Disturbing Spirits
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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.

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. While historians 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. 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.”

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.”

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. 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.” 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. 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. 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.


1. Vernacular Healing in Greater Syria

2. The Origins of Greater Syrian Medical Institutions

3. Medical Missionaries and the Lebanon Mental Hospital, 1899–1983

4. Secular Healing and Ibn Sina Mental Hospital, 1922–2018

5. Literature, Civil War, and (Ef)facing Syrian and Lebanese History




Publié par
Date de parution 15 juin 2021
Nombre de lectures 0
EAN13 9780268200749
Langue English

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Mental Illness, Trauma, and Treatment in Modern Syria and Lebanon
University of Notre Dame Press
Notre Dame, Indiana
University of Notre Dame Press
Notre Dame, Indiana 46556
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 undpress@nd.edu
CONTENTS Acknowledgments List of Abbreviations A Note on Transliteration Introduction ONE Vernacular Healing in Greater Syria TWO The Origins of Greater Syrian Medical Institutions THREE Medical Missionaries and the Lebanon Mental Hospital, 1899–1983 FOUR Secular Healing and Ibn Sina Mental Hospital, 1922–2018 FIVE Literature, Civil War, and (Ef)facing Syrian and Lebanese History Conclusion: On Pain, Surviving, Coping, and Healing Appendix Notes Bibliography Index
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.”
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)
I follow a simplified version of the system used in the International Journal of Middle East Studies . Except for the ʿ ayn (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.
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.
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, only to see hundreds killed in “large cross-country protests commemorating the thirtieth anniversary of the Hama Massacre” in 2012. 44 The regime unleashed tanks and snipers on peaceful demonstrators, leading to protests at their funerals. From 1979 to 1982, security forces that repressed “active social and political protests” and engaged in armed conflict with Islamists “were given the green light to commit atrocities to their heart’s content against the defeated, robbing them of their lives, property, and social connections.” 45 One survivor of Hama recalled in a 2011 interview that an officer’s jacket pocket in 1982 had the words “Death Squad” on it and regime forces occupied her home for two weeks after killing her husband and one of her sons in front of her. She remembered, “electricity was disconnected and there was no water. People were starving. . . . In one week anywhere between thirty and forty thousand people were killed in Hama.” 46 The journalist who relayed this information to Samar Yazbek in 2011 reflected, “anyone who travels to Hama will feel as though they are entering a giant wound. . . . Fate had brought me there in order to investigate atrocities; the city itself was one big atrocity.” 47 Salwa Ismail notes in her 2018 book The Rule of Violence: Subjectivity, Memory, and Government in Syria that when she conducted fieldwork in Hama in 2005 and remarked on the silence around 1982 to a Syrian friend living in Damascus, “it is as if Hama was forgotten,” her friend responded, “We will never forget Hama.” Ismail, reflecting on the exchange, notes that “The said and the unsaid in conversations like this one and in the work of memory, led me to think that the Hama silence is infused with meanings and feelings that are powerfully present in Syrians’ lives.” 48
Beyond silences stemming from fear of reprisal and from the deep pain of the wound, there are also silences from publishing interests prioritizing certain literary voices over others. In researching depictions of political violence in Middle Eastern fiction, Yara Amr El Masry relates the experience translator Peter Clark had when he tried to publish a translation of works by Syrian physician ʿAbd al-Salam al-ʿUjayli. Even though ʿUjayli wrote poetry, short stories, novels, and criticism depicting “tensions of individuals coping with politicization and the omnipotent state,” as Clark notes, his British publisher rejected the proposal because “He’s old and he writes short stories. Can you find a young female novelist?” 49 While discrimination privileging younger women over older men seems a reversal of power, perspectives are nevertheless marginalized through such processes.
There are multiple “pasts” related to why Syrians and Lebanese perceive mental health and trauma in supernatural as well as natural frameworks. There is the historiographic past; scholars have numerous approaches to twentieth-century Syrian and Lebanese medical and political history. There is also a literary past; Syrian and Lebanese writers of historical fiction make meaning of their traumatic past as well as engender hope for facing the challenging future of rebuilding their fractured country (and, arguably, their fractured selves). Just as we connect past to present to more ably face challenges of the future, one may consider “connecting pasts and challenging futures” even more literally, drawing strength from understanding the past to challenge the notion of an inevitable future where present obstacles to engaging with our past might otherwise continue. The past and present healing practices that refuse to make space for supernatural ways of coping with trauma, and the past and present sectarian challenges in politics, need not dictate future medical and political landscapes. They need not hinder opportunities to build states that face traumatic pasts and address collective pain to admit complicity or acknowledge accountability. This is where healing through facing (rather than effacing) history can flourish. Building resilience in communities means, in part, finding ways to cope with the past and to inspire individuals to work together in a productive and even reconciliatory way. 50 This is critical for young survivors of trauma who must find healthy ways to cope with the constant threat of new trauma given that sectarian politics, a central feature of both the Lebanese and Syrian civil wars, is unlikely to be dismantled soon or bloodlessly. These issues are analyzed in greater detail in chapter five and the conclusion.
As historian Susan Reverby once wrote, “not all medical encounters are the same nor all research.” 51 Looking at the nature of medical research as well as the intersectionality of various markers of identity, as Reverby does in her US case study, helps scholars analyze the complex encounters that Syrians and Lebanese had with state agents. Ethnicity and religious practice, ordinarily salient markers of identity in studies of Middle Eastern communities, did not affect health-seeking behavior in Syria as much as cultural worldviews (informed by gender norms and class-based practices) did. In Lebanon, sectarian tensions between the various Catholic and Eastern Orthodox sects, Protestants, and Sunni and Shiʿi Muslims made religion a more significant factor in health-seeking behavior than class or gender. In both Lebanon and Syria, elites favoring medical concepts challenged spirit-based healing, supporting a worldview of chemicals over demons to project their medicalized selves as “modern.”
