It Takes (Away) A Village: The Nuclear Family, Its Problems, and Alternatives

It Takes (Away) A Village: The Nuclear Family, Its Problems, and Alternatives

Summary: Wisdom tells us that it takes a village to raise a child. But the modern nuclear family often does the exact opposite: it isolates family units, making everyone’s lives more stressful and difficult, and leaving us with disconnection and trauma. It takes away the village. But it doesn’t have to be this way. Through learning and imagining alternatives, we can uncover new possibilities for social connections, better relationships, happier lives, and collective healing.

Contents:

1. In a Nutshell   

2. Rise of the Nuclear Family  

3. Problems with the Nuclear Family

4. Why the Nuclear Family Persists

5. Where Do We Go from Here?  

6. Toward Healing

1. In a Nutshell  

The nuclear family is central to the myth of the American Dream. Two married parents, two or three kids, a house in a safe neighborhood. The members of this nuclear family usually spend a large part of their time together, in relative isolation.

Many of us – especially those in the middle-to-upper-classes – grew up in nuclear family households. And we turned out fine, right? So, what’s the problem? Why not just continue living in small, isolated family units?

For some people, there might not be a problem. Some have childhoods filled with love and freedom and close, connected relationships with a small family unit. For others, as ME O’Brien wrote, the family was perhaps a solution to bigger problems – a source of support and care against the injustices of capitalism and a racist police state. Either way, the nuclear family was good for some.

For others, the nuclear family is hell; they feel trapped in a stress-filled and terrifying unit. Physical abuse, emotional manipulation, and overbearing control – this is also the nuclear family.

For many, the family is something between the extremes: a sometimes-uncomfortable, sometimes-supportive, stressful yet loving experience. For these people in the middle, abolition of the nuclear family might sound extreme. But the status quo isn’t quite satisfying either.  

Even though many of us take the current situation as a given today, the nuclear family is anything but. And it may be making some of our lives harder than they need to be.

Personally, I had never really considered that there were other possibilities for family life until I was well into adulthood. But I have since learned what millions of people (especially people who aren’t white, middle-to-upper-class U.S. citizens) already know: there are many possible ways to arrange families and raise children. For instance, multigenerational and communal living have long been sources of support and happiness in many communities and cultures.

In short, the nuclear family is not inevitable. In fact, historically, it’s an anomaly. Throughout history, and in many cultures and communities today, children were and are raised communally: parents, relatives, and friends all share in the responsibilities of caring for young people.

Wisdom tells us that it takes a village to raise children. But the modern nuclear family sometimes means the exact opposite: isolated family units and limited social interactions. With two parents trying to do the work of an entire village, everyone’s lives can become more stressful and difficult.

Now, I want to be clear that I am not saying the nuclear family is “bad” or that enjoying or desiring a nuclear family is morally wrong. My point is that, for many people, the nuclear family structure doesn’t meet their needs, and that other arrangements are possible.

It comes down to prioritizing care and people’s wellbeing over rigid structures and ideologies.

We all want loving, resilient relationships and communities where everyone has the support and autonomy they need. The nuclear family can provide these things, but often it is a barrier to meeting our needs.

What we need to do is create the conditions where options for alternative family and child-raising arrangements are possible and achievable.

But first, let’s explore how the nuclear family came about; how it fails to meet the needs of many; and why it persists.

In other words, I’m going to ask: how did we end up so stuck in one paradigm that many of us can hardly even imagine alternatives? And how do we get unstuck? 

2. Rise of the Nuclear Family

For tens of thousands of years, in early human societies, people relied on their extended family and wider kin for support in every realm of life. This included everyone in the community – not just biological kin. So, how did we shift from these wide family networks to the nuclear option?

According to some, the origins of the modern nuclear household owe much to the Protestant Reformation, when the domestic divine (the father) began replacing the Catholic Church as the center of life. The ideal of a small household of father, mother, and children became something that middle-class Europeans strove for.

Then, as Ilana Strauss writes, during the latter half of the 19^th century, the rise of industrialization made it possible to earn a living and support oneself without extended communities. According to Kay Hymowitz, this trend accelerated in the West after World War II: “As societies became richer and goods cheaper and more plentiful, people no longer had to rely on traditional families to afford basic needs like food and shelter.”

A related trend, explains David Brooks, is that the decline in multigenerational living exactly tracked the decline in farm employment.

But the rise in the nuclear family hasn’t happened equally across society. The nuclear family isn’t really how most people live, even in the U.S.

As Brooks notes, “Today, only a minority of American households are traditional two-parent nuclear families and only one-third of American individuals live in this kind of family.”

So, who lives in these nuclear families? Privileged people, mostly. Meanwhile, immigrants and people of color are more likely to live in multigenerational and extended-family households. This is partly due to the greater economic and social stress these populations often face.

For instance, the oppressive conditions in the U.S. – from slavery to Jim Crow to police violence – have made it so African Americans have always relied on extended family more than white Americans. Mia Birdsong says that “black families are expansive, fluid, and brilliantly rely on the support, knowledge, and capacity of ‘the village’ to take care of each other.”

In short, the nuclear family is a relatively recent phenomenon that is most common in privileged segments of society.

3. Problems With the Nuclear Family

For many of us, especially those who grew up in communities where the nuclear family is the norm, it can be so ubiquitous that we don’t realize how it fails to meet our needs. The nuclear family can become so internalized that we don’t see its problems. But it does have limitations, and it can cause problems. I will briefly discuss ten of these issues.

First, the modern nuclear family liberates the most privileged, while making the vulnerable more vulnerable. It provides freedom for rich adults but takes away the family safety net that is crucial for poorer families. David Brooks explains that rich people have the resources to effectively buy extended family and child-care labor, while low-income families cannot. As Brooks argues, “The shift from bigger and interconnected extended families to smaller and detached nuclear families ultimately led to a familial system that liberates the rich and ravages the working-class and the poor.”

