Disturbing Spirits: Mental Illness, Trauma, and Treatment in Modern Syria and Lebanon

By Beverly A. Tsacoyianis

This book investigates the psychological toll of conflict in the Middle East during the twentieth century, including discussion of how spiritual and religious frameworks influence practice and theory.

The concept of mental health treatment in war-torn Middle Eastern nations is painfully understudied. In Disturbing Spirits, Beverly A. Tsacoyianis blends social, cultural, and medical history research methods with approaches in disability and trauma studies to demonstrate that the history of mental illness in Syria and Lebanon since the 1890s is embedded in disparate—but not necessarily mutually exclusive—ideas about legitimate healing. Tsacoyianis examines the encounters between “Western” psychiatry and local practices and argues that the attempt to implement “modern” cosmopolitan biomedicine for the last 120 years has largely failed—in part because of political instability and political traumas and in part because of narrow definitions of modern medicine that excluded spirituality and locally meaningful cultural practices.

Analyzing hospital records, ethnographic data, oral history research, historical fiction, and journalistic nonfiction, Tsacoyianis claims that psychiatrists presented mental health treatment to Syrians and Lebanese not only as a way to control or cure mental illness but also as a modernizing worldview to combat popular ideas about jinn-based origins of mental illness and to encourage acceptance of psychiatry. Treatment devoid of spiritual therapies ultimately delegitimized psychiatry among lower classes. Tsacoyianis maintains that tensions between psychiatrists and vernacular healers developed as political transformations devastated collective and individual psyches and disrupted social order. Scholars working on healing in the modern Middle East have largely studied either psychiatric or non-biomedical healing, but rarely their connections to each other or to politics. In this groundbreaking work, Tsacoyianis connects the discussion of global responsibility to scholarly debates about human suffering and the moral call to caregiving. Disturbing Spirits will interest students and scholars of the history of medicine and public health, Middle Eastern studies, and postcolonial literature.

• Language: English
• Publisher: University of Notre Dame Press
• Release date: Jun 15, 2021
• ISBN: 9780268200749

Beverly A. Tsacoyianis

Beverly A. Tsacoyianis is an associate professor of history at the University of Memphis.

Book preview

DISTURBING SPIRITS

DISTURBING

SPIRITS

Mental Illness, Trauma, and Treatment

in Modern Syria and Lebanon

BEVERLY A. TSACOYIANIS

University of Notre Dame Press

Notre Dame, Indiana

University of Notre Dame Press

Notre Dame, Indiana 46556

undpress.nd.edu

All Rights Reserved

Copyright © 2021 by University of Notre Dame

Published in the United States of America

Library of Congress Control Number: 2021931605

978-0-268-20072-5 (Hardback)

978-0-268-20071-8 (WebPDF)

978-0-268-20074-9 (Epub)

This e-Book was converted from the original source file by a third-party vendor. Readers who notice any formatting, textual, or readability issues are encouraged to contact the publisher at [e-mail]

CONTENTS

ACKNOWLEDGMENTS

Research and writing for this book (and for the dissertation on which this is partly based) were made possible thanks to funding from the Fulbright-Hays Doctoral Dissertation Research Abroad award administered by the United States Department of Education in 2009, the Chancellor’s Graduate Fellowship Award and the International and Area Studies travel grant from Washington University in St. Louis, a 2011 P.E.O. Scholar award administered by P.E.O., an international Philanthropic Educational Organization for women’s education, a Marcus Orr Center for the Humanities (MOCH) Freeburg Fellowship in 2017, and a Professional Development Assignment (PDA) at the University of Memphis in 2018.

