For two years now, I have been doing research on the history of mental health stigma in Japan. Consequently, I have also written some reports and papers about this topic and the history of psychiatry in general. During my year at Kobe University, I wrote a paper in Japanese about the link between the hamlet Iwakura in Kyoto and the Belgian city of Gheel. Since this is perfectly acceptable Nippaku material, I thought it could be interesting to post a translated version on this blog!
In Flemish, we have a proverb “going to/coming from Gheel” which means being crazy. In Japan there is a similar expression about Iwakura, a hamlet North of Kyoto. Both places appear to be related to mental health patients: Gheel as well as Iwakura have gained fame as “colonies of the mad”. At the end of the 19th century, Gheel attracted worldwide attention because of its unique family care system. Since it was believed that traditionally a similar system existed in Iwakura, it was called “the Japanese Gheel”. We cannot deny that there are many similarities between these two places, but is it really true that family care which emerged from a very specific (religious and economical) context in Gheel is also ingrained in the history of Iwakura? In this post, we will compare the relevant history of both places in chronological order and take on the question whether or not Iwakura can truly be called “the Japanese Gheel”.
1. The history of Gheel
Gheel (Geel in Dutch) has been an important pilgrimage destination since early times. From the 12th century on, ill people from all corners of Europe came to Gheel because they had heard about the legend of Sint Dymphna (Dimpna in Dutch), the city’s patron saint. It was believed that seeing and touching her relics had curative powers. According to the legend, Dymphna was the daughter of an Irish king ruling in the seventh century. When the queen died, the king started looking desperately for a woman to remarry who looked exactly like his deceased spouse, but could find no one who resembled her more than his own daughter. The king, by then insane from grief, proposed to Dymphna. She refused him and fled together with father confessor Gerebernus and some trusted others to Gheel. They were eventually tracked down and the king beheaded his daughter himself and had Gerebernus killed as well. Both were declared martyrs. The people in Gheel buried their bodies, but later exhumed the bones to function as relics in the Dymphna Church they established in the vicinity of their grave.
In the beginning, Gheel attracted all kinds of diseased people as a place of pilgrimage, but from the 15th century on St. Dymphna became known as the patron saint for the mentally disordered, and the number of visiting “mad people” increased rapidly. The standard procedure was a “novena”, a nine-day ritual that required the diseased to stay during that period in Gheel. For that purpose, sick rooms were set up inside the church. However, space was limited and in high season (i.e. around May, since May 15 was St. Dymphna’s feast day) the number of pilgrims largely surpassed the number of novena participants the church could deal with, and those who arrived sometimes had to wait for weeks before they could receive spiritual healing.
The inhabitants of Gheel provided a solution in the form of lodging at their own homes. Moreover, not few pilgrims wished to stay for an extended period longer than the nine days in church to maximize the healing effects of St. Dymphna’s relics. From this custom the family care system was born: for an unlimited period, the people of Gheel “adopted” one or two mental patients and in return received a compensation. The patients who could also helped with farming work. In other words, families without any medical knowledge lived together with mental health patients under the same roof, unlike the situation in hospitals or specialized boarding houses.
From 1532 on, the Communal Council of Gheel took care of the accommodation, supervision and novena for mentally ill pilgrims. In the 17th century, however, the patients were placed directly in the host families via a sponsored organization called the “table of the poor” (“De Armentafel” in Dutch). As a result, several pilgrims with a mental disorder stayed in Gheel and lived together with their foster family for the rest of their live. Although Gheel become known as “the merciful city”, the explanation behind this charity was mainly an economic one: for the authorities, family care was simply a cheaper solution to keep “mad” people off the streets than having them treated at mental asylums in surrounding cities.
In 1850, Belgium’s National Mental Illness Law legally recognized family care as equal to other forms of psychiatric care. The village was renamed “the Colony of Gheel”. A mental hospital was established in 1862, but the family care system remained, even today. In 1893, there were 1,156 foster families and in 1938, there were 3,736 mental health patients staying at the colony. Nowadays, many families still host one or more patients in exchange for a compensation [interesting video here]. The sight of mentally ill patients on the streets of Gheel is far from unusual. Today, as well as during previous centuries, the “pilgrims” enjoyed a relatively free life style, and there were remarkably few incidents or crimes involving the “mad”, a fact often used as an argument against the assumed strong connection between mental health patients and violence or crime. From the 1860s on, the colony gained fame as the model by excellence for family care and renowned psychiatrists and scientists from all over the world gathered in Gheel. Among them, there were also Japanese visitors. This is the point in history when the comparison with Iwakura began.