Second, it has been bad for many elders. (See my post on Elderhood here.) Until 1850, approximately three-quarters of Americans over age 65 lived with their children and grandchildren. In 1990, only 18 percent did. This has created widespread loneliness: According to the AARP, 35 percent of Americans over 45 say they are chronically lonely.

Third, it has been bad for many kids. The nuclear family can be suffocating and put too much pressure on kids. They can become the sole focus of “helicopter parents” and develop anxiety and narcissistic tendencies. It’s also bad for kids who are in abusive or emotionally toxic family situations. In the nuclear family, there is no escape valve; and foster care is often a worse option. Moreover, children still largely are treated as property, and it is legal in all 50 U.S. states for parents to hit their kids. The nuclear family perpetuates these harmful ideas of ownership.

It takes a village because different people have different needs at different times in their lives. Kids – and adults – need exposure to different people and ideas and perspectives. They need a variety of social interactions and relationships. In a communal situation, kids live around many adults, learning different perspectives, relating to a variety of people. But the nuclear family limits these opportunities. The nuclear family isolates children from the village.

Fourth, the nuclear family causes more instability and uncertainty in families and society. Extended families and social groups provide resilience because more people can share burdens and can help deal with unexpected problems – if a family member gets sick or loses their job, there are more hands to help out. But the nuclear family has weakened these networks. This creates a cascade of instability. The nuclear family leads to individualistic mindsets, which in turn leads to more isolation. Which leads to more uncertainty and instability. It’s a self-perpetuating cycle.

Fifth, the nuclear family can be bad for health and wellbeing because it causes more isolation and loneliness. In an article titled Alone, Kay Hymowitz says there is an American epidemic of loneliness: “Only around half of Americans say they have meaningful, daily face-to-face social interactions…Loneliness, public-health experts tell us, is killing as many people as obesity and smoking.” In contrast, multigenerational and communal living means more social interactions.

Sixth, the nuclear family can create more stress and greater burdens for adults and parents. R.D. Laing, a radical psychiatrist active in the 1960s, examined the irreconcilable demands and pressures of modern family life. “‘In the nuclear family’, Laing explains, ‘husband and wife are supposed to be everything to each other to satisfy all economic, emotional and sexual needs... They’re kicked in but feel too guilty to escape. And their frustration and resentment sticks to their children. It’s a pretty miserable scene.” The nuclear family may be making our lives more difficult because it means more work and pressure for the parents, and more pressure on the kids. Having only two adults in the household can mean greater burdens and more stress for all.  

Seventh, the nuclear family has long been criticized by feminists for its central role in regulating gender and sexual freedom; subordinating women and children; and epidemic amounts of private, gendered violence. Women were – and often still are – expected to do the majority of the domestic labor. Women were long treated as passive property and are still subjected to horrific levels of domestic violence. A 2018 UN report, which found that a majority of female homicide victims worldwide were killed by their partners or family members, was released with the telling headline that the home is “the most dangerous place for women.”

Eighth, the nuclear family perpetuates inequality and class divisions. The wealthy nuclear family manages and passes down property and wealth to children, rather than distributing resources for the betterment of society.

Relatedly, the nuclear family can work against taking care of others in the community. People start looking out for their children at the expense of others. Many parents will do “anything” for their kids, but they do nothing for the unhoused, hungry, and oppressed who live in their communities.

Ninth, the nuclear family weakens community and strengthens the power of the state and corporations. When we live in small, isolated families, we rely on our broader communities less and have fewer social connections. When people and communities have fewer connections, they communicate less; they don’t build collective power. They become more polarized and easier to manipulate. In turn, they need to rely on the state and corporations to provide for their needs.

Tenth, the nuclear family is harmful to the environment because it consumes more resources and energy, per capita, than more communal forms of living. From an environmental perspective, it is usually less efficient because there is less sharing of resources and energy. For example, each small family unit might have their own dishwasher, washer/dryer, food pantry, kitchen, etc. They prepare meals and clean for four or five people at a time. They might have two cars for four people. This is much less efficient than large, communal meals, which use common spaces and share resources. The nuclear family is good for consumerism and capitalism but arguably bad for the environment.

4. Why the Nuclear Family Persists

If the nuclear family has all these problems, why is it still so common?

The first and most obvious reason is that, while many childhoods are unhappy, most families are actually not that miserable. For many people, the nuclear family is a relatively happy place. If there is no visible alternative, there is nothing to compare it to. It becomes ingrained. By accepting what is (or, what seems to be), many people find happiness in the nuclear family.

A common reason given for the popularity of the nuclear family is that it can provide more freedom and independence than communal living. According to this view (which is held by David Brooks, for example), in a nuclear family, everyone can have their own space and do their own thing. The flip side of this narrative is the assumption that living with extended or communal families offers less freedom and privacy.

But I think this is a limiting, Western-centric view that is biased toward the nuclear family. The reality is that many people who grow up in nuclear families feel controlled, stifled, and trapped. And many people who grow up in multigenerational or extended-family households have lots of freedom and autonomy.

Moreover, this biased view misses a key point: the nuclear family can actually undermine the values of autonomy and freedom. Individual freedoms can’t effectively be realized without community support. Individual wellbeing depends on interdependence and community – on loving relationships and care.  

Another possible reason is that “the market” wants us to live alone or in isolated units. In other words, the nuclear family is better for wealthy capitalists. That way, as Brooks describes, the rest of us “are mobile, unattached, and uncommitted, able to devote an enormous number of hours to our jobs.” And the nuclear family is good for companies selling consumer goods, because then we need to buy more products for each household.