The Lebanese and Syrian past and present are deeply intertwined even as their leaders placed their economies and political systems on separate trajectories. From mutual Ottoman legacies to French Mandatory rule, and from the more recent Syrian occupation of northern Lebanon during the Lebanese Civil War (with Syria’s withdrawal of their military forces from Lebanon only in 2005) to the recent influx of over 1.5 million Syrian refugees in Lebanon (more than one quarter of Lebanon’s entire population), the two countries have shared traumas and have been intimately involved in each other’s politics. 52 Some Lebanese leaders—particularly within the Maronite population, historically privileged since the French Mandate period and the 1943 National Pact—have argued that the political system in Lebanon is routinely destabilized by Syrian elements, while some Syrian leaders argue the very existence of an independent Lebanon is an insult to a unified Greater Syria.
Studies of madness in modern and early modern society, with mid-twentieth century pioneers like Michel Foucault, often analyze disciplinary techniques governments used to control and monitor citizens. 53 Early modern perceptions of mental illness were more closely related to ideas of divine blessing or demonic curse than to stigmatizing natural flaws in the physical body. By the 1940s, however, Syrian health professionals had adopted British and French ideas of illness as deficiency. Yet vernacular healing remained a complex system of religious beliefs, local rituals, and localized adaptations of biomedical concepts. This created a syncretic medical system through exposure to biomedical concepts and tools popular with state-run hospitals and medical schools, like areas outside the Middle East where communities formed a “vernacularized version of ‘western’ medicine.” 54
Cases elsewhere complicate Foucault’s notion of bio-power through gendered analyses and recourse to local legal sources. 55 Narratives of the professionalization of healing in Greece show that medicalization “succeeded . . . by demoting and disallowing existing knowledge of the body and replacing it with new discourses based in biology and medicine.” 56 Mental health treatment in many French and British colonial and postcolonial spaces reveal a racist and violent encounter between groups. 57 Sloan Mahone’s work on asylums in 1930s Kenya, Uganda, Tanganyika, and Zanzibar shows how asylums grew out of “the quasi-medical problem of the ‘educability’ of the African subject” and attempts of British colonial officials to “predict the future social and political behaviours of increasing numbers of ‘detribalized’ Africans.” 58 Sadowsky’s work on British colonial Nigeria reveals numerous instances of “contradictions in colonial psychiatry” that blended racism with scientific study. 59
Yet colonial psychiatric spaces have been, as Richard Keller has shown, productive places “for examining science and its contexts, and the historical circumstances of practices in centers and at the margins.” 60 Historical research can effectively present psychiatric practice as “a metaphor for state power” in the colonial period and as “a space for expressing the paranoia that shaped the collective mentality of a postcolonial society.” 61 The new discourses psychiatrists brought to colonies occasionally produced a higher incidence of disease categories their specialty invented. For some doctors, certain mental disorders were a natural byproduct of the colonial condition; as a country became “more civilized” under British or French control, “native” individuals (particularly intellectuals) were vulnerable to psychic crises and a degenerated mental state. 62 While Fanon wrote of this in Algeria, he did not address the widespread popularity of vernacular healing through saint shrine visits, or marabouts and their use of baraka (blessing power) among Arabs and Berber populations (Kabyle, Tuareg) in Algeria. 63 Keller notes that Algerian novelist Kateb Yacine (much like Fanon) saw an intense “physical, emotional, and psychological trauma” in the colonial encounter and even (in Yacine’s novel Nedjma ) explored “the clinic as a space of colonial violence” and psychiatry as “a biopolitical machine for the regulation of colonial order.” 64
Unlike Fanon, psychiatrists in the British- and French-funded hospitals of Asfuriyeh and Ibn Sina did not make explicit connections between political turmoil in the early twentieth-century Levant and mental disorders. In fact, one 1927 article in L’Hygiène Mentale went as far as denying any impact of the French bombardment of Damascus on the condition of patients at Ibn Sina—a claim one might find suspect given the hospital director Col. Leon Rene Jude’s position as a French military doctor with previous experience at a hospital in Tunisia. 65 It would have been in his government’s interest to allay fears of further negative consequences in French Mandate Syria after the government brutally suppressed civil unrest with bombardment. 66
With periods of devastating civil war, however, the legitimacy of psychiatric approaches has appeared to grow—as if the stigma of psychiatric illness lessens (and the utility of psychiatric treatment increases) when the entire population suffers violent conflict. A study by researchers in Beirut from Saint Joseph University, Hôtel-Dieu de France, and the Psychiatric Hospital of the Cross found a more than twofold increase in the number of Syrians admitted to Lebanese psychiatric hospitals between January 2009 and December 2013 from the numbers before 2009, due not only to the influx of refugees but also to the “diverse stresses . . . and lack of support” they faced in Syria. The researchers found that while Syrian refugee admissions in Lebanese hospitals for schizophrenia, brief psychotic disorders, and bipolar disorders increased, many Syrians “who need hospitalization for mental illness are not being admitted [to hospitals in Lebanon] because of health care access difficulties and financial problems.” 67 Researchers elsewhere are finding stigma is lessening as the numbers needing support grow; one study found that “as a result of ‘shared experiences of violence, loss and displacement,’ the stigma associated with mental illnesses has been reportedly decreasing and Syrians are showing more acceptance towards participating in psychosocial programs” for refugees in Turkey. 68 Syrian refugees in northern Iraq even “cited mental health services as the most-needed service in their setting.” 69 Health-seeking behavior of Lebanese Civil War survivors a generation ago may not show significant increases in the use of psychiatric treatment, but researchers surveying Lebanese mental health institutions in 1983 did document “evidence of PTSD symptoms, including insomnia, depression, stomach problems, and phobias.” 70 Unfortunately these wars devastate the very infrastructure potential consumers now feel they need, and neighboring countries strain to meet the needs of refugees at their gates. It is a tragic irony that people seek out these services at the very moment when services have largely collapsed because of the war.