In the United States, I am thankful for the guidance I received in graduate school (and since, in Nancy’s case) from my main advisors Nancy Reynolds and Timothy Parsons, as well as from Ahmet Karamustafa, Hillel Kieval, and Jonathan Sadowsky. I am also grateful for the input of Nancy Berg, who showed me the exciting directions interdisciplinary work could take when informing medical and social history research with approaches in comparative literature and film studies. My gratitude also goes to Kristina Richardson and Sara Scalenghe for encouraging this project at annual meetings of the Middle East Studies Association (MESA) and the American Historical Association when I was in grad school, and again at a small but excellent workshop on Middle Eastern Disability History at the University of Maryland in November 2015. Sara also generously provided me with digital copies of numerous primary sources from Asfuriyeh Mental Hospital and gave me feedback on a 2018 MESA paper based on parts of this book. My appreciation also goes to Dr. David Satin at Harvard Medical School for inviting me to present in the colloquium series in the History of Medicine and Psychiatry in December 2013. I also treasure the connections I made with many women whose paths as academics, administrators, or students intersected with mine over the years, whose conversations, meals, advice, and laughter nourished me as I grew from graduate student new to archives to more seasoned traveler and early career professional, including Elsa Abou Assi, Michela Gatti, Anneka Lenssen, Sheri Notaro, and Michaela Sinibaldi. In Memphis, a Professional Development Assignment in fall 2018 and the MOCH Catherine and Charles Freeburg Faculty Fellowship in spring 2017 afforded me the time to work on the book proposal and parts of the manuscript. Conversations I had with then MOCH director Sarah Potter and MOCH fellows Melanie Conroy, Kathryn Hicks, and Carey Mickalites advanced my thinking on source analysis and thematic connections across disciplines. I am also deeply thankful to my colleagues in the University of Memphis Department of History for their friendship and advice: my department chairs Janann Sherman, Aram Goudsouzian, and Dan Unowsky, Beverly Bond, Peter Brand, Peggy Caffrey, Michele Coffey, Charles Crawford, Andrew Daily, Guiomar Dueñas-Vargas, Christine Eisel, Jim Fickle, Chrystal Goudsouzian, Benjamin Graham, Brian Kwoba, Denis Laumann, Scott Marler, Greg Mole, Susan O’Donovan, Suzanne Onstine, Catherine Phipps, Sarah Potter, Amanda Lee Savage, Steve Stein, Cookie Woolner, and Andrei Znamenski, among others. Graduate students in my department and in the Department of Communication were also helpful, especially Noor Ghazal Aswad, Matt Isaacs, Kalemba Kizito, and Andrea Ringer. A very special thank-you goes to Peggy Caffrey for carefully reading the entire manuscript as it neared completion; her guidance erased long passages as if by magic and with surgical precision. I also thank the editorial staff at the University of Notre Dame Press, especially Eli Bortz, Rachel Kindler, and Elizabeth Sain, for their patience, good humor, expertise, and support, and I thank the two anonymous reviewers for their detailed reports.

In France and the United Kingdom, I am indebted to the staff of the government archives in Nantes, Paris, and Kew Gardens. I am especially thankful to archivists and officers of the Val-de-Grâce Psychiatric Hospital and of the Service Historique de la Défense at the Château de Vincennes, and to archivist Debbie Usher at the Middle East Centre Archives of St. Antony’s College, Oxford University. In Lebanon, though I largely worked remotely with records from Saab Medical Library, I appreciate the archivists of the Arabic Collections Online, especially Elie Kahale, Director of Digital Initiatives and Scholarship at American University of Beirut, and Samar Mikati, Associate University Librarian for Archives and Special Collections at American University of Beirut, for their permissions and assistance in securing high-resolution images of the Lebanon Hospital data in the appendix.

In Syria, I would like to thank the staff and scholars affiliated with the Institut Français du Proche-Orient (IFPO) in Damascus, civil servants in the Syrian Ministry of Culture and Syrian Ministry of Health who approved my research access to government hospital records in 2009 and 2010, and employees of Ibn Sina Mental Hospital, especially former director Dr. ʿAbdul-Massih Khalaf and former staff psychiatrists Dr. Mahmood Naddaf and Dr. Usama Alshughry, among others, for their generosity, research, and friendship as I collected my data in 2009 and 2010 and in conversations we’ve had in the years since then. I am also thankful for the kindness and vision of Syrians like Mustafa Alhaj Ahmed, whose hard work as founder and principal of the Tuyoor Al-Amal Schools has helped thousands of Syrian refugee children who found their way to Lebanon. In Jordan I am grateful to the staff and scholars at the IFPO in Amman, to Syrian psychologist Adnan Al Rebdawi, and to Syrian psychiatrist Mohammad Abo Hilal for their insights and generosity. I also thank Syrian artist and musician Anas Homsi, born and raised in Damascus, for his permission to incorporate his Wall of Memories, painted while he was a refugee in Lebanon in 2015 and sold in the United States in 2018, as part of this book’s cover design. I found his generosity in our conversations via video chat and email in 2020 while he, his half-Syrian half-Lebanese wife (also an artist and musician), and their young son live in Germany deeply inspiring.

I owe a very special debt of gratitude to family and friends, particularly my mother, Sylvia Maria Reyes Levine, and my father, Robert Alan Levine, for encouraging me, my sister, Amy, whose resilience gives me hope, and my husband, Matt, for helping me through times I was unable to cope with challenges on my own. In the last few years, as Matt and I have welcomed our children into our lives, we experienced the incredible awe and joy of seeing these fragile-looking little bodies grow and thrive in a country where they have easy access to urgent care, clean food and water, safe shelter, antibiotics, and routine checkups and vaccinations. I cannot fathom the pain of those who have lost their children and whose lives have been destroyed in the Lebanese and Syrian civil wars. I dedicate my book to all survivors as I mourn for you and your grieving families. I can only imagine how horribly the mind and spirit breaks in such outrageous circumstances, so let us be grateful for the experts, both medical and religious, who make it their duty and respond to that calling to comfort the wounded and to try to heal against all odds. I have fond memories of good people, compassionate healers, and remarkable places in Syria and Lebanon. Let us hope (and work) for a peaceful resolution to violent conflict, and for effective and meaningful healing systems to care for all victims of physical, mental, and emotional trauma. For the children, for their families, and for us all, as the prayer goes: may we see the day when war and bloodshed cease, when a great peace will embrace the whole world.