Laws and business practices in the U.S. also make other family arrangements difficult. The legal and economic system routinely favors and promotes conventional marriage and family arrangements. For example, it’s difficult to get a loan for cooperative or shared housing. And child protection agencies often privilege conventional nuclear families over alternatives, which has a disproportionate effect on Black, Indigenous, and other families of color. For instance, social workers often interpret a Black or brown child moving between different households as instability, when it might actually be a sign of community resilience, adaptability, and support. 

Inertia is another reason the nuclear family sticks around. Many people never learn that alternatives to the nuclear family are possible, so they continue to follow the same patterns.

But some people do learn about alternatives. They might then question the idea of the nuclear family and realize it isn’t above criticism; they might see how it actually harmed them. For these people, reversion to the nuclear family might be caused by psychological resistance. Most people want to tell themselves a story about how they had a happy childhood, and how their parents did the right things. Questioning the nuclear family means questioning that story. That learning process can feel uncomfortable and painful. Some people may find it easier to ignore the issue.

Finally, the nuclear family persists because it can be a refuge from violence in society, especially for the most vulnerable. As Kathi Weeks points out, “while it is clearly not a separate haven from capitalism, the private family may nonetheless offer a place of sanctuary” where love, tenderness, and compassion can find refuge from ruthless capitalism, racism, and other oppressive forces.

5. Where Do We Go from Here?

We now know that the nuclear family is not inevitable. We know that there are many problems with the nuclear family. We know it can cause harm. And we know there are alternatives.

So, what comes next?

My feeling is that we should do whatever best helps us meet our needs and support one another. This means exploring different options for family and social arrangements. These options could certainly include the nuclear family. But we should have more freedom to pursue alternatives. 

Some say that the way to achieve these goals is to abolish the nuclear family. “Abolish the family” is a startling phrase to many people. The proposal is triggering and is rife with uncertainty. M.E. O’Brien says that the idea of the abolition of the family evokes “the complete, almost inconceivable transformation of day-to-day life.”

But what if we tried to conceive it? What could it look like?

According to ME O’Brien, “The abolition of the family could be the generalization of human care in the real human community.” In other words – a world where we all care for each other, regardless of blood or legal ties.

The abolition of the nuclear family could also mean a much richer, more diverse, and realistic view of relationships. As Kathi Weeks writes, the nuclear family model “imagines that a single partner can serve for a lifetime as sexual partner, romantic lover, friendly companion, income-pooler, co-parent, domestic co-worker and partner in aging.” If we disaggregated some of these roles, and spread them around to different people, we could, as Weeks says, “open up infinite possibilities for different households, patterns of intimacy and social networks to develop.”

So, basically, one path forward would be to reimagine our relationships and their functions; creating new ideas about who can fill different roles in our lives. We can reimagine who cares for who. And we can be open to new possibilities and arrangements.

In a world filled with options, some may choose a form of the nuclear family as their desired household setup. But as Weeks writes, “The point of the exercise is not to celebrate or condemn, but to imagine a future in which no one relational or household model is expected, privileged or over-invested with hope.” In other words, the abolition of the family is not about moralizing or shaming those in nuclear families; it’s about opening possibilities for how we relate to and care for each other.

Okay, but how does this practically come about?

As discussed above, multigenerational and extended-family living is one time-tested form of community. Other concrete alternatives include cohousing and other forms of communal living. One barrier to these, in the U.S., is the difficulty in getting loans for cooperative housing. In contrast, Danish and Swedish governments have long supported cohousing, and made it easier for cooperatives to get loans because cohousing provides more supports that strengthen the middle class and allows for better community and childcare support.

But while cohousing works for some, other problems still need to be addressed. Care needs to become more widely available. Michele Barret and Mary McIntosh explain, in The Anti-Social Family, that “What is needed is not to build up an alternative to the family…but to make the family less necessary, by building up all sorts of other ways of meeting people’s needs.”

For instance, Sophie Lewis has argued for a version of family abolition in which the family as we know it no longer exists: “Everyone, regardless of gender, is a surrogate; we mother each other” and do collective child-raising.

Another possibility would be state-provided financial and housing support for young people so that they wouldn't remain economically dependent on their nuclear families. Basically, making it possible for kids to leave families they don’t like by giving them resources to live independently.

It really comes down to meeting people’s needs. Different people have different needs at different times in their lives. Our social arrangements should accommodate these changing needs. That means they need to be flexible and responsive. So, the best approach is probably no single proposal. The best approach may be to continuously listen to and care for each other. Once we understand each other’s wants and needs, and commit to caring for each other, solutions will flow from that.

6. Toward Healing

The nuclear family has created fractures in our social lives. The disconnection and fragmentation of social relationships has created trauma. There is trauma from isolation. There is trauma from instability and uncertainty. These are deep intergenerational and societal traumas.

Healing will be a long process during which we learn to reestablish social bonds and create new connections and relationships. Healing will mean learning to care for each other again. Not just our parents or immediate family; not just our extended family; but our entire community.

As we learn, we heal. We can learn about what kinds of connections and living arrangements are possible. We can look to arrangements that have worked in the past – and that continue to work for many cultures and communities – and see how to make more satisfying and supportive living situations and relationships possible. We can imagine alternatives. Through this learning and imagining, we heal.

The point is not that the nuclear family is morally bad or wrong. But the nuclear family has caused us harm and trauma through isolation and disconnection. Healing is needed. Imagination and learning can help us find alternatives that better meet our needs. And these new connections and relationships could provide us with happier and more meaningful lives. 

Universal Basic Income Should Include Kids

Would kids get a universal basic income (UBI)? 

Andrew Yang and other proponents of universal basic income typically say that UBI is for adults 18 and over. 

That doesn't seem very universal to me. 

