activity centres, open to clients and families.
  • Sheltered work (arbeidszorg) workshops: woodwork, bicycle repair, bookbinding and printing, industrial work, grounds maintenance.
  • Individually supported volunteer work in the regular labour market.
  • Leisure pathway support (vrijetijdstrajectbegeleiding): leisure and sport, an information point and buddy work that links clients to mainstream clubs.
  • The arts house Yellow Art, for artistic projects outside a therapeutic frame.
  • [source: Van de Walle]
• The trend is to join mainstream provision (work, clubs, sports clubs, creative projects) rather than run activities inside the centre [source: Van de Vel 2022].
• Steps:
  1. Ask about interests and past skills.
  2. Start with an in-house or sheltered option if needed.
  3. Use buddy support to try one mainstream activity [source: Van de Walle].
  4. Fade the buddy once the client attends on their own [synthesis].
• Example language (illustrative): "You liked fixing bikes before. There's a workshop for that, and later maybe the cycling club in town."
• Watch for: the client staying in segregated activities by default. Working if the client attends with less support and names people they meet there.

4.12 Social network work

• Purpose: strengthen the client's web of relationships. The social worker has a key role here and is also consulted about contact with the client's family of origin [source: Van de Walle].
• Network as listed by OPZ: family of origin, the foster family, the neighbourhood, fellow clients, OPZ, the voorlopig bewindvoerder (court-appointed administrator), the health insurance fund (ziekenfonds), the public social welfare centre (OCMW) and government services.
• Steps:
  1. Map the network with the client [mapping format: synthesis].
  2. Choose one tie to strengthen. Brochure examples include renewing contact with relatives, weekly outings and volunteering [source: Van de Walle].
  3. Plan contact with the family of origin with the client: visits, calls, the hosts' role [synthesis].
  4. Coordinate practical matters with the administrator and with welfare and insurance services.
• Example language (illustrative): "Who would you like to see more of? Shall we plan a visit to your sister next month?"
• Watch for: conflicts of loyalty between the family of origin and the hosts [synthesis]; a network that is only professionals. Working if the client has at least one non-paid relationship outside the house.

4.13 24/7 on-call service and crisis response

• Purpose: foster families can call one central on-call number at any time, which reaches the district nurses [source: Van de Walle]. Families and clients can get advice or support day and night, and because the centre is in the town, the team can be there in about half an hour [source: Van de Vel 2022].
• Steps:
  1. At the start, give the family the number and examples of when to call [examples: synthesis].
  2. The on-call nurse triages: telephone advice, a home visit, or arranging a time-out admission (4.14).
  3. Assess risk to the client and the household using standard crisis assessment, including suicide risk and safe storage or removal of medication and other means in the home [synthesis].
  4. Debrief with the hosts the next day and adjust the care plan [synthesis].
• Example language (illustrative): to a host on the phone, "You did the right thing calling. Tell me what you're seeing right now. Is anyone in danger?"
• Watch for: hosts waiting too long before calling. Working if most calls are early and are handled by advice or a visit.

4.14 Time-out admission and temporary return to the living unit

• Purpose: give a short break or treatment without ending the placement. Options are a short admission at OPZ (time-out), or a temporary return to the living unit when:
  • the client's mental state worsens;
  • living together becomes difficult;
  • the family is unavailable and no respite family (opvanggezin) has a place.
  • [source: Van de Walle]
• OPZ guarantees that it will take back care (garantie van overname van zorg) [source: OPZ, Een nieuwe toekomst].
• Steps:
  1. Agree the reason and the expected length with the client and the hosts.
  2. Keep the bed in the family open where possible [synthesis].
  3. Keep the same key person of trust throughout [source: OPZ, Een nieuwe toekomst].
  4. Before the client returns, review what led to the admission and what will change at home.
• Example language (illustrative): "This is a pause, not the end. Your room at the Janssens' is still yours."
• Watch for: time-outs becoming the only way to manage strain. Working if the client returns to the same family.

4.15 Respite and holiday cover

• Purpose: cover the family's absence or rest. The brochure mentions respite families (opvanggezinnen) and yearly OPZ holiday trips that clients may join [source: Van de Walle].
• Steps: plan host holidays in advance, then book a respite family or a holiday trip, or a short stay in the living unit if neither is available [sequencing: synthesis].
• Watch for: hosts who never take a break [synthesis].

4.16 Rematching and ending a placement

• Purpose: handle a placement that fails or a change in life stage. If a placement fails, the district nurse can propose a new family (brochure case of Daniel and Mia). The brochure describes a waiting period after a breakdown as a rest period for the family [source: Van de Walle]. A placement can also pass to the hosts' child when a host dies or becomes too old [source: Bradshaw 2009; Belga]. Temporary stays end with a move to independent living or a nursing home [source: OPZ, Een nieuwe toekomst].
• Steps:
  1. Review what failed: the match, the support level, or a change in the client [synthesis].
  2. Support the client through the loss and the move, and let them say goodbye where possible [synthesis].
  3. Rematch using what was learned (4.3).
  4. When a host dies, give grief support to the client and the household, and assess whether the next generation is willing to take over [synthesis].
• Example language (illustrative): "It didn't work out with this family, and that isn't a failure on your part. Let's look at what you'd need next time."
• Watch for: clients blaming themselves; repeated breakdowns, which call for reassessing the indication. Working if the next placement holds.