2. The history of Iwakura
During the Middle Ages (1185-1603) in Japan, a handful of religious institutions offered services for mental health patients, such as Chinese herbal medicine treatment and moxibustion (burning plant material close to or on the skin) in Buddhist temples, and incantations and exorcism sessions in Shintoist shrines. Because psychiatric treatment avant la lettre was often associated with spiritual healing, those in need undertook pilgrimages to “places of healing” that provided special treatment. Nevertheless, this was still exceptional, and most temples and shrines started to develop facilities for the mentally ill only late in the Edo period or at the beginning of the Meiji period. Hence, from the 17th century on, the number of religious institutions specializing in mental health treatment rose significantly. Shortly before the Meiji revolution, the reading of sutra, incantations, water treatment, moxibustion and Chinese-style herbal medication were available in 28 shrines and temples nationwide. Additionally, 2 mental asylums were established in the first half of the 19th century.
Among these institutions, the Daiunji-temple in Iwakura, north of Kyoto, is a well-known example of a popular destination for mentally disordered pilgrims. Its reputation as a place of healing was based on a legend from 1072. The third daughter of emperor Go-Sanjō who suffered from a mental disorder, recovered by drinking from a well and bathing under a waterfall at the place that was later called Iwakura. From around the year 1765, people started to flock there, which urged the provision of housing, first inside the temple domain and then at inns and local farmers’ houses. The expansion in population called Iwakura as a hamlet into existence. In 1875, a private mental hospital was established, and the people in Iwakura were forbidden to accommodate mental patients any longer because they could not provide adequate treatment. The hospital, however, was closed in 1882 due to financial difficulties. Consequently, many patients returned to the inns and local families’ houses. A second hospital was established in 1884.
During and after the Taishō period (1912-1926) Iwakura experienced a facilities construction boom and at the beginning of the Shōwa period (1926-1989), 10 sanatoria were established there to take care of the mentally ill. Many of the patients stayed for a longer period, some of them for the rest of their life. Those who could, helped with household chores, worked on the land or in the mountains. At the same time in Japan, the custom, and later on legislation of confining “insane” family members at home in zashikirō 座敷牢, cage-like wooden constructions, was widespread.
Compared to this way of dealing with mentally disordered people, it is assumed that those staying at Iwakura could enjoy a relatively free lifestyle. Nevertheless, previous research has pointed out that patients who were difficult to handle, were often locked up and physically restrained. In the past as well, the inhabitants of Iwakura who were entrusted the care of these patients and therefore responsible for them, did not want to take any risks. As a result, the “mad” were tied down to prevent them from escaping or causing any harm.
At the end of the year 1935, more than 500 mental health patients were admitted to the Iwakura hospital, and 300 more stayed at the surrounding sanatoria. The Second World War caused severe food shortage, and the mortality rate at mental hospitals nationwide rose sharply. The mental hospital and many of the sanatoria in Iwakura were forced to close their doors. Two new hospitals were established after the war, but the inns and sanatoria played no longer an important role. In the Iwakura of today, mental patients are mainly cared for at the hospital, and inhabitants taking on the task of housing them are hardly seen anymore.
It is believed that the famous Japanese physician Kure Shūzō 呉秀三 (often called the founder of psychiatry in Japan) was the first to draw the attention of specialists on the particular situation in Iwakura. Consequently, the “mad” of Iwakura and its psychiatric history attracted worldwide attention at the beginning of the 20th century. Many western psychiatrists visited Japan and pointed out the resemblance between the existence of sanatoria in Iwakura and the family care system in Gheel. Moreover, the interest in Iwakura was rooted mainly in the comparison with Gheel. We can assume that without the perception of Iwakura as “the Japanese Gheel”, the traditional practice of caring for patients at inns and farmers’ houses would have disappeared much sooner. The attention Iwakura gained during the early years of the 20th century “prolonged”, in a sense, the duration of this tradition. But on what exactly was the comparison with Gheel based?