As I see it, there are five major approaches. 

1. The most common -- the Yang approach -- is that kids don't get any UBI. Not for them, not for their families. Only people age 18 and over get UBI. 

2.  A "child allowance." This approach is gaining in popularity. It means a set amount of money given to parents/guardians for each child. This approach means that adults don't receive UBI for themselves, only for their children, if they have them. 

3. UBI should be extended to kids, but it should be given to the parents or guardians. This would operate like the PFD does in Alaska, where cash payments are made annually to parents/guardians -- a set amount for each child -- and then the parents/guardians can do what they wish with the money. It's basically a combination of approaches 1 + 2. 

4. Give UBI directly to children. Of course, with very young children, the money would need to be put into a trust, so that they have it when they are capable of using it. One notable supporter of this idea is the Stanford philosophy professor Juliana Uhuru Bidadanure, who advocates for this approach in her recent book Justice Across Ages. 

5. Give UBI directly to children, but only above a certain age. For example, all children old enough to work could be given UBI (say, 14 years old, in most U.S. states). 

I think the fourth approach makes the most sense. If it is truly "universal" basic income, it needs to be for everyone, regardless of age. 

Youth poverty is a massive issue. And because most young people can't get paying jobs -- and the jobs they can get are usually low-paying and precarious -- young people especially need the extra financial support. 

Finally -- and this is probably one reason for adult resistance to the idea -- a UBI for kids would mean that kids are no longer as economically dependent on their parents/guardians. Kids would have more independence and more autonomy. They could leave abusive or unhealthy living situations, and they could follow their own path and seek supportive communities. And they would have the resources to do it. 

Let's Talk About Universal Basic Income

Universal Basic Income (UBI) is the idea that everyone (well, sort of everyone) would receive an income just for being a person, with no qualifications. 

Let's discuss four issues regarding work and UBI.  

First, even from a capitalist perspective, fewer people working could be a good thing. 

Second, let's talk about the assumption that "people want to work." 

Third: UBI would finally compensate people doing "care work" and other "informal" labor. 

Fourth: Why so much concern about people working? What happened to machines doing most of our work and people living the good life? 

Let's take these one at a time. 

First, from a capitalist perspective, fewer people working could be a good thing.

One of the oft-repeated talking points against the proposal for UBI is that if everyone got paid just for being a person, this would reduce the incentives to work. And so fewer people would work. 

The assumption behind this argument is that having fewer people who work would be a bad thing (because it's good for people to work). 

But what if fewer people working would be a good thing? Let's put aside the empirical debate about whether or not UBI decreases the number of people entering the workforce, and assume that it would (although this is far from clear). Then what? Or, so what? 

Many of the same people arguing against UBI are the same people that value efficiency in the capitalist economy. But if what we really want is efficient production, then we should want to have the fewest people working as possible. Here's why. 

Currently, companies can rely on cheap exploitable labor. But with UBI, everyone would have enough money to live. People wouldn't need to take exploitative, low-paying, mind-numbing, exhausting, unfulfilling, dangerous, jobs just to survive. 

Instead, companies would have two options. 

They could create more meaningful positions that would satisfy the basic human desire for creative, satisfying work. This would result in more responsibility and creativity for workers. Which, in turn, could certainly lead to more productivity and efficiency. 

Or, without as many available workers, companies would have to get creative to achieve better efficiency. If fewer people are working, companies would have incentives to innovate and develop more efficient production. 

So, we see that fewer workers could increase efficiency. 

Second is the idea that "people want to work." This is an argument often used by people in favor of UBI. They say that even if people had a basic income, they would still work, because "people want to work." 

But I don't think that's quite right. 

I think what we really mean is that people want to be valued. We want to contribute to our communities. We want our actions to have meaning. We want to be a part of something. 

In our current society, the primary and most recognized way to accomplish all of these goals is to work for money. That could mean working for a start-up, becoming a teacher, building houses for a construction company, or working at a non-profit that helps kids. Wage labor is the dominant channel for people's desire to be valued and contribute. 

This doesn't mean, though, that "people want to work." It means that people want to live meaningful lives, with and/or for other people. 

Work is the dominant way for people to do this currently. But it doesn't have to be. We could (and already do) find other ways of achieving meaning, outside of wage labor. 

This leads to the final point. 

Third, much of the work already being done is unpaid. UBI could help address this injustice. 

This point is well known to feminists, undocumented immigrants, people of color, and many others involved in social justice struggles. 

Basically, much (perhaps the majority) of the value produced in our current economy is unpaid work. This includes many forms of care work, taking care of children, emotional labor and support, etc. 

The existing scheme of wage labor exploits -- and only exists because of -- this unpaid work. 

And precarious labor is only getting more common, and increasing numbers of people enter (or are forced into) the "gig" economy, informal sectors, or other forms of precarious labor. 

UBI would ensure that these people would be compensated. Likely not as much as they should be, but it would be a start. 

Finally, why so much concern about people working? What happened to machines doing most of our work and people living the good life? 

In a society where 40% of people (in Western countries) think they have "bullshit" jobs -- jobs that don't need to and probably shouldn't exist -- why are we still working so hard? 

A free market was supposed to eliminate inefficient, unnecessary jobs. 

What happened? 

There's obviously enough technology to easily provide for all of our basic needs. For example, only a small fraction of all workers are involved in agriculture and food production. And even there, inefficiency reigns supreme because of large pools of exploitable labor.  

Of course, one response is that consumer culture controls. People work so that they can consume things they want but don't need. Nice things. Fun things. 

Another response is that capitalism has made work necessary by depriving people of their basic needs, withholding support until and unless people do wage labor. 

But even beyond this, many people have come to believe that work is morally good (see, e.g., the Protestant work ethic). 

