Writing history through mental health is another means through which to examine a country’s socio-political history. Joelle M. Abi-Rached’s study, “Asfuriyyeh. A History of Madness, Modernity and War in the Middle East” (MIT Press, 2020), looks at Lebanon’s history through an in-depth assessment of mental illness and the different trajectories it took as the country transitioned from being a colonial vassal state to a nation ravaged by civil war.
Abi-Rached writes, “the book uses the “biography of an institution to examine the historical processes of continuity and discontinuity and of stability and instability, and to question the politics and ethics of memory.”
Endorsed from its inception by Lebanon’s intellectual and political elite, the mental health hospital, Asfuriyyeh, was founded in 1896 by a Swiss Quaker missionary. Its focus on providing a more humane approach to treating mental illness was not merely a question of medicine, but also a reckoning with the perceptions of mental health in Lebanon and the Middle East.
Starting with a historical overview of madness, Abi-Rached discusses the Orientalist perception of mental health in the Middle East and how writings by Western writers, including respected medical journals, simplified the concept in relation to the region. One example given by the author is the Lancet’s description: “The chief form of insanity acknowledged in the East is demoniacal possession.” However, the author’s research portrays complex scenarios: civilization, modernity, colonialism, war, and violence as contributing to mental illnesses in Lebanon and the Middle East, studied within the context of Asfuirryeh’s role.
The author refutes the perceptions of Asfuriyyeh as a colonial tool through which missionaries played a role, pointing out the conflicts between different religious orders and describing the hospital as “a microcosm of the wider geopolitical region.” This analysis is imparted clearly towards the end of the book, when the reader has grasped the earlier transitions of the hospital from a fledgling missionary project to a renowned institution that upheld the principles of non-sectarianism.
Abi-Rached identifies two main phases in Asfuriyyeh’s practice prior to its decline and eventual closure just weeks before the Israeli invasion of Lebanon in 1982: pioneering humane treatment to the locals, thus altering perceptions of mental health, and consolidating psychiatry through a focus on science and academia. The hospital’s insistence on humane treatment for patients was a departure point from earlier practices which perceived asylums as prisons influenced by cultural norms, not just criminal liability.
The hospital’s insistence on humane treatment for patients was a departure point from earlier practices which perceived asylums as prisons influenced by cultural norms, not just criminal liability.
While Asfuriyyeh evolved, juxtaposed against the rapidly evolving political scenarios of French and British influence after the collapse of the Ottoman Empire, its focus on psychiatry led to the hospital gaining a reputation for professionalism. It sought to employ qualified staff and to be a pioneer in its approach to mental health. The professional institution flourished until the end of the French mandate.
One notable progressive step was the role psychiatry played in state institutions; Ottoman law required an admission order to a mental health asylum to be signed by a doctor, but the legislation was not heeded. As psychiatry gained recognition at state level in 1945, its influence was exerted over society, in terms of reach and regulations, as well as providing fellowships funded by the World Health Organization (WHO).
At the same time, within society, the concept of a psychiatric institute started to gain ground, thus minimizing the stigma associated with mental health and, in due course, Asfuriyyeh became renowned in the Mediterranean region for its expertise.
In terms of mental health practice and patients approach, Asfuriyyeh provided a glimpse into mental health from a socio-political level. Abi-Rached notes that most patients were active members of society and a strict admission policy was followed to prevent overcrowding in the premises. The author establishes a link between emigration, war, and mental health, noting that such changes contributed to an increase in the need for psychiatric services.
In a clear break from past perceptions, Asfuriyyeh was seen as liberating for people with mental health issues, who were isolated and ostracized from society, or subject to the performing of religious rituals for purported cure.
Lebanon’s civil war, plagued by sectarianism and regional violence, contributed to the hospital’s demise. In the aftermath of the 1967 war, Israel extended its colonial grasp over Palestine through military occupation, and the Palestine Liberation Organization’s (PLO) presence in Lebanon was legitimized by Egypt’s Gamal Abdul Nasser, who — through the Cairo Agreement of 1969 — allowed the PLO to utilize Lebanon as a base for its armed resistance. Asfuriyyeh found itself in the crosshairs of sectarian violence, at a time when post-traumatic stress disorder was prevalent in society.
Abi-Rached’s discussion of this era is particularly insightful, notably the discernment on what constitutes “madness” in terms of psychological disturbance and violence.
Professionals in the field of mental health at times were also active participants in the civil war and even aggressors, as a psychiatrist who worked at Asfuriyyeh recalled: “sophisticated, educated, professional people – one of them I know to be an exceptionally fine doctor – standing on balconies with snipers’ rifles killing almost at random with seeming pleasure.”
The confluence of health, politics, and sectarianism is artfully brought together providing an in-depth analysis of normality versus pathology.
The book is a well-written and meticulously researched history of Asfuriyyeh until its dissolution. The confluence of health, politics, and sectarianism is artfully brought together providing an in-depth analysis of normality versus pathology, as well as colonialism and subjugation versus sectarian conflict.
Abi-Rached notes that following the civil war in Lebanon, Asfuriyyeh’s non-sectarian model became obsolete, as sectarianism permeated the field of mental health, thus reflecting Lebanon’s political chaos at the time.
Towards the conclusion of the book, the author discusses the consequences of the civil war upon infrastructure, including health institutions, and how central these consequences are to constructing a country’s historical memory. Abi-Rached coins the term “medical ruins” to describe sites previously functioning as safe havens for patients, transformed into sites of death and destruction.
The ruins are discussed in terms of power relations and the author expounds upon how such sites are part of the Middle East’s historical trauma and hence should be preserved. According to Abi Rached, memory “provides a way to think more critically about the traces and remains of events and people.”
Asfuriyyeh’s history and the aftermath of its downfall are an example of the centrality of people to the collective memory of a country, which can also be affected by the marginalization of experiences that are not deemed central to politics and the entrusting of memory sites to entities that work for oblivion.
Editor’s note: Joelle M. Abi-Rached, MD, PhD, is a Fellow at Columbia University’s Society of Fellows in the Humanities and an invited researcher at the École Normale Supérieure and École des Hautes Etudes en Sciences Sociales. She is the co-author of “Neuro: The New Brain Sciences and the Management of the Mind.”