3. Comparing Gheel and Iwakura
In 1906, The Latvian physician Wilhelm Stieda visited Iwakura, and wrote the words “In this village – a Japanese Gheel” (original in German: “In diesem Dorfe – einem japanischen Gheel -” in a specialized journal article. The notion of a resemblance between these two places was widely publicized, and Iwakura gained worldwide recognition. However, if we carefully examine the background against which this comparison was drawn, we learn that Kure Shūzō was the one who pointed out the similarities with Gheel to Stieda. Kure mentioned in his “Essentials of Psychiatry part II” (1895) that in Gheel as well as in Iwakura, there existed a similar system of family care. Before that, no other Japanese physician had mentioned such a thing during study trips to Germany, the place-to-be for psychiatrists at that time and also the country where efforts were made to introduce a family care system based on Gheel’s example.
In contemporary Japan, the traditional treatment in Iwakura was being perceived as “outdated”. After he visited Gheel in 1901, Kure compared the city once again with Iwakura, and this time, he expressed his disapproval of the Japanese situation. This was because Kure actually desired the development of a family care system exactly like in Gheel (which was not the case in Iwakura), but the accommodation of mental health patients at inns and tea houses became prohibited by the Mental Patients’ Custody Act promulgated in 1900. Furthermore, the care for mental patients at the sanatoria that resembled hotels rather than family homes, differed greatly from Gheel’s family care system. In other words, based on the strong desire that “Iwakura should be the Japanese Gheel”, Kure and other Japanese psychiatrists strived towards an introduction of the Gheel system. This failed.
So we can assume that when Stieda met Kure in 1906, he was not really under the impression that Iwakura had a similar family care system like in Gheel. Probably, he referred to the religious background, high population rate of mental health patients and history of lay treatment that both places shared. Nevertheless, Iwakura became mainly known to western psychiatrists for its alleged family care system. As I explained before, this was not the case then, since mental patients stayed at the hospital or sanatoria, and were no longer “adopted” into the farmer’s families. There are examples of family care in Iwakura before 1900, but calling it a “system” would be incorrect. However, the Japanese side did not deny and even supported this erroneous understanding. Hence, Iwakura’s history was recreated as “the Japanese Gheel”. Because Iwakura was already being compared to Gheel, the (re)introduction of a family care system should be possible, Japanese psychiatrists such as Kure thought.
According to specialist Akira Hashimoto, the words “Iwakura is the Japanese Gheel”, written in a time the world of psychiatry was fascinated by the family care system in Gheel, should be understood as an idea created on Japanese soil. I agree that the model of “family care” did not really apply to 20th-century Iwakura, but besides that, there are many resemblances here that should not be overlooked. Moreover, it is clear that in both places, people earned their living by caring for mental health patients. The influx of mentally ill pilgrims resulted in economic profits. The culture of lay psychiatric treatment is also remarkable. By nursing people with a mental disorder on a daily basis, the villagers developed a particular set of skills and became fully experienced, despite their lack of medical knowledge. Furthermore, mental patients enjoyed a relatively free lifestyle and the boundaries between “patient” and “villager” were rather blurry in both places.
I hope this post was able to convince you that Gheel and Iwakura deserve special attention because of their exceptional history of mental health care. More posts on this topic will follow (soon)! In the meantime, those who are interested in psychiatry can read a previous blog post on forensic mental health in Japan here: part 1, part 2.
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- Official site city of Gheel
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- Mueller, Thomas. “Re-Opening a Closed File of the History of Psychiatry: Open Care and Its Historiography in Belgium, France and Germany, c. 1880-1980.” In Transnational Psychiatries Social and Cultural Histories of Psychiatry in Comparative Perspective, C. 1800-2000, edited by Ernst Waltraud and Thomas Mueller, 172–99. Newcastle upon Tyne: Cambridge Scholars, 2010.
- 八木剛平, 田辺英『日本精神病治療史』東京: 金原出版, 2002.
- Wilhelm Stieda. “Über die Psychiatrie in Japan.” Centralblatt für Nervenheilkunde und Psychiatrie 29 (1906): 514-522.
- full text of “Gheel: the city of the simple” (1869)
- time line history of Gheel