UBI can help us break these patterns. At least I hope it can. 

Because I would love to live in a world where machines do all the boring stuff, where all people have their basic needs met, where care work is compensated, and where we pursue projects not because it is paid "work," but because we are doing what we love. 

Radically Inclusive Mental Health Care

Mental health care in the United States is inadequate. But models of radically inclusive community-based mental health care programs may offer a partial solution. 

The Challenge of Mental Health Care

The city in which I live lacks adequate systems of support and care for people experiencing mental illness. The result is many individuals who are houseless, suffering, and left with few good options for securing shelter, support, stability, or community. 

These tragic outcomes are far too common. The existing mental health care system, while arguably improving, is still devastatingly inadequate and causes substantial harm.  

At a high level, some psychologists argue that current mental healthcare isn't truly person-centered; it is overly bureaucratic and too focused on predetermined timelines and pathways to recovery. 

Other problems are more visceral and disturbing. 

For example, millions of people each year are coercively, forcibly institutionalized in psychiatric facilities. These can often be very traumatic experiences. One psychiatric survivor described their experience in Canada’s psychiatric system as "years of white-knuckling it through months-long wait-lists just to get an intake appointment, late nights in the ER with panic attacks that wouldn’t stop, wards with doors that lock behind you with a gut-wrenching click." 

Moreover, the rate of people with mental illness who are incarcerated is an atrocity. According to one study from 2017, roughly half of all incarcerated people in the U.S. have a diagnosed mental illness. This indicates that something is seriously wrong with our existing systems of care. 

And because of its largely Western biases, psychiatry often fails to provide effective mental health care for groups such as certain Indigenous peoples, who may have different conceptions of health and wellbeing. 

I used to often wonder whether there was a better way to provide support and care for people with mental illness. But, like many people, I usually just assumed that it is a tragic part of life with no good solutions. 

That is until I first heard about Geel. 

Introducing Geel 

In the small town of Geel, Belgium, the residents have a centuries-old tradition of welcoming people with mental illness into their homes and community and caring for them as long-term members. 

Geel offers a place for people who are unable to cope on their own and who don't have other supports. These include people with chronic psychiatric issues like schizophrenia, personality, and mood disorders. 

It is, in essence, a therapeutic community. 

But it is not primarily about psychiatric treatment. The people with psychiatric diagnoses are not called patients. They are known as "guests," "boarders," or simply part of the family, and they share a life with the residents of the community, often for decades. They are treated like members of the family and community -- because they are. 

This model seemed to go against what I had previously learned about mental health care. Instead of primarily viewing psychiatric diagnoses as "problems" belonging to "patients" requiring "treatment," often in segregated "facilities," the Geel model understands people with psychiatric diagnoses as people, first and foremost. The community appreciates difference, rather than medicalizing and stigmatizing it. 

How and Why The Geel Model Works 

The Geel model creates a baseline of radically inclusive acceptance. It also demonstrates a person-centered approach to mental health care. 

As one psychiatrist put it: "Accepting what is, not demanding what should be, seems to be the motto." [1]

A Geel resident explains the secret of its success by pointing to three factors: 

• "Geel acknowledges and accepts the human needs of boarders. 
• The city responds to those needs, rather than acting on unfounded or exaggerated fears, by providing social outlets and events as well as opportunities to do meaningful work. 
• Most importantly, those with mental illness in Geel are members of not just a foster family, but a foster community as well." 

There is tremendous evidence of success. For one, the average length of stay in the family care program is roughly 30 years. Moreover, due to the general well-being and a sense of security among guests, levels of medication often drop significantly. [2]

A description of the system in Geel explains how instead of focusing on problems with the guests, the aim is to highlight their abilities and strengths; the focus is on care, not cure. It further explains that: 

"Most radically, the program works to reshape society to be fully inclusive instead of forcing people with mental illnesses to try to accommodate an intolerant society. The end goal is for boarders to be able to live in a world that accepts them for who they are." 

Another reason it works so well is that inclusivity can be healing, while exclusion can lead to further harm. And many other cultures are isolating. As one psychologist describes it: 

"When there is little opportunity for personal contact with [severe mental illness]...this limited, unrealistic exposure to mental illness can feed community fear. It can also help to keep alive the insidious social stigma associated with mental illness, a stigma that contributes to isolation for persons with [severe mental illness] and complicates successful diagnosis and treatment."   

In other words, our current system often isolates people with severe mental illness, rather than including them, or offering the option of inclusion. This limited exposure can further stigmatize mental illness and inhibit understanding and care. 

In contrast, the Geel model of community-based and family care normalizes psychological differences. It allows everyone to see that mental illness is a part of life. And it fosters participation, acceptance, and understanding, which leads to compassion and support. 

Of course, the Geel model has also been criticized. The debate over the efficacy of the family care system was known as “The Geel Question”: Was the boarder system more humane than that of the psychiatric institution, and was it something that could be replicated elsewhere? 

Since the introduction of modern psychiatry as a way to supplement family care and the boarder system, this debate has largely been settled. As the experiences of many people with psychiatric diagnoses make clear, community-based care can be profoundly therapeutic. Geel's approach is considered by many, including the World Health Organization (WHO), to be an example of best practice. 

It is also important to note that the current Geel model works with modern psychiatry. Thus, people experiencing mental illness get the benefits of the incredible advances in psychiatry, while still maintaining a primary focus on inclusion and care. It's not an either/or situation: the approaches are complementary. 

Community-Based Mental Health Care in the U.S. 

If the Geel model is considered best practice, why had I never heard of the family care system until a few years ago? And why is Geel seemingly one of the few places in the Western world where this practice exists? 

After doing some research, I found that similar models do exist. In fact, American psychiatrists have been interested in the Geel model of family care for over 150 years, and have implemented similar programs in the U.S. 