ABBREVIATIONS

AUB American University of Beirut

BNA British National Archives

CADN Centre des Archives Diplomatiques de Nantes, France

ECT Electroconvulsive Therapy

EST Electroshock Therapy

IFPO Institut Français du Proche-Orient

ISHR Ibn Sina Hospital Record

LH Lebanon Hospital for Nervous and Mental Disorders at Asfuriyeh

MAE Ministère des Affaires Étrangères, France

SOAS School of Oriental and African Studies

SPC Syrian Protestant College (renamed AUB in 1921)

A NOTE ON TRANSLITERATION

I follow a simplified version of the system used in the International Journal of Middle East Studies. Except for the ʿayn (ʿ) and hamza (ʾ), I omit case endings and diacritical marks in the body of the text but retain diacritics in the footnotes and bibliography. For words in English and French sources, I retain spelling where appropriate (for example, the mental hospital in Lebanon known as Asfuriyeh to the committee based in London) and for authors published in English and French, I write names as the authors spelled them. Where authors published in Arabic, I use the transliterated spellings as they are listed in library catalogs.

Introduction

The title of this book, Disturbing Spirits, draws from two different but not necessarily mutually exclusive understandings of spirits. The first will be familiar to religious studies scholars: that many twentieth-century Syrians and Lebanese believed a supernatural world of spirits mingled with the natural world of human beings, and that spirits (jinn among them) could cause physical and mental disturbances, even illnesses, in people. This disease etiology is rooted in the premise that the supernatural and natural worlds can influence each other—that a person might conjure or exorcise a spirit should they know the proper way to do so, and that a spirit might possess a person should the spirit be so moved. Supernatural ideas about mental illness (discussed in chapter one) were part of all major religious communities in the Eastern Mediterranean as well as Europe and beyond in the nineteenth and early twentieth centuries. These spirit-based (supernatural) ideas were disturbed (marginalized and derided) by scientific (natural) ones that medical doctors and psychiatrists espoused in the early twentieth century.

Another meaning of the book’s title develops from trauma theory: that the dramatic political, economic, and social transformations of twentieth-century Lebanon and Syria have disturbed the psyche and emotional well-being of ordinary Lebanese and Syrian people, whether any one individual among them had a preexisting medical or psychological condition or not. This aspect of the title connects to a comment Syrian American lawyer and novelist Alia Malek made recently, that the Syrian civil war had reached a level of violence that would consume it whole and eventually damage the collective mental health of its people.¹

With these two meanings of spirit in mind, this book argues that a tension between psychiatrists and vernacular healers developed while political transformations since the late nineteenth century devastated collective and individual psyches and disrupted social order. It has not only been political upheaval that has damaged collective well-being, and the mental illness as metaphor aspect of community trauma should not diminish experiences of people who struggled with the very real challenges of other serious and persistent mental illnesses. Psychiatric and vernacular practices could themselves cause trauma even as they sought to heal, and scholar-activists in the disability studies movement in many parts of the world have begun to address the silences in proponents of the medical model of disability that sought to target and shape abnormal minds and bodies in the image of what healers decided was normal. While the biomedical explanations of health and wellness threaten to promote the replicating of a standard and ideal body at the expense of atypical ones, supernatural understandings (especially in situations of intense conflict between people or communities) of jinn or demonic possession as an explanation for abnormal (or brutally violent) behavior threaten to absolve humans of accountability or to remove human action from the political and cultural conditions that shape human agency.

Anglophone and Francophone scholars who have worked on healing in the twentieth century Middle East have largely studied either psychiatry or spirit-based healing, but they have rarely studied both and their connection to political changes. The development of psychiatric treatment in the Middle East has largely been a story told through French, British, or American roles in developing asylums, hospitals, and schools, or through regional efforts to combat foreign control, as with Mehmet ʿAli’s schools and army in Egypt.² While historians tend to focus on psychiatric institutions, anthropologists analyze the culturally specific role of jinn (spirits) and magic, with some brief forays into the nebulous area between jinn-possession and psychiatric notions of mental illness.³ Anthropologist Celia Rothenberg, for example, notes a 1996 report where Palestinian psychiatrist Eyad Sarraj (director of the Gaza Community Mental Health Program [GCMHP]) considered political context important to etiology and treatment, but he did not recogniz[e] the role of sheikhs in ‘curing’ patients of their problems.⁴