This book’s main contribution to the field of Middle Eastern studies is in its interdisciplinary approach and its contextualizing of the two meanings of “spirit” hinted at in the title Disturbing Spirits . By complementing psychiatric history approaches with those in disability studies, trauma studies, and cultural studies, this book argues that government and international attempts at instilling a hegemonic cosmopolitan biomedical landscape in the last 120 years have largely failed in Syria and Lebanon—in part because of traumatic political developments.
Chapter one argues that vernacular treatment remained widespread in the region and remains widespread today. Though early reformers of the Salafi movement (which drew its intellectual basis from practices of ancestors or salaf predating Sunni legal schools of the ninth century) fiercely opposed practices they considered heretical and un-Islamic, such as saint veneration, later groups such as the Syrian Muslim Brotherhood drew members from individuals with connections to Sufi orders that engaged in such “heretical” practices. 71 Physicians wrote of vernacular practices in part to justify their own agendas, but some saw value in vernacular treatment stemming from a “do no harm” philosophy of Quranic healers who used a form of talk therapy using religious verses, as opposed to “warlocks” and “sorcerers” who claim connection to jinn for supernatural healing powers. Biomedical experts distinguishing between various forms of vernacular healing see a viable partner for culturally relevant therapy in the Quranic healer while maintaining a marginalizing and delegitimizing perspective on the sorcerer. Historical fiction produced after the 1960s reflects a traumatic memory of the French Mandate colonial experiences that marginalized vernacular treatment like saint shrine visits and home-based healing, treatments that in fact persisted in popular culture.
Chapter two connects significant moments in the late nineteenth and early twentieth century to the development of changing health practices since the mid-twentieth century. From the devastation and famine of World War I to the territorial losses and transformations in the mandates and the rise of the repressive Baʿath party and Assad regimes, Syrians and Lebanese have witnessed great trauma. Though there are medieval roots to aspects of mental health care in the Middle East (as with the bimaristan or Islamic hospital), 72 psychiatry only developed in the region (as it did in Europe) in the midst of late nineteenth-century government reforms in health and higher education; the 1876 Ottoman Mental Health Hospitalization Act, the 1899 opening of the Lebanon Hospital, and the 1903 founding of the Ottoman (then Arab) Medical School at the Syrian University in Damascus are major markers in Greater Syria’s psychiatric history. The school grew to rival foreign missionary medical colleges in Beirut and Ottoman schools in Istanbul. Ibn Sina Hospital, founded in 1922 as the first modern public psychiatric hospital in Syria, was the only mental hospital in the country until 1953, when a second public mental hospital (Ibn Khaldun, in Dweirina) opened near Aleppo. 73 While they succeeded in training a small number of elite Syrian men and women in biomedical and psychiatric practices, 74 doctors and administrators failed to supplant local ideas about the spirit-based causes and cures of mental illness in the general population.
Chapter three argues that, though Asfuriyeh staff consciously positioned themselves against the sectarian conflicts that came to characterize Lebanese society, their overt Protestant proselytizing cast them in a negative light among some Lebanese and detracted from their medical (and political) effectiveness. Asfuriyeh’s supporters, including influential men and women of the Lebanese diaspora in Europe, nevertheless continued to view themselves as a beacon of modernity to the Middle East—a modernity tinged with a Westernized, text-based Christianity in opposition to folk practices of Eastern Christian communities in the region. This chapter shows the first of two psychiatric approaches in French Mandatory rule that failed to supplant local treatment: an approach that associated modernity with psychiatry as well as with European and American missionary understandings of “legitimate” religious expression.
Chapter four argues that doctors at Ibn Sina used wholly psychiatric models of illness even as some patients’ families continued to use vernacular ones. Intellectual elites sought a medical path to health that would produce a modern nationalist community free of non-modern vernacular healing. Yet doctors relied on treatments like electroshock therapy and antipsychotics such as chlorpromazine that did not produce the quick and dramatic results many of their patients’ families expected, and vernacular treatment persisted in the spaces where psychiatric treatment failed. This builds on the previous chapter by showing the second of two psychiatric approaches in French Mandatory rule that failed to supplant local treatment: an approach that associated modernity with psychiatry as a completely secular enterprise, coupled with dismissal of the legitimacy of religious expression in healing practices.
Chapter five focuses on literature written during and about both the Lebanese Civil War and the ongoing Syrian civil war. In Lebanon, the war lasted over fifteen years, destroyed the country’s sense of a singular self, and engendered a traumatic rupture for millions of Lebanese and Palestinians within Lebanon’s borders. Branded “schizophrenic” from its 1943 origins by scholars writing in the postcolonial period, Lebanon’s Civil War traumatized the country even as sectarian memory continues to selectively efface painful pasts. In building on the narrative arc about the ways patients, doctors, and other survivors coped with the physical and emotional toll of the Lebanese Civil War, literary sources (and their frank discussion of resistance, torture, illness, and sexuality) push beyond medical history by reflecting on death in literature as social critique and violent resistance to oppression as a form of healing. State efforts to shape hospital admission procedures, standardize medical training, enforce legal consequences of diagnoses, and even to criminalize certain vernacular practices, ultimately failed to fully delegitimize and marginalize alternative treatments. This is in no small part a result of the lack of trust citizens had in their government—a government built not only of some of the same parties but even of some of the same men who had caused death and tragedy during the Lebanese Civil War. The chapter then connects traumatic conflicts of Syria’s past to the devastating and horrific events of the current Syrian civil war. It illustrates the widespread trauma of the present war and the sense by writers and filmmakers in the Syrian diaspora, as with writers in the Lebanese diaspora and in Lebanon during and after the Lebanese Civil War, that storytelling and bearing witness to tragedy will spark regional and even global conversations about justice, accountability, and memory.