As early as 1885, family care programs were successfully operating in the United States. Psychiatrists carefully documented these programs and noted that "patients placed in family care were generally found to be comfortable, contented, and in good bodily condition." [3] Early analyses concluded that the family care/boarding system was practically feasible and generally ran smoothly, with no violent incidents [4]. 

By the 1940s, there were family care systems operating in Pennsylvania, Utah, Illinois, Maryland, Michigan, California, and Rhode Island. [5] There was an abundance of willing host families, which was encouraging because many people had questioned whether the different social environments in America would be receptive to family care. [6] But contrary to pessimistic predictions, families embraced persons with mental illness, no evidence of exploitation was found, and family care thrived for a period in the U.S. [7] 

These findings dispel the myth that the family care system is unique to Geel and thus impractical elsewhere. In fact, family care has already been done successfully in American communities.  

Today, community programs still exist in the U.S., although they are not very widespread. 

Examples include the Village (which has spread to Full Service Partnerships -- a comprehensive community-based system of care throughout California); Broadway Community Housing; and the Gould Farm, established in 1913 and located in Monterey, Massachusetts. 

Another example is Toward Local Care (TLC), a program run by the state of South Carolina, which aims to help clients remain in the community and decrease reliance on and costs of psychiatric hospitalization. TLC's "Homeshare" program is very similar to the Geel model, and clients overwhelmingly experience significant improvement in perceived quality of life after entering TLC programs. 

All of these programs focus on mental health and wellbeing through human relationships, meaningful work, stability and support, and fostering a sense of community. Together, the various programs discussed here demonstrate that community-based care can be -- and currently is -- done successfully in the U.S. 

However, there is also a large mental health gap between what is available in wealthy countries and poorer countries. [8] A lack of resources and trained professionals in low-income countries often leads to less community mental health care. And in many countries, forms of involuntary or forced treatment are commonly practiced. [9] 

This gap shows the importance of both developing local solutions as well as providing international assistance and resources when they are needed and wanted by communities. 

The Geel Tradition Fades As New Challenges Arise 

Despite its success and its role as an inspiration and model for effective mental health care systems internationally, the tradition of family-based care in Geel has been fading due to several factors. One reason is the increased use of psychiatric medication: more individuals with clinical diagnoses can now live with varying degrees of independence. Deinstitutionalization, medication, therapy, and supported living systems have made care in the community the norm. 

Fortunately, the Geel system has evolved to accommodate these changes even as it cares for fewer people. The improvement and integration of modern psychiatry with the Geel system show how Western psychiatry can coexist with, and supplement, community-based mental health care. It is not an either-or situation. Rather, each individual person has different needs that can be served by a combination of different approaches, including therapy, a supportive community, a stable home environment, and medication. 

Yet another reason for the decline of the Geel system is that few families are able or willing to take in boarders. One reason is that government support -- in the form of stipends -- for the program has decreased, making it more difficult for families to care for additional people.

Moreover, most families no longer work on farms or around the home, so it is more challenging to do traditional day-to-day integrated care. And modern cultural shifts, like the desire to have the freedom to travel, disrupt the patterns on which daily care is based. 

These are all obstacles to any modern community-based family care system in a wealthy industrial society. Implementation of such a system in an American city will have to address these challenges. 

These problems are also related to the increased isolation of the nuclear family so common in middle-to-upper class communities in America. I plan to expand on this idea in a future post. For now, let's note that the isolation of the nuclear family, and the reduced connections with extended family and community experienced by many Americans, have led to a greater sense of insecurity and greater burdens placed on individuals. Because fewer people are burdened with more responsibility, taking care of each other is harder. 

Moreover, in the U.S., millions of people struggle just to pay rent and put food on the table. And the social safety net is full of holes or nonexistent for many. In these situations, it is unreasonable to expect people to take on the responsibility and financial cost of caring for strangers with mental illness. 

In other words, creating systems of support and care is not just a mental health issue, it is a societal problem. As author and historian Mike Jay puts it: 

"Who would not wish to live in a community where such extraordinary resources of time, attention and love were available to those who needed them – but who these days can imagine being in a position to offer them?"

Many of us feel burdened, unrooted, disconnected, and financially insecure. Under these conditions, it is hard to imagine devoting such significant time, energy, care, and resources to a vulnerable person. 

The Shift to Community-Based Care 

Many mental health professionals would probably argue that this shift has already been occurring, and they have a valid point. 

In recent decades, there has been a massive shift toward deinstitutionalization. The success of psychiatric medication has allowed many people with mental illness to live and thrive in their communities. And programs like Assertive Community Treatment (ACT) and others discussed above have facilitated greater community integration and holistic care (at least in the relatively few places where they are available). So, in a sense, we are already moving toward community-based care. 

However, as noted at the beginning of this post, while we can acknowledge that some progress has been made, we must realize that we still have a long ways to go. This is especially true for young people experiencing mental illness and distress. For example, in Alaska, hundreds of foster youth have been sent to facilities out-of-state because there are inadequate community-based mental health programs in Alaska. 

A shift toward more and better community-based care programs would be a positive step. Many successful examples of community-based care exist. Yet people often become discouraged in applying these examples to the existing system because of what they perceive to be a complex and overwhelming problem with no good solution. [10] 

I hope that some of this discouragement can be overcome by better understanding the success of Geel-type programs, and seeing how they could be implemented in our communities. In other words, Geel helps us see how to shift away from a system of fear and isolation, and towards a system of support and acceptance. 

What Does Implementation of Community-Based Care Look Like? 

First, we can continue studying the communities where community-based care is more of a norm. We can learn from these communities and begin implementing or expanding these programs in our own communities. Studying these details can help us imagine how a system like this might work in our own communities. 