Scholars cannot fully comprehend the significance of psychiatric history to the development of the modern Syrian and Lebanese states without considering the political contexts of natural and supernatural understandings of mental illness. This study challenges the binary nature of research that separates foreign from local spaces of knowledge and practice, and it joins other histories of medicine and psychiatry that, as Matthew Heaton notes, break down artificial dichotomies between colonizer/colonized, traditional/modern, and science/belief at local and national levels.⁵

These issues present conceptual difficulties in the Eastern Mediterranean as in other parts of the world, particularly in areas with minority groups and a history of repressive rule. One must avoid an oversimplified narrative of suffering and exploitation at the hands of cruel, racist, or imperialist doctors, as well as an oversimplified narrative of heroic resistance to the medical encounter.⁶ Steven Epstein’s concept of biopolitical citizenship moves beyond such binaries to highlight how political issues of justice and equality get worked out in a biomedical domain.⁷ Applying this to the Syrian and Lebanese context can highlight how war, repression, sectarianism, and medical marginalizing of nonmedical practices produced silences and traumas. The binary of suffering and resistance is one challenge for historians.⁸ Another is balancing two simultaneous historiographic agendas. The first deconstructs positivist attitudes towards science and culture, as science is the product of complex cultural formations. The other agenda challenges essentialist views about static Islamic cultures or sciences by showing they (like cultures and sciences outside the Islamic world) are dynamic and organic processes.⁹

The book frames arguments about healing in the later chapters within the traumatic legacies wrought by political upheavals addressed in the early chapters. It moves from discussion of health and treatment in the early twentieth century, World War I, and the French Mandate period to analysis of continuities and ruptures in treatment during and after political upheavals of the postcolonial periods, particularly the 1958 crisis in Lebanon, the coups and Baʿathist repression in Syria, the Lebanese Civil War and the Syrian civil war. This postcolonial period (from the late 1940s to the post-9/11 Middle East) has witnessed numerous important political and economic changes in Greater Syrian society that continue to shape a diverse health arena.

The terms modern, modernity, and modernizing have varying meanings in historical scholarship as well as in primary sources.¹⁰ Since the 1860s, many doctors meant Westernize when they wrote of plans to modernize peoples of the Eastern Mediterranean. For some, modernity brought with it secularization in the public sphere and at home, but this was not the case for medical missionaries in hospitals like Asfuriyeh who saw Protestant proselytizing as a path to modernize Muslims and Eastern Christians (both Orthodox and Catholic). To government officials, modernity meant a modernism in architecture and urban planning that broke with past practice, or modernization policies for economic and political development that changed local infrastructure—from railroads and wider city streets to reforms in landownership and taxation. Debates on what is modern address a wide range of social, cultural, religious, political, and economic issues. For the purposes of this project, modern is defined here through its connection to modern medicine, a cosmopolitan biomedical system predicated on beliefs in the natural (tangible, physical, chemical) rather than supernatural (intangible, spirit-based) in physical and mental illness. Yet modernity for medical missionaries was couched in spiritual transformations valuing Western Christian practices over ones of Eastern communities.

Just as religiously trained Sunni and Shiʿi elites criticized vernacular practices among Sufi followers in Syria and Lebanon, they connected modern to a high-religion practice where spirit-based practices of low religion were non-modern.¹¹ Syrian officials used biomedicine to foster the country’s modernization as an antidote to backwardness.¹² With peasants, women, and Islamist populist groups, proponents of vernacular healing practices were people elites saw as obstacles to a modern social order. Contemporary and twentieth-century amulet use and saint shrine visits suggest the incomplete adoption of psychiatric healing practices in twentieth-century Greater Syria. The institutional dualism that persisted in politics and society also existed in health practices.¹³

Psychiatric labels and healing practices emerged in a plural medical and scientific landscape where both elite Western-trained physicians and well-connected local healers contributed to a multilayered discourse of the healthy body and citizen. This plural landscape reveals an emerging state apparatus that was unsuccessful in controlling health discourse and promoting biomedicine over vernacular healing among all its citizens. While this research does not argue for a causal relationship between the existence of diverse healing systems and the emergence of the modern Syrian and Lebanese states, efforts to create medical schools, hospitals, and legislation on mental health were part of agendas to create a modern state infrastructure that aimed to marginalize fields government experts considered non-modern, such as vernacular healing. Government-run mental hospitals in the Middle East faced numerous obstacles gaining trust, procuring funding, and producing beneficial results for patients (namely, remission of symptoms and improvement in physical and emotional well-being) in the 1920s–1940s.¹⁴ Medical schools and mental hospitals in Syria and Lebanon did not adequately adapt their understandings of the etiology or treatment of disease to be culturally meaningful to local communities. Syrian psychiatric patient case files, interviews with Syrian psychiatrists, psychologists, and clergy, and articles in the Arabic- and European-language press reveal disorienting experiences of mental illness. People with local healing knowledge faced marginalization in Syrian and Lebanese states that hoped to convince citizens of biomedicine’s authority through the work of government- and foreign-funded medical schools and hospitals. Interviews with Syrian psychiatrists and psychologists and recent reflections by other medical experts suggest the situation has hardly changed in recent decades. The medical marketplace of the twentieth century was a diverse field for those seeking diagnosis, treatment, and rehabilitation through a return to work and to their families.¹⁵