The conclusion connects this discussion of global responsibility to scholarly debates about human suffering and the moral call to caregiving. Combatants in both the Lebanese and the Syrian civil wars have manipulated communities by instrumentalizing religious and sectarian notions of power and loyalty. It argues that mental health initiatives are a matter of public health as well as a form of social justice. Healing is an aspect of both daily and exceptional events that we as scholars should not ignore in our attempts to understand the past and the present. And now, with one of the largest refugee crises of our time and the political, economic, and health consequences of so many years of war that have internationalized the conflict, Syria has become a place the world can no longer ignore.
Vernacular Healing in Greater Syria
The widespread belief among Muslims as well as Christians and Jews in Greater Syria 1 that a world of spirits existed alongside the world of the living led to the use of various charms, drugs, and amulets to protect human bodies from spirit possession, an illness that revealed itself in symptoms physicians considered to be signs of mania or schizophrenia. 2 Such practices are by no means isolated to the Middle East; the interdisciplinary and international topic of vernacular healing has attracted research in anthropology, history, religious studies, psychiatry, and the newly emerging field of cultural neuroscience. 3 Though sectarianism is a frequent focus for historians on the Middle East, mental illness and healing were places of unity across ethnic and religious boundaries, both in spirit-based ideas of possession and in biomedicalized notions of sick bodies and treatment. 4 Muslim, Christian, and Jewish Syrians shared ideas about possession and spirit-based treatment for mental illness.
According to British physician E. W. G. Masterman, who worked in Jerusalem and Damascus in 1900, “belief in demoniacal possession is universal. Practically all madness is accounted for in that way, and methods of treatment are entirely devoted to bringing out the demons. If an ordinary native gave an account of the case of a mad person, he would certainly say that the English doctor had turned out some devils.” 5 He recalled a woman he treated in Damascus who under his orders needed only “rest and quiet,” but when she did not improve immediately, “an ignorant Moslem sheik was brought in, and, after making a series of incantations, brought, as he described, the demon down to the woman’s great toe, and then out altogether! The people all firmly believed this was the mode of her cure; the mad person always believes it afterward, and often, too, while mad, states that there is a demon in him or her.” 6 Publishing this report in The Biblical World , a theological journal whose audience would have been familiar with Christian scripture, the doctor cited a passage of the Gospel of Mark (5:1–16) about Jesus exorcising demons from a man who was frequently chained in caves as further proof of the long-held beliefs in the region of demoniacal possession. 7 Dr. Masterman noted in a typical Orientalist fashion that Syria was “a land of emotion—of undisguised joy and grief,” and that “the life of the majority [of Syrians] is wonderfully simple in a way—not half so complicated by crosscurrents of ambition, rivalry, and desire as are our lives.” 8 This data from Jerusalem and Damascus is like that of Beirut in the same decade. In 1909, some patients explained their illness to psychiatrists at the Lebanon Hospital (Asfuriyeh) as “[having] a devil” in a particular spot in their body and requested that the doctor or another patient cast it out. 9 That same year, Asfuriyeh’s medical superintendent H. Watson Smith noted “another patient, a Bedouin girl, was removed by her parents within a week of arriving, because they were thoroughly convinced that the English doctor could not cast out devils.” 10
For Jews, the “dybbuk” was a demon who could possess a human and cause great mental distress. 11 In his 1907 publication, Hanauer related a story told to him in Jerusalem by Dr. Chaplin, former head of the London Jews Society Medical Mission: a young Jewish woman came to the doctor with “a nervous complaint which he considered curable, but only by long treatment.” 12 Her family decided at first to bring her to the hospital, but later (against the doctor’s wishes) removed her from the hospital and left her in a cave on Mt. Carmel they believed was visited by the prophet Elijah. Their reasoning for using spirit-based treatment rather than psychiatric services, according to Dr. Chaplin, was that “they were sure that she was not really ill, but only under the influence of a ‘dibbuk’ or parasitical demon, and they intended to treat her accordingly.” 13 Interestingly, given the bias against spirit-based treatment psychiatrists often expressed, Dr. Chaplin revealed that he later saw the young woman and discovered “to his surprise that she was well again” as a result of her visit with Elijah in the cave. 14 She told him that while she sat alone in the cave overnight, “she saw an old man all in white, who came slowly towards her, saying, ‘Fear not, my daughter.’ He laid his hand gently on her head, and disappeared.” When she awoke the following morning, “she was perfectly well.” 15 For this Jewish woman and her family, Mt. Carmel was a place of healing for sufferers who were “not really ill” in a way doctors could cure, but who suffered from a spirit that would leave only with proper spiritual treatment. This family did not see her symptoms as the “nervous complaint” Dr. Chaplin felt his hospital could cure; rather, a night in the cave where the Prophet Elijah could cast out the “parasitical demon” was the most effective treatment possible. 16
For other patients, vernacular cures did not work as well. 17 The brother of a patient “of good Moslem family” took him to Asfuriyeh in 1902 but “a sensible uncle” had him released “by the insistence of the women of the family” to take him to a “so-called ‘saint,’ ” where vernacular treatment left the patient considerably thinner after thirteen days of near-starvation at the hands of the saint. 18 Another patient’s husband told the psychiatrists his wife (who “[gave] a great deal to do, especially in the matter of cleanliness”) had first seen a priest who “stated that she was possessed” and had her use “the same consecrated water” for forty days “in order to get rid of the demon” but saw no improvement. 19