For example, in Geel, the acceptance into a family placement typically requires that (a) the acute phase of psychosis or other problems has passed, (b) aggressive behavior needs to be reasonably well under control and there is no history of sexual offenses or serious crime, and (c) patients should be capable of emotional attachment, some form of communication and doing things independently. [11] While these are not always strict rules, they do help us understand the potential scope and limits of a family care program, because we see that not all people could be supported in that way. And they help us see how potential host families could feel more encouraged through having predictable boundaries. 

Another detail is that the foster families in Geel are not trained in psychiatric treatment or care. [12] It is not a medical approach, but a common-sense approach based on experience -- a practice of "radical compassion and kindness." [13] However, when psychiatric expertise would be helpful, there are mental health clinicians available to support families whenever they need it. 

As for the day-to-day life of the guests, half work (at local businesses or in the psychiatric treatment center in town) or attend occupational therapy, while the other half stay at home. All boarders are welcome to frequent one of three community centers. [14]

And, yes, for those of you wondering about the costs -- the Geel-style model is much, much less expensive than psychiatric hospitals or supported living. [15]

Geel can also help us address the relationship between mental illness and violence. [16] The Geel system appears to have successfully prevented violence by people with mental illness and has never had an extraordinary problem with violent behavior. [17] The reasons for this success are varied and include the fact that the community has experience with nonviolent de-escalation and stabilization of potentially agitated or aggressive persons with mental illness, and there is a familiar and reliable support system to do this work. [18] 

The Geel model gives us ideas about which people might be best suited for family care; what training is needed for host families; what day-to-day life could look like; and how to understand issues of violence. 

In the short term, we can push for concrete solutions like more community centers where people with mental illness can spend time; more and better community-based mental health programs; and reform or abolition of coercive psychiatric practices. We can also create educational programs so people can learn to understand and care for those with mental illness; we can teach acceptance and care. 

These can largely be local efforts. But the implementation is only going to occur if there is social and political support. This begins with a culture of acceptance. 

The Cultural Shift 

The transition to radically inclusive community-based mental health care may require a cultural shift. Geel is so unique because there is a long-standing tradition of embracing neurodiversity and supporting those who need additional care: "Because of their exposure to and experience with mental illness, the entire population protects rather than fears members of their community who are mentally ill." [19] 

That said, as discussed above, early family care programs in America showed widespread support and acceptance from families and communities. This suggests that Geel is perhaps not so unique in this respect.

Still, I question whether, with the cultural and psychiatric developments of recent decades, many Americans would be willing to try a similar program. 

I am sensitive to this because when I first learned of Geel, I asked myself: would I be willing to invite a stranger with severe mental illness to live in my home for years? My initial reaction told me a lot about my unconscious biases. However, over time I have come to believe that I would be grateful for an opportunity like that. 

Like many things, the shift will happen over time. If people began inviting and accepting those with mental illness -- and without other supports -- into their families and communities, there would be greater understanding and embrace of neurodiversity. Which would lead to more inclusivity and support. 

I should also note again that this is just one model of care among many. People with mental illness or disabilities are all unique, and each has individual needs and preferences. A model of care that works for some might not work for others. My point is not that all people with mental illness should live as guests with families. I am simply showing that this model has worked for many; that it should be an option; and that greater inclusion of and support for people with mental illness is an important aim to work toward and demand. 

In conclusion, the Geel model -- and others based on it -- has much in common with modern approaches to community-based mental health. But it has changed my perspective through its commitment to inclusivity, acceptance, family relationships, and community participation. 

As two keen observers of the Geel experience noted: "Perhaps Geel just offers one intervention: radical compassion and kindness. And the outcomes are lives lived." [20]

Elderhood: A Summary

I recently finished the book Elderhood by Louise Aronson (2019). While it was a bit repetitive and poorly organized, I learned quite a lot from it. I am writing this post to summarize and synthesize what I’ve learned into a few major points. Feel free to skim the numbered, bulleted, and bolded points below.

Louise Aronson is a geriatrician – a physician who specializes in the care of the elderly. She has been immersed in the medical field for decades, so the book is written from the perspective of a medical professional and focuses on health-related aspects of “Elderhood.”

The overall gist, as I understood it, is this: In the United States, our society and health care systems do not adequately care for the elderly.  

The book’s main points can be grouped into three thematic areas: (I) how we fail the elderly; (II) the underlying causes for those failures; and (III) how we can do better.

 

I.            How We Fail to Care for the Elderly

Aronson offers numerous illustrations of ways that our society and health care systems fail the elderly. Because the critiques were wide-ranging and sometimes hard to keep track of, I grouped them into the following three categories

1. Problems With Medical Education:

In medical education, there is generally very little emphasis on geriatrics. As a result, many doctors do not adequately understand issues that more commonly affect elderly patients, like dementia or mobility issues. Medical textbooks can also be problematic because they typically devote minimal pages to elder-specific issues, and often lump all people over age 18 together as “adults,” ignoring the unique needs of older patients.

2. Problems With the Health Care System:

Aronson repeatedly challenges what she perceives as the limited scope of what counts as medical (i.e., the work of doctors counts more than the work of nutritionists, physical therapists, and social workers). She says that “the line between medical and social care is created by politics, not biology. Most European countries began providing glasses, hearing aids, walkers, and dentures as part of National Health care.”[1] However, in the United States, these same treatments are often viewed as nonmedical, and therefore receive less attention and resources.

Another major problem is the health system’s focus on medicalization rather than care. This results in over-medication and over-hospitalization. According to Aronson, it’s far too common for older persons to be given medications that are not appropriate, which then cause hospitalization, where other adverse events follow.[2] Moreover, a fragmented medical care system – i.e., a system composed of many specialists who don’t communicate – results in “prescription cascades” and redundant tests and procedures.