As with the conceptual borders around modernity, the geographic borders here also require some explanation. The Asfuriyeh and Ibn Sina mental hospitals existed in what are today the separate political entities of Lebanon and Syria, respectively. However, after World War I and League of Nations intervention, nearly all of what is modern Lebanon and Syria became French Mandates. Though subdivided into states (Alawi, Druze, Aleppo, Damascus, Mount Lebanon, and the Bekaa Valley), there was significant interaction between economic, cultural, and scientific institutions in French Mandate Lebanon and Syria.

The chronological borders for this study span over a hundred years marked by significant political and medical changes. The Ottoman government enacted the 1876 Ottoman Mental Health Hospitalization Act (amid the many reforms of the Tanzimat) and allowed the 1899 opening of the Lebanon Hospital at Asfuriyeh, as well as the 1903 founding of the Ottoman (then Arab) Medical School at the Syrian University in Damascus, a school that grew to rival foreign missionary medical colleges in Beirut and Ottoman schools in Istanbul. Ibn Sina Hospital was the first modern public psychiatric hospital in Syria, founded in 1922 and the only one of its kind in the country until 1953, when a second public mental hospital (Dweirina) opened near Aleppo. Rather than seeing a turning point at the time of Lebanese independence in 1943 and Syrian independence in 1946, this study argues that medical processes remained relatively unchanged in the 1940s and 1950s as physicians faced similar challenges in disseminating a legitimate and effective psychiatric worldview for mental health.

This book argues that such diverse health-seeking behaviors developed because of two main conflicts: one between political leaders and ordinary people, and another between believers of natural versus supernatural etiologies of illness. Vernacular healers and believers did not trust that biomedical treatment worked. This persists into the twenty-first century despite local government material (and international philanthropic) support for cosmopolitan biomedicine and psychiatry, though some organizations now coordinate with some vernacular approaches.

Mental illness and spirit possession afflicted people, and family, neighbors, and healers identified those coping with such situations as impaired or disabled. A diagnosis of mentally incompetent or incapacitated could carry weighty legal and social implications. Certain diagnoses affected citizenship as people were denied privileges and rights to income, inheritance, marriage, custody, and occupation. The 1949 Syrian Civil Code treated mentally incompetent citizens as minors in contract law, including in marriage and divorce. Article 230 of the 1949 Syrian Criminal Code exempted from persecution anyone who attempted suicide, while perpetrators of other violent crimes were not exempt. Suicidal people were not accountable for their actions of self-harm because courts believed they lacked the capacity to act rationally.¹⁶ This exclusion would, to physicians, police, and judges involved, contain the disruptive potential of numerous eccentricities and maintain a requisite measure of social stability.¹⁷ People sometimes labeled others ill to minimize threats to political as well as social order. A French official’s October 12, 1942, letter referred to a Badr Demachkie in 1942 who tried this on Lebanese Prime Minister Sami Sulh, cousin of Riad el-Sulh. Each Muslim notable reacts his own way to the authoritarianism of the head of government, and Demachkie, who hasn’t hid his ambitions to become chairman of the board visited French officials numerous times the previous winter to volunteer that during the last war Sami Solh, while in Constantinople, had been hospitalized for a mental illness.¹⁸ This was also a tactic in Egypt and British East Africa in the twentieth century.¹⁹

This book begins with the tension between vernacular and biomedical healing systems but moves thematically from this discussion to the political and historical context in which these tensions existed: the dramatic upheavals of the twentieth century. Yes, the institutions in this healing landscape were changing, but they did so against a backdrop of many different struggles. From the suffering of forced conscription, blockades, and famine during World War I, to the end of the Ottoman Empire and the humiliation of the French Mandates in Syria and Lebanon, to the rise of new (and repressive) political elites in the Syrian Baʿath Party during the postcolonial period, communities found ways to cope with trauma and mental illness in diverse ways. The sources for such coping strategies, and for discourse around the legitimacy of different strategies, are similarly diverse. With medical records from mental hospitals on the outskirts of Beirut and Damascus, with ethnographic material and oral history research on spiritual healers, and with the historical fiction and journalistic nonfiction of Lebanese and Syrian witnesses to tragedy over the past century, this book urges us to acknowledge the multiple ways to understand illness and healing and to encourage resilience-building efforts among multiple survivor populations through facing (rather than effacing) their histories.