Certain caves were associated with particular saints or prophets from all three monotheistic traditions. The cave of Quzhaya was well-known among Christians in the vilayets of Beirut and Damascus as a place to take relatives suffering from diseases of the mind. 20 When Ottoman officials established a mental hospital near Bethlehem, they named it after St. George, a saint associated with physical and mental healing who overlaps in ideas both with al-Khidr (The Green One) invoked by Muslims and with Eliyahu the prophet invoked by Jews. 21 A Western traveler noted in 1907 that the northern side of Mt. Carmel held “another celebrated centre of El Khudr [al-Khidr] worship . . . frequently visited by Jewish, Christian, Moslem, and Druze pilgrims” where “very remarkable cures are said to have been performed.” 22 Affixing the name of a culturally relevant saint well-known for healing among the community, as the Bethlehem hospital staff had done, was likely an attempt to ascribe a local legitimacy to the hospital that aimed ultimately to usurp the authority of popular healers and beliefs about saint intervention and install medical intervention as the locus of authority instead. In addition to shrines associated with al-Khidr, Muslims brought sick relatives to shaykhs who were thought to perform exorcisms, expelling jinn from the sick person’s body by means of special amulets or protective verses of the Quran. 23
A 1970 ethnographic study of health rituals at a saint shrine in Lebanon showed “a surprising survival of the practices of folk medicine” that thrived while medical services failed to “attract sufferers from certain kinds of illnesses.” 24 While anthropologist David Howell described his observations at a Lebanese shrine, he also noted similar practices in Damascus and surrounding areas. On some level the individuals who sought such treatment considered these practices therapeutic. Connecting the treatment to religious symbols imbued them with a level of legitimacy, making them attractive and culturally permissible options.
Howell looked at St. George shrines and churches connected to Christian and Muslim legends about St. George and al-Khidr, an immortal saint ready to come to the aid of any who invoked his assistance “of whatever faith they may be.” 25 Ideas about St. George’s healing power are widespread throughout the region, including at the Dome of the Rock in Jerusalem, in villages near Beirut, and at the source of the Jordan river, stemming from al-Khidr’s connection to providing water. 26 Palestinian physician Tawfiq Canaan’s 1927 publication Mohammedan Saints and Sanctuaries in Palestine found similar associations between St. George, al-Khidr, and mental health cures. 27 Canaan, a Lutheran and a physician at the German Deaconesses’ Hospital in Jerusalem and the International Moravian Leper Home in Jerusalem, and president of the Palestine Oriental Society, hoped to dispel widespread beliefs about spirit-based healing. However, he also took an ethnographic interest in documenting their prevalence and influence on daily life of Muslim and Christian communities. His study was a detailed account of a variety of vernacular practices of nearly 350 “holy and mysterious” shrines, where he documented not only the belief in spirits but also descriptions of which springs and caves held which kinds of spirits, and which saints, shrines, springs, and tombs were relevant in seeking treatment for particular kinds of spirit-based illnesses. 28
A Greek Orthodox cemetery in Damascus in 1966 had “small votive plaques of metal in the shape of afflicted limbs,” presumably for individuals who suffered from rheumatism. In churches throughout Damascus, Bethlehem, and Beirut, childless women hung “small pieces of ribbon and metal plaques in the shape of babies” on icons of St. George and visited the shrine of the Virgin Mary in Maʿaloula to pray for fertility. 29 Visitors to one Lebanese shrine were mostly women with adolescent girls and mixed families with babies in tow. While gendered, this cohort was of diverse socioeconomic background; there were peasants and urban workers as well as middle-class women. Women brought children presenting a range of symptoms, including agitation after a traumatic incident, to be cleansed with a tas al-ri ʿ b (cup of fear, also called Tasit al-Rajdfeh ). 30 The cup Howell identified as a shallow metal bowl with a flat rim and raised center affixed with Quranic verses is also mentioned in Mina’s Fragments of Memory. 31 Throughout the early and mid-twentieth century, shrine visitors felt that “the evil eye of a jealous or angry fellow human being” could cause mental derangement ( ikhtilal al-shu ʿ ur ), rheumatism, sterility, and infant mortality. 32 It may have seemed only natural, to those who believed evil eye caused illness, that they seek out healers who could offer treatment using supernatural forces. 33
Foreign Christian records on this practice exist for many decades prior to the 1920s. In his 1873 work The Women of the Arabs , missionary Henry Jessup related to his American audience that:
Dr. Meshaka of Damascus says that those who believe in the Evil Eye, “think that certain people have the power of killing others by a glance of the eye. Others inflict injury by the eye. Others pick grapes by merely looking at them. This power may rest in one eye, and one man who thought he had this power, veiled one eye, out of compassion for others! The Moslem Sheikhs and others profess to cure the evil eye, and prevent its evil effects by writing mystic talismanic words on papers, which are to be worn. Others write the words on an egg, and then strike the forehead of the evil eyed with the egg.” 34
Jessup’s reference to “writing mystic talismanic words on papers” echoes that of later commentators on the practice who discuss amulets with Quranic verses or alphanumeric tables and charts. Such treatments have continued throughout the Eastern Mediterranean even today.