4.17 Support and team consultation for foster families

• Purpose: keep hosts able to carry on. Support comes from the district nurse, the psychologist and team consultation (overleg) when problems arise, and families can bring questions to the district centre [source: Van de Walle]. Reviews should attend to what is going well [source: Van de Vel 2022].
• Steps:
  1. Schedule regular review conversations with the hosts [regularity: synthesis].
  2. Open with what is going well.
  3. Name one current difficulty and agree a concrete tip or action.
  4. Escalate to team consultation if the difficulty persists.
• Example language (illustrative): "Let's start with what's working. Then tell me the one thing that's hardest right now."
• Watch for: host burnout; during COVID-19 the care burden on families rose sharply and some withdrew [source: Belga]. Working if hosts stay in the programme and take on new guests.

4.18 Children and adolescents strand

• Purpose: family care for under-18s with psychiatric problems; one project targets children with dual problems. The supportive and treatment-oriented form of stay is already used with young people [source: OPZ, Een nieuwe toekomst; Van de Vel 2022]. OPZ employs case managers for this strand [source: Flemish government vacancy listing].
• Steps: [uncertain] no published procedure is given. Follow your jurisdiction's child-protection and foster-care law and involve parents or guardians and the school [synthesis].

4.19 Adapting outside Geel: individual foster families linked to a hospital [synthesis, with a source caution]

• Purpose: apply the model where no Geel-type community exists.
• Source caution: in a Dutch-language report, hospital therapists placed younger patients with personality disorders in individual families that had no professional role, while the therapists continued psychotherapy. Results were "rather mediocre": of 16 patients, 2 died by suicide and 5 were readmitted. The authors recommend stricter selection and better preparation of both patients and families. In the same report, the Geel organisation, with supervision by psychiatrists and nurses and a central hospital as backup, achieved relatively good integration in 49 of 64 chronic patients [source: Pierloot & Demarsin].
• Steps [synthesis]:
  1. Replicate the backbone: careful selection, a preparation stay, matching, a named nurse or key worker, 24/7 on-call cover, guaranteed readmission, and a payment and legal framework.
  2. Do not place people in families without that infrastructure.
• Watch for: schemes that use families as cheap beds without team support. OPZ and the 2022 interview stress that Geel's model grew over generations and is hard to copy quickly [source: Van de Vel 2022].