This introductory chapter situates a medical and cultural history of mental health and political conflict within a larger paradigm of efforts to destigmatize non-biomedical understandings of illness and changing discourses on collective and individual memories of trauma and treatment. The clash that advocates of modern medicine perceived between their approaches and those of traditional healers is mirrored in historical research about the causes and effects of modernization in Lebanese and Syrian societies in the twentieth and twenty-first centuries. Yet research on conflicting worldviews on mental illness has been surprisingly rare in the field, even as studies of the causes and effects of World War I, the mandates, territorial losses, migration, and numerous wars and coups abound. Since scientific concepts are embedded in social, political, and religious contexts that vary across time and space, a study of natural and supernatural understandings of health in Syria and Lebanon can contribute to trauma studies, disability studies, and Middle Eastern history more generally.²⁰

This study is based largely on psychiatric and literary sources from Lebanon and Syria. The psychiatric sources are drawn predominantly from two mental hospitals. The first is the Lebanon Hospital for the Insane (later known as the Lebanon Hospital for Mental and Nervous Disorders, known locally as Asfuriyeh), which opened its doors to its first patients on August 6, 1900. It nearly went bankrupt in the 1970s, most of the hospital was closed on April 10, 1982, after bombing by the Israeli military, it lost its newer location at Aramoun to Israeli military occupation until October 17, 1982, and it operated at limited capacity until closing in the mid-1990s.²¹ The Lebanon Hospital sources include annual reports, committee meeting minutes, and correspondence between hospital administrators and philanthropists. The second psychiatric institutional source base is Ibn Sina Mental Hospital in Douma near Damascus, which admitted its first patients in 1922 and continues to operate, albeit at restricted capacity and under regime control in the current Syrian civil war. The Ibn Sina Hospital sources are 110 patient case records from the 1920s to the 1990s, an ethnographic report from the late 1950s, articles and speeches by Syrian and Lebanese physicians, and interviews and oral history research this author conducted with Syrian psychiatrists and psychologists between 2008 and 2019.

The psychiatric data is complemented by literary and artistic sources such as historical fiction, film, journalistic nonfiction, and memoirs and family histories by Hanan al-Shaykh, Lebanese former political prisoner Souha Béchara, nephrologist Anas A. Ismail, journalist Samar Yazbek, civil rights lawyer and journalist Alia Malek, and Syrian former political prisoner Yassin al-Haj Saleh. Just as these two (psychiatric and literary) source bases complement each other by including different perspectives of people (doctors, shaykhs, patients, survivors, family members, or perpetrators and witnesses of trauma among others) involved in these changing healing landscapes, the interdisciplinary approach in reliance on secondary psychological and anthropological research complements the medical and cultural history approaches that thread throughout the narrative. Together these trace the failure of elite attempts at a medical hegemony for mental health treatment and connect the traumatic nature of political conflict and sectarianism to religious as well as psychiatric understandings of disturbed spirits.

The artificial dichotomy between traditional and modern treatment felt real to medical elites who held widely divergent ideas from local religious healers about the causes of and treatments for abnormal minds. Medical, governmental, charitable, and community groups in the early and mid-twentieth century struggled to present legitimate and authoritative images of themselves to the would-be consumers of their health practices. Yet mental health experts did not receive much support from communities or leaders. It was physical hygiene, not mental hygiene, that officials saw as a more pressing concern, as infectious diseases (especially trachoma, cholera, malaria, and tuberculosis) presented more significant threats than mental health to the economy and military. Nevertheless, some physicians did work to modernize Lebanon and Syria, to teach that insanity is physical disease . . . no more to be attributed to supernatural agencies than are rheumatism, gout, or typhoid fever.²² Images of healing a weakened nation center on competing notions of the normal and abnormal body as well as competing or complementary ideas of the causes and treatments of these abnormalities.²³ Even as psychiatry advocates dispelled nonpsychiatric understandings of disease etiology and treatment, the field of psychiatry and its relationship to general medicine was changing.²⁴ The use of psychiatric treatment in early twentieth-century Syria, particularly in the mental hospitals of Beirut and Damascus, was also an effort to cure a pathological disability. The pathology that doctors saw in Syria was that of a widespread belief in supernatural spirits and their effect on the minds and bodies of Syrians. Doctors aimed to make human bodies modern and healthy by convincing them of the legitimacy of medical rather than supernatural origins of disease and, by corollary, of the legitimacy and effectiveness of psychiatric rather than spirit-based treatment of mental illness. In this mission, physicians of the early and mid-twentieth century were largely unsuccessful.