Protection from danger came through wearing charms and amulets or burning magical or religious symbols into affected parts of the body. Medical directors noted that numerous patients at Asfuriyeh were admitted with scars on their heads from cautery and bloodletting. 35 One photo in the 1923–1924 Asfuriyeh annual report showed the back of one patient’s head, “one of the many patients, both men and women” who had a cross “burnt with hot iron to exorcise demon.” 36 E. S. Stevens similarly included such an image in her discussion of the cave of Quzhaya in her 1926 Cedars, Saints and Sinners in Syria . 37 These writers perhaps hoped to sensationalize such treatment for European and American readers. 38 Cautery ( kayy ) was the use of a hot iron to damage tissue, close wounds, or mark physical affliction anywhere on a person’s body. For people thought to be mentally ill due to spirit possession, cautery focused on the skull and was “a time-honored form of treatment” according to psychiatrist John Racy. 39 It was a constant problem for doctors in Lebanon, Syria, and Egypt.
Exorcism was also a popular treatment option and remains relevant as supernatural influence is still considered in some groups to be a factor in mental distress. 40 One form of exorcism is known in the Levant, Egypt, Sudan, Ethiopia, and elsewhere as the zar ritual. Of all the magical practices, Racy considered zar practices to be the most expensive, being “a several-day affair involving a number of sufferers and their relatives and presided over by a woman, the ‘Sheikha,’ . . . who leads a series of incantations, exhortations, and dancing that culminate in ecstasy and collapse.” 41 Racy understood these treatments in a psychological and psychiatric framework, noting that “neurotic and frustrated women” achieved some measure of relief in these healing practices “through a combination of abreaction, suggestion, and direct or symbolic gratification.” 42 Spirit-based illness could act as avenues for empowered speech and action where gendered practices and political turmoil would otherwise restrict behavior. 43 Though such rituals alleviated anxiety and stress for some, others did eventually seek medical assistance when “a wrong diagnosis of a physical ailment as an evil eye sickness end[ed] in a near disaster.” 44 But disasters were not always averted; one Asfuriyeh patient died at the hospital of wounds sustained during vernacular treatment prior to his admission. 45
There were several categories and labels for sexual, physical, and mental difference. Ideas about the makhbul (an idiot or insane man, from the word khabal for mental confusion), the majnun (a man driven mad by spirit possession, from the word jinn for spirit), and the majdhub (or majzub or magzub , an insane but holy man who has lost his mind as a result of the burden of God’s spiritual attraction or jadhb to him) circulated widely in the nineteenth- and twentieth-century Eastern Mediterranean. 46 Dr. Thwaites wrote in 1908 of Damascene Muslims’ belief that a majzub was “a special visitation from God, involving the possession of a new spirit, leading to a markedly tolerant line of treatment in which are exhibited love, respect, and even veneration.” 47 Elites in early twentieth-century Syria recognized the challenges they faced as they advocated biomedical understandings of illness over spirit-based ones. A 1910 article in the Damascene monthly al-Muqtabas that published on “scientific and sociological” issues complained that the medieval writer Najm al-Din al-Ghazzi’s biographical dictionary should not have included biographies of majadhib (the plural form of majdhub ) as they “trespassed the boundaries of Islamic law with their pretensions that violated mores, and who manipulated the minds of the populace.” 48 Medicalized suspicious understandings of nonnormative individuals were new phenomena, as urban educated elites in early nineteenth-century Syria considered majadhib to be holy men, not deviants. 49 Debates that emerged on which Syrians (and non-Syrians) had authority to decide such issues expose false dichotomies of French and local health practices and avoid totalizing assumptions of what “modern” meant in treatment.
Late nineteenth-century worldviews about “holy fools” ran counter to the modernism Salafi leaders such as Rashid Rida espoused. While some elites formed secular groups like the National Bloc that supported certain notable families in their pursuit of political power (a “nationalism of the pashas ” that did not concern itself with appeals to ordinary people), others such as Rida turned to religiously oriented frameworks that were explicitly against vernacular practices. 50 A Syrian-born prominent religious scholar and disciple of the Egyptian reformer Muhammad ʿAbduh, Rida advocated a conservative approach to living in modern society. 51 Though some Syrian leaders supported a “modernist” approach that welcomed certain contemporary European practices, Rida and other Salafis felt political and social life could be both “modern” and Islamist in orientation. 52 “Modern” life meant accepting certain innovations and foreign accretions such as the telegraph and European dress, while preserving values they considered culturally appropriate such as monitoring morality in public spaces and separating foreign and local populations in schooling and cinemas. 53 This reform had its roots in the 1880s with the “Ottoman-orthodox tendency in Damascus” that saw prominent Salafi reformers in league with central authority in Istanbul. 54 Men of the “Ottoman-orthodox tendency” conflated Salafi goals with Westernizing ones. 55 Rida and other Salafi reformers expected a certain level of rationalism (or “reason and unity”) in religious practice, and Sufi practices in popular culture were evidence of irrational and backward ideas that were obstacles to the region’s “progress.” 56 In the early 1900s, Salafi thinker Jamal al-Din al-Qasimi felt Muslims were supposed to “employ reason . . . [in] both material and spiritual realms” and that “modern discoveries in astronomy, physics, geology, and anatomy enhance[d] man’s faith rather than diminish[ed] it.” 57 When Rida disparaged the belief popular in Damascus that a majdhub was spiritually blessed in 1929, it was from within this rationalist scientific framework. He stressed to readers of his journal al-Manar that the majdhub was not a saint but either a madman afflicted by mental torment or an immoral person manipulating the public and flouting social conventions of hygiene and modesty. 58