Here are a few of the other major issues with the health care system and its treatment of the elderly:

·       Scientific medical research/studies on the effects of medications often ignore the unique needs of the elderly or fail to include adequate numbers of older persons in study populations.

·       In the medical field, “normal” is often defined in terms of a middle-aged adult. This means that something normal for an older person is often perceived as a problem to be fixed, rather than a natural development to be accommodated.  

·       Too many older people are forced to go on once they’ve passed their natural and preferred thresholds because of medical “care.”[3]

·       Nursing homes are often so fearsome and have such terrible conditions that many older people won’t admit to serious needs for fear of ending up there.[4]

·       There is a lack of home-based care and support. This results in over-hospitalization, which can be traumatizing and lead to worse outcomes.

 3. Problems With Society’s Treatment of Older Persons:

The lack of attention and care dedicated to older persons is not only a feature of the health care system; it permeates society at large.

Some of the major problems include:

·       Lack of accessibility. It is often difficult for the elderly to navigate basic public spaces and services because they are not designed with older persons in mind.

·       A cultural fear of death and an emphasis on prolonging life at all costs, even where not appropriate or wanted. This means that many older people endure prolonged suffering even when they would prefer to end their lives because our society generally does not deal well with death. As Aronson notes, “different people draw the line in very different places as far as where they would like to die.”[5]

·       The segregation of older people. Many families have transferred their responsibility for care to the state, via nursing homes and institutions. This puts elders “out of sight and out of mind,” similar to how those with mental illness are often treated. We still haven’t found a satisfactory solution for the segregation of older persons. Aronson suggests that this means our approach to care is probably fatally flawed.[6]

·       Failure to respect privacy and autonomy rights of the elderly. Too often, the privacy rights of the elderly are not respected: “Too often younger people assume incapacity in old people until proved otherwise, instead of the other way around.”[7]

·       Arbitrary age lines: “[T]he dividing line of sixty-five is historical and in many lives outdated.”[8] This line – designating people over 65 as elderly – can result in an older person’s autonomy and agency being taken away if a younger person disapproves of their lifestyle choices and calls Adult Protective Services.

·       Marginalization and lack of purpose. For many older people, the deepest pain is caused by not having a reason to get up in the morning. Many older persons, wanting “to make a difference in the world but, finding no role for themselves, [are] treated as socially useless and even invisible.”[9]

 

II.          Underlying Causes of the Failure to Care for the Elderly

After detailing the problems with the health care system and society’s treatment of older persons, we must ask: Why is this the case? What are the causes of our failure to care for the elderly?

One reason is that: “We treat old age as a disease or problem, rather than as one of three major life stages.”[10] So, we would do better to treat old age as a natural stage of life. We could properly acknowledge its upsides: “the decreases in family and work stress or the increases in contentment, wisdom, and agency that accompany most years of old age.”[11] But why isn’t this done in the first place?

A possible explanation is that ageism – age-based discrimination – is deeply rooted in our society. Ageism dehumanizes the elderly; it means seeing older persons not as unique human beings but as group representatives. Ageism results in othering and stereotypes; casting the elderly as sick, frail, lonely, senile, and rigid in their thoughts and beliefs.

But why has old age come to be so reviled in our society? What is the source of this ageism against the elderly? As one explanation, Aronson observes that the United States is a “productivity”-centric society (where productivity is measured in conventional economic output, defined as increasing monetary wealth). Therefore, the ability to produce consumable goods and services – creating monetary wealth – is valued. And, because a person’s function, efficiency, and therefore conventional economic output, typically decrease with advanced age (i.e., they can’t work as hard or as fast or for as long), a productivity-centric society values them less. This is especially so when their care requires more resources and time from younger people.

Of course, this is not the case in all societies. And it’s not the case in many cultures, communities, and families with the United States. But the devaluing of the lives of older persons is a dominant reality in the United States that is reflected in policies and practices at nearly every level.

 

III.        How We Can Do Better

“The first step toward a less ageist health system is acknowledging the problem.”[12] First, we need to understand that our society marginalizes older people and neglects their health. Then we can begin developing solutions to fix that problem.

Aronson suggests a new paradigm focused on care that “begins with the desired outcome, rather than an approach that may or may not lead to that outcome.”[13] In other words, instead of linking treatment to what is deemed medically wrong with patients, we should focus on finding out what a person needs to do to be happy and safe in their individual daily life.[14] Once we know this, we can work together to achieve those daily life goals.

More specifically, Aronson makes several policy recommendations. First, she suggests that, whenever we apply medical science or care “to people by age and are tempted to divide the lifespan into just childhood and adulthood, we should add elderhood to the list as well.”[15] This would apply to CDC health guidelines and FDA approval of medications, for example.

Second, she proposes “Silver” building standards to increase accessibility for the elderly and disabled: easy, safe access that doesn’t require walking long distances, opening heavy doors, climbing stairs, etc. It should accommodate wide walkers and wheelchairs and offer spaces to rest. Ideally, this would be implemented in all public spaces and homes.[16]  

Aronson observes that “lives can have meaning despite significant decline and disability.”[17] But meaning is rarely found in segregation. Therefore, we should aim for more integration of the elderly in society, and more opportunities for community participation and purpose.

In sum, there are many things we can do as a society to improve the care of older persons and work towards meaningful lives for every person, at every age.

 

---

[1] Page 111.

[2] Page 149.

[3] Page 309.

[4] Page 171.

[5] Page 309

[6] Page 187

[7] Page 307

[8] Page 306

[9] Page 311

[10] Page 71

[11] Page 74

[12] Page 72

[13] Page 379

[14] Page 145

[15] Page 323

[16] Pages 353-354

[17] Page 309