5. Handling problems

• A smooth start followed by deterioration. The brochure notes that clients with traumatic childhoods often start without problems, and difficulties appear later [source: Van de Walle].
  • Warn hosts about this pattern in advance.
  • Keep visit frequency high for longer than the honeymoon seems to need.
  • When difficulties appear, describe them as an expected phase, not a sign the match failed. [response: synthesis]
• The client tests the family's patience (often without meaning to) [source: Van de Walle].
  • Hold team consultation with the hosts.
  • Turn the behaviour into one or two concrete household agreements.
  • Offer a planned time-out before the strain becomes a crisis.
  • If it persists, consider rematching rather than letting the placement break down in anger. [source: Van de Walle, for consultation, time-out and rematching; sequencing: synthesis]
• Over-attachment to a host. NPR describes a host who encouraged a guest who was too attached to her to find other companionship [source: Chen 2016].
  • Support this with network work (4.12) and day activities (4.11) so that the client's emotional life does not rest on one person. [synthesis]
• Odd behaviour, hallucinations and delusions in the home. The Geel stance is to accept such behaviour as part of the person [source: Chen 2016].
  • NPR quotes a host who used to play along with a former guest's hallucinations (pretending to chase away lions he saw) and says this always worked [source: Chen 2016]. Treat this as an anecdote, not a technique.
  • Coach hosts toward a calm, non-arguing presence and practical comfort, and to report changes in content or distress to the team.
  • Hosts should not be asked to challenge beliefs. Any psychological work on symptoms is for the clinician, not the family. [synthesis]
• Wandering or leaving the house. Bradshaw mentions a guest who opens doors and leaves, which means the host has to stay constantly alert [source: Bradshaw 2009].
  • Assess this before matching (4.2).
  • Agree with the client and hosts what the host does if the client is missing, and when to call the on-call number and the police.
  • Review whether the level of supervision is sustainable for the family. [synthesis]
• Non-adherence to medication.
  • The nurse and the host share checking (4.8).
  • Explore the reasons with the client: side effects, meaning, feeling controlled.
  • Involve the psychiatrist early.
  • Keep the host out of enforcement so the home relationship stays protected. [synthesis, building on Van de Walle]
• A client who refuses the day programme or stays in their room.
  • Return to the weekly schedule (4.10).
  • Use a buddy for one low-demand activity (4.11).
  • Check for depression, sedation or physical illness. The GP's daily walk-in hours make the medical check easy [source: Van de Walle, walk-in hours; rest: synthesis].
• Ruptures between the client and the hosts.
  • Hold separate conversations, then a joint one led by the key person of trust.
  • Agree specific changes and set a short review date.
  • Use time-out if feelings are running high (4.14). [synthesis; time-out from Van de Walle]
• Ruptures between the family and the team (for example, the family feels unheard or blamed).
  • The nurse acknowledges the family's experience, and the team names concrete supports it will add.
  • Remind the family of the guarantee that OPZ will take back care [source: OPZ, Een nieuwe toekomst; rest: synthesis].
• Host burnout or withdrawal. During COVID-19 some families withdrew because the care burden rose [source: Belga].
  • Watch for fatigue.
  • Offer respite families or holiday trips (4.15), and adjust payment and support where the rules allow.
  • Accept a family's decision to stop without penalty. [synthesis]
• Too few families, and the pool getting older. Candidate families are mostly older people, and younger households are hard to recruit because both partners usually work. Responses proposed in the sources:
  • better financial recognition, so that one partner can stay at home;
  • new forms such as part-time stays, day foster care and assisted living next to a family's home;
  • recruitment campaigns.
  • [source: Van de Vel 2022; Belga]
• Changing clinical profile. Guests used to be mostly people with intellectual disability; now psychiatric problems predominate and needs vary widely. The sources' response is a more diverse pool of families and more flexible forms of stay [source: Van de Vel 2022].
• Risk of violence. People with a history of violence are usually not admitted, and NPR reports that studies have found little violence by guests [source: Chen 2016].
  • If aggression emerges: arrange immediate on-call contact, take steps to make the household safe, use time-out admission, and carry out a full review before any return. [synthesis]
• Suicide risk. In the non-Geel individual-family scheme, 2 of 16 placed patients died by suicide [source: Pierloot & Demarsin].
  • Assess risk at referral and at every crisis contact using current standard practice.
  • Agree with hosts how medicines and other means in the house are stored or removed, as part of lethal-means counselling.
  • Agree how hosts report warning signs immediately. [synthesis]
• Exploitation or neglect of a guest (not covered in the sources used here) [synthesis].
  • Warning signs: unequal treatment within the household, a guest's money handled by the hosts outside the court-appointed administrator's oversight, or excessive unpaid work.
  • Response: see the client alone, involve the administrator and the team, and follow the local procedure for safeguarding vulnerable adults.
• Loyalty conflict with the family of origin [synthesis]. Hold planned contact through the social worker [source: Van de Walle] and agree openly with the client and both families what role each one plays.
• Death or ageing of a host. Placements may pass to the hosts' children [source: Bradshaw 2009; Belga].
  • Plan succession while the hosts are still well.
  • Give grief support to the client.
  • Make a fresh match agreement with the new carers. [synthesis]
• A client who wants more independence.
  • Treat this as a goal, not a problem: OPZ explicitly works on independence, and the temporary form of stay is designed as a bridge to independent living [source: OPZ, Een nieuwe toekomst].
  • Plan stepwise moves, and keep the key person of trust through the move.

Sources

Sources:

• Een nieuwe toekomst voor (psychiatrische) gezinsverpleging (OPZ Geel)
• Gezinsverpleging: zorg van velen (OPZ Geel brochure, L. Van de Walle)
• Van de Vel, T. (2022). De Geelse Gezinsverpleging. Psyche 34(1), 8–11 (interview with W. Bogaerts)
• UNESCO (2023). Safeguarding foster care heritage in the merciful city of Geel: a community-based care model (Register of Good Safeguarding Practices, file 00622)
• Bradshaw (2009). The Low Countries yearbook 17, article on Geel family care
• Belga News Agency. The remarkable story of Geel: 700 years of community-based mental health care [uncertain: date not shown]
• Chen, A. (2016). For centuries, a small town has embraced strangers with mental illness. NPR, via MPR News
• Pierloot, R.A. & Demarsin, M. Verwijzing vanuit het psychiatrisch ziekenhuis naar pleeggezin en gezinsverpleging. Tijdschrift voor Psychiatrie (abstract) [uncertain: year not shown]
• Geel family care research project. Tijdschrift voor Psychiatrie (abstract only)
• Lobo, K. (2018). Care not Cure: Insights from the Family Foster Care System in Geel, Belgium (poster record; poster contents not read)
• Goldstein, J. Bibliography of Geel publications (listing only)

Further reading (not drawn on; named for orientation only; no content above is drawn from them): Goldstein, J.L. & Godemont, M.M.L. (2003). The legend and lessons of Geel, Belgium. Community Mental Health Journal 39(5), 441–458; Roosens, E. (1979). Mental Patients in Town Life: Geel, Europe's First Therapeutic Community; Roosens, E. & Van de Walle, L. (2007). Geel Revisited: After Centuries of Mental Rehabilitation; the UNESCO nomination form (the request was refused); the OPZ case-manager vacancy for children and young people (the page failed to load).

[uncertain] Overall: OPZ does not publish an operational manual. The steps above that are marked [synthesis] are the author's reconstruction around the components the sources describe. Current payment amounts, foster-family training content, the details of how F-ACT is applied, and the procedures for children and young people were not found.