Other religious reformers, such as the Wahhabis (who referred to themselves as muwahhiddun , those who profess the unity of God) also found Sufi practices inappropriate. Wahhabis considered saint shrines a form of idolatry, and their efforts in the nineteenth century to destroy tombs of individuals local Muslims venerated as saints were extremely unpopular with ordinary Syrians as well as some Damascene ʿ ulama ʾ (religious scholars). 59 By the 1920s, however, Wahhabi supporters had developed Islamist networks among some Sunni leaders in Syrian lands, and they faced intense opposition from people who continued to engage in saint intercession rituals. 60
Vernacular practices were not accepted by all people who identified as Muslim, Christian, or Jewish. There was often a “low-religion” / “high-religion,” or a folk-orthodox split, in religious beliefs and practices. Some leaders advocating for “purer” forms of religious practice scorned saint worship and Sufi customs, but many also noted that the Quran did mention the world of the jinn as largely invisible to the living. 61 In religious practices as in most other aspects of everyday life in the nineteenth and early twentieth centuries, reforms existed alongside long-standing practices. This is part of what William Cleveland called the “institutional dualism” of the period since Tanzimat reforms of the 1830s. 62 Institutional reform, as with laws and schools, existed alongside traditional institutions such as Shariʿa legal codes and kuttab (primary school). Though Salafi reformers such as Rida attacked Sufi practices, a Salafi-Sufi dualism reached even into some of the highest echelons of political power as certain Sufi or Salafi shaykhs gained or lost favor with government authorities in the late Ottoman and French Mandate periods. 63 After independence, Salafi and Sufi tensions continued to shape political action as “traditional [Sufi] social and religious structures persisted” in peripheral towns like Hamah while Salafi leaders grew to hold power in Damascus. 64 Despite such divisions in religious practices, belief in jinn was widespread across all social groups, even religious scholars and physicians. As one historian noted, “some religious scholars asserted that denial of the existence of jinn was equivalent to heresy and believed that possession of human bodies by jinn could cause diseases such as insanity and epilepsy.” 65
The medical benefit of certain Sufi practices is just one example of the complex role Sufism has played in communities in the Middle East. 66 For example, “Sufi-inspired yet politically aware” initiatives in Syria’s private sector like Jamaʿat Zayd (Zayd’s group) have supported hundreds of lower income Syrians through provision of food, medicine, clothes, furniture, and books, and even subsidized dowries for people to afford marriage. 67 On the occasion of a mawlid , the birth celebration usually of the Prophet or a member of his family but occasionally also a birthday of a famous shaykh, wealthy people expressed piety through charitable donations, some of which went to health projects. Sufism, as a mystical path “to elevate the spiritual quality inherent in people,” exists in an official capacity through the creation and dissemination of fraternal orders or turuq , but beliefs in Sufi leaders’ powers and blessings also touch ordinary people in their everyday life. 68 An eight-day celebration in Egypt of the mawlid of thirteenth-century religious scholar and Sufi leader al-Sayyid Ahmad al-Badawi included donations of “food and sweets . . . to the needy and visitors as signs of blessing,” as participants hoped to harness blessing or baraka from the shaykh whose mawlid was celebrated that day. 69 Similar activities in Yemen show how “popular Islam” has an “ambiguous relationship” with scholarly orthodoxy even as it addresses some of the same health-based concerns people had when they turned to spirit-possession rituals such as the zar . 70
In 1923, Father Jules-Antonin Jaussen, a priest of the Dominican order at the French Biblical and Archeological School (l’École Biblique et Archéologique Française) in Jerusalem, noted that a certain shaykh Saʿad al-Din al-Jabawi in Palestine was a successful exorcist. 71 When he prepared to diagnose and heal a person, al-Jabawi first determined if their illness had either natural or supernatural sources:
I heal all diseases. And yet, not all diseases have the same origin. There are some that have ordinary causes, such as [being] cold or too hot; others, and [these are] a great many, are engendered by the evil eye; and finally the third category is occasioned by a jinn that takes possession of the patient’s body. 72

For al-Jabawi, just as for the Jewish family that turned away from Dr. Chaplin’s hospital in Jerusalem, illnesses caused by evil eye or jinn had to be treated by an expert who knew the diseases for what they were: a supernatural disorder. A psychiatrist perceiving symptoms to be of a natural disorder would be unable to help since they could not treat the true cause of the illness.
According to Jaussen, al-Jabawi was an “illustrious” healer known throughout the region in the 1920s because he was thought to heal all manner of diseases, whether due to natural origin, evil eye, or jinn. 73 Since two of the three causes of disease, according to al-Jabawi, were extraordinary, effective treatment for such causes had to be extraordinary. Treatment to ward off the evil eye and dispel jinn involved a range of vernacular healing practices familiar to consumers of prophetic and folk medicine, including the use of amulets, magical religious incantations, saint shrine visits, and exorcisms.
Jaussen reported his findings to the Palestine Oriental Society, an organization formed just after World War I by the American Assyriologist Albert Clay and associates of similar interests regarding “the cultivation and publication of researches on the Ancient Near East.” 74 These European and American Orientalists saw the end of Ottoman rule and the beginning of British mandatory rule (in Palestine and the Transjordan) and French mandatory rule (in Lebanon and Syria) as an opportunity for academics—as well as bureaucrats and missionaries with scholarly interests, “learned representatives of various countries, societies and religious bodies”—to meet and discuss their research. 75 The society published its first journal issue in October 1920 with the efforts of European and American philologists, missionaries, and others interested in topics from folklore and ethnography to religion and semiotics. Though they published in Jerusalem and drew contributions from Arab and Jewish officials locally (including, for example, S. Loupo of the Alliance Israélite Universelle in Jerusalem), the majority of their members came from universities, Christian missionary societies, and government offices in the United Kingdom, France, Canada, or the United States. 76
Edith Szanto’s research among Twelver Shiʿis at the Sayyida Zaynab shrine in Damascus in the 2000s found that ruqiya shar ʿ iyya (religiously permissible magic) was widespread, and that men and women of various nationalities and religious sects (including Iraqis, Palestinians, and Syrians, and Sunnis, Shiʿis, Christians, and Alawis) sought out the help of a tabib ruhani (literally “spiritual doctor,” meaning a magician or sorcerer) who used herbs and Quranic incantations for such diverse aims as preventing divorce or healing illnesses clients presumed to be jinn-based. 77 One 2009 interview between Szanto and an Iraqi Shiʿi woman in Damascus found that healing could also be connected to auspicious dates in the calendar (similar to the Jewish practice connecting Lag b’Omer to healing opportunities mentioned earlier). During the month of Rajab, the seventh month in the Islamic calendar, “people with ‘needs’ or ‘desires’ buy silver rings with semi-precious stones, especially carnelian and turquoise, and had them engraved with hirz [prayer formulas or charms] from books such as Mafatih al-jinan [a Shiʿi prayer compilation, literally ‘the keys to the heavens’].” 78 Her fieldwork reveals that Syrians distinguished between “white magic” and “black magic,” the kind that Syrian psychiatrists and psychologists I interviewed consider sorcery. 79 Whereas white magic might involve amulets citing only Quranic verses and recitations of the Quran, black magic could involve a sorcerer’s commanding of certain jinn to attack each other or a person.
Though spirit-based ideas of illness were widespread in the pre-Islamic world, evil eye and jinn in the Middle East were also substantiated in a rich Islamic tradition. The classical period of Islam (eighth to fourteenth centuries CE) produced “intellectual and spiritual debates . . . [when] theologians, Sufis, Qur’an commentators, poets, literary critics, historians, and geographers mused and deliberated on the concept of the jinn .” 80 Numerous textual and oral sources validated people who understood illness through supernatural worldviews and used them to cope with the traumas and diseases of these harsh decades. The Quran and numerous ahadith mention the world of jinn and their role in human suffering. 81
When Jaussen interviewed shaykh Saʿad al-Din al-Jabawi in Nablus in 1920 to gather data on vernacular healing, his project came at a particularly sensitive moment of political and social upheaval. The centuries-old Ottoman Empire had witnessed a massive restructuring of its provinces. The League of Nations mandated British and French control of much of the Eastern Mediterranean and beyond. Palestinian and Iraqi families struggled under British mandatory rule, Syrians and Lebanese under the French. Jamal al-Din Al-Afghani’s pan-Islamist belief in the unity and political action of the umma (community of believers) to overthrow Muslim leaders corrupted by European exploitation and influence, and to encourage local leaders to take political control, also had a major impact on the region. 82 Salafis prior to World War I shared some common ground with al-Afghani; Muhammad ʿAbduh felt Muslims should rid their lives of corrupting accretions to their practices by looking to practices of Muslims of the Prophet Muhammad’s time (the salaf ) for guidance. 83 By the start of the French Mandate however, Salafi leaders had turned from reform to preservation, and practiced some of the very rituals that earlier Salafi leaders had hoped to purge from daily practices. 84 Their focus switched to an Islamic populism that challenged the credibility of the failed “Islamic governments” of the last Ottoman sultan and the Hashemite prince Faysal, whose political cooperation with the British was, for Rida and Arslan, a quality that made the Hashemites “ineligible for Islam’s most esteemed office.” 85 Rida and Arslan built a post–World War I social movement that recruited members from all over the country, including lower-class areas of Damascus, Homs, Hama, Aleppo, Latakia, and Tripoli. They drew in this demographic with promises to take the government from “secularist elites” and place it in the hands of leaders who, in their understanding, held religious authority to rule. 86 They were more vocally anti-colonial than pre–World War I Salafi reformers had been in speeches, in part because Rida felt betrayed by British maneuvering after the war. 87 Even with the tensions between supporters and detractors of Sufi and folk practices, however, government leaders in this period did not prioritize mental health treatment for patients.
For many patients, the hospital was not the first point of contact between the sick person and a healer. One Ibn Sina Hospital case file mentioned that treatment had been at home in Saydnaya prior to admission to the hospital in 1927. 88 Another patient’s family member asked in 1946 that he be released “for treatment at my house” in Damascus. 89 Foreign and local physicians and social scientists often commented condescendingly about “superstitious” practices. In a 1909 report, Waldmeier felt “often the patients are sooner cured from their mania than their relatives and friends from their superstition, which has become chronic and incurable through the past centuries.” 90 Local elders gave patients amulets wrapped in paper with Quranic verses to protect the patient from evil spirits. 91 The patient would drink water containing ink bled from these inscriptions. Even men educated at Saint Joseph University in Beirut harbored beliefs about the miraculous curative properties of vernacular treatment at places such as the cave of Quzhaya, beliefs the Western traveler Lady E. S. Stevens (in her 1926 publication Cedars, Saints and Sinners in Syria ) called primitive and misguided. 92

Lebanese American psychiatrist John Racy had much to say about what he called “folk psychiatry” in his 1970 publication Psychiatry in the Arab East. 93 “Magical therapy of various sorts has existed in the Near East since the dawn of history,” he asserted, and such therapy was syncretic, “borrowed from adjoining regions, mainly Africa and Central Asia, and . . . encrusted with multiple accretions over the ages. Thus a belief or practice may reveal traces of Mediterranean folklore, Judaic taboo, Christian faith, and Muslim ritual.” 94 People used charms or amulets “in the form of a blue bead, a cross, or Koranic verses” and placed some “about the neck to ward off evil influence,” and “frequent invocation of Allah by using one of his many names (‘ya Hafeez,’ ‘ya Muʾeen’