Part of the key to understanding the persistence of widespread use of nonpsychiatric treatment is community wariness of the government and its agents—a constant throughout the century whether they were Ottoman civil servants before 1920, French or other foreign physicians during the mandates in Lebanon and Syria, or postcolonial Syrian or Lebanese medical officials. Ordinary people viewed them as agents of a state that imposed a range of burdens on their communities. These burdens could be highly visible and crippling, as with taxation and conscription, but they also reached people through other interventions: schools, census taking, and other systems of monitoring. In each of these periods (late Ottoman, French Mandate, and postcolonial), people had much to fear of government intrusion in their lives. In reflecting on this hesitance to engage with government officials including physicians, Abo-Hilal and Hoogstad note that in the twenty-first century, after decades of oppression, widespread corruption and involvement of secret police in every aspect of life in Syria, many families do not easily trust formal [organizations] of structures, as they fear members of the regime may have infiltrated them.²⁵ This is something many Syrian doctors have sought to combat, especially as some doctors are survivors of Assad’s torturous regime. Healers throughout the twentieth and twenty-first centuries struggled to help Lebanese and Syrian citizens find ways to live and thrive despite the obstacles to a flourishing individual spirit and body in the wake of individual and collective experiences of political tumult, oppression, and bloody sectarian conflict. These struggles are a focus of chapter five in the context of the Lebanese and Syrian civil wars.

The dilemmas of how to identify, explain, and treat mental illness forced a local reimagining of modern Syrian and Lebanese citizens in the twentieth century. Community practices and institutions during the late Ottoman Empire, the French colonial project, and the early postcolonial Syrian state point to a history without neat categories separating biomedical from folk practices and foreign from local. Scientific knowledge is produced in culturally specific ways, and doctors in cross-cultural spaces had to adapt to local customs and beliefs to effect real change in health-seeking behavior. Just as medical and scientific knowledge change, so too are local health practices informed by variance in religious and cultural practices.

FICTION, NONFICTION, AND FILM:

ACCOUNTABILITY AND CONTESTED HISTORY

In her 2018 chapter Coming Out Mad, Coming Out Disabled, Elizabeth Brewer remembers wondering, as a graduate student a decade earlier, where her voice might fit into disability studies as a sibling of someone diagnosed as schizophrenic, given the field’s important commitment to disabled people speaking for themselves, claiming their identities, and demanding ‘nothing about us without us.’ She was particularly concerned with the contexts in which people with psychiatric disabilities might be deemed rhetorically credible.²⁶ These are difficult questions of identity politics, and though neither Lebanese nor Syrian, nor a consumer/survivor/ex-patient of mental hospitals, I approach my sources as an ally in the disability studies movement. The movement is young, especially in Middle Eastern studies.²⁷ Disability studies scholars writing of body politics benefit from interdisciplinary approaches and draw on discussions in medical anthropology, sociology, and social and medical history.²⁸ Elizabeth Donaldson’s 2018 edited volume Literatures of Madness: Disability Studies and Mental Health is a pioneering collection of studies on the intersections of disability studies and mental health through a variety of sources, including fiction. Because this book takes an interdisciplinary approach, disability studies research as well as literary productions help complicate a narrative in Syrian and Lebanese psychiatric history that has predominantly been framed in the institutional records through a medical model of disability.

A recurring theme in the Literatures of Madness collection is the need for scholars to build on works such as medical anthropologist Arthur Kleinman’s Writing at the Margin: Discourse between Anthropology and Medicine by analyzing literary sources for depictions of the experiences of people whose invisible cognitive disabilities shape their lives even while the field of disability studies continues to be dominated by theorists and researchers working on visible physical disabilities.²⁹ Medical records from Ibn Sina and the Lebanon Hospital come from the hands of physicians, psychiatrists, and affiliated staff who frequently dismissed or derided the vernacular beliefs and practices of patients and their families, and who saw their own medical interventions as the only legitimate and effective treatment. But Syrian and Lebanese literary sources (both journalistic nonfiction and historical fiction) by writers as diverse as Hanan al-Shaykh, Hanna Mina, Samar Yazbek, Alia Malek, and Anas A. Ismail depict vernacular healing more sensitively and psychiatric and medical healing more ambivalently.

Intersectional research in mental health and disability studies highlight consumer, survivor, ex-patient, and mad (c/s/x/m) communities, who, like queer communities, are bound together across messy identity categories and shared experiences of otherness.³⁰ Historians interested in the material conditions of the body, and the body as a material condition, have an excellent resource in historical fiction as primary source.³¹ Literary works give readers a thicker and more personal description of illness and treatment than medical records from Asfuriyeh and Ibn Sina do.³²

Literary and film scholar Abir Hamdar notes in The Female Suffering Body that the sick body has multiple meanings in Arabic literature—most often as a social, cultural, and political signifier.³³ Very few scholars have studied the body as a feeling and suffering somatic entity in Arabic literature.³⁴ Depictions of the suffering female—by male and female writers—focus on bodies of women derailed by psychological disturbances and emotional distress.³⁵ Yet some fiction writers (like Hanan al-Shaykh) push the boundaries of such labels, suggesting even that one main character’s mental illness is the result of distress caused by external circumstances (violence acted on the woman’s body outside of civil war, and violence on the body as a result of the Lebanese Civil War). This is addressed in more detail in chapter five. The mental illness as metaphor aspect of this suggestion is reminiscent of the reactionary psychosis analyzed in Franz Fanon’s Wretched of the Earth, where his treatment of Algerian psychiatric patients during the brutal Algerian war for independence from France led him to opine that the condition of the native is a nervous condition and that the traumatic and repressive systems of colonial rule naturally engendered illness in the colonized.³⁶

Fiction and nonfiction writers of the Syrian civil war have common ground with writers in Lebanon. Different groups in the same country have very different memories of what violence occurred, who was the aggressor, what was at stake, and what legacies remain. Hanna Mina’s 1975 Fragments of Memory, Etel Adnan’s 1977 Sitt Marie Rose, and Hanan al-Shaykh’s 1980 The Story of Zahra and 1992 Beirut Blues all include characters witnessing violence and suffering trauma. Mina’s semiautobiographical narrative of surviving banditry in the countryside and the precariousness of migrant life in 1930s Syria suggests a bitterness in the memories of those living on the margins of society as poor, forgotten, and outcast. Adnan’s narrative (written polyphonically through first-person perspectives of numerous characters) of the brutal murder by Maronite militiamen of Syrian Christian schoolteacher Marie Rose Boulos in front of her class of deaf-mute children (who see but can never speak of her gruesome death) is framed in a bitter indictment of grotesque violence, sexual abuse, and socioeconomic injustices in the Lebanese Civil War. Like Adnan’s narrative, Al-Shaykh’s The Story of Zahra (also polyphonic first-person) and Beirut Blues (written as ten imagined letters by one woman to multiple readers, including the city of Beirut and the war itself) slip across time and place as traumatic memory does, while main characters confront their own personal tragedies and mourn the collective tragedies of the civil war.

Some Lebanese confronting public silence through memoirs and fiction have bemoaned the country’s hesitancy to engage with its past.³⁷ In 2005, al-Shaykh lamented that "all [her] books are being widely read and taught in Lebanon except Beirut Blues. . . . It was not even reviewed. They didn’t want to deal with what it represented."³⁸ Illustrator and writer Zeina Abirached, who has published graphic novels in French on her experiences as a child born in 1981 and raised in Beirut, noted in 2013 that while some have been translated into English, none of her graphic novels have been translated into Arabic.³⁹

Film scholar Lina Khatib, who also grew up in Beirut during the civil war, remembers the immediate postwar period as a good-time decade. . . . Those of us who were lucky not to have lost our homes or loved ones embraced the decade’s promises of prosperity and peace. We did not talk about the war. We behaved as if it had not existed. We tried our best to enjoy our present and look forward to the future.⁴⁰ She notes that by 1998, with the release of Ziad Doueiri’s West Beyrouth, Lebanese cinema was one of the few arenas where the ugliness of the war was confronted. It was a place where history was chronicled, questioned and sometimes condemned. It was a necessary conciliatory space.

Some obstacles to speaking out are psychological—to avoid retraumatization. Other obstacles are more politically threatening; the 1991 law in Lebanon granting amnesty for crimes during the civil war denies victims the opportunity to hold perpetrators accountable. In Syria, political dissidence and criticism of the government can lead to imprisonment, torture, or death. Alawi novelist and journalist Samar Yazbek went into self-imposed exile after researching her 2011 book A Woman in the Crossfire: Diaries of the Syrian Revolution because of death threats, though she has since crossed borders numerous times to continue recording testimony and to promote Syrian women’s economic independence, which led to her second journalistic account of the war in 2015, The Crossing: My Journey to the Shattered Heart of Syria.⁴¹ She dedicates The Crossing to the martyrs of the Syrian revolution. I am writing for you: the betrayed. Syrian novelist Nihad Sirees, author of The Silence and the Roar, also went into self-imposed exile in 2012 following personal and political harassment to protect himself and his family, and though the Arabic version was published in 2004 about Assad’s surreal leadership cult, he bitterly notes in his August 2012 afterword: the leader is leveling cities and using lethal force against his own people in order to hold on to power. We must ask, alongside the characters in this novel: What kind of Surrealism is this?⁴² Sirees hints at the many kinds of silences and roars in Syrian society: the silencing of political dissidence and free thought, the silence of the international community in the face of the roars of brutal regime supporters, and the roars of tanks and planes. Scholars elsewhere have commented on the silences in Syrian literature, and here Mohja Kahf’s question from 2001 can be painfully reinterpreted: has the Syrian body become so accustomed to the poison—silence—that the antidote would kill?⁴³

There are echoes of Sirees’s and Kahf’s remarks in Anas A. Ismail’s A Melody of Tears: Sorrows of Syria, where characters comment on how no one dared speak about the Hama massacres of 1982, but instead struggled privately with their trauma and kept silent publicly for nearly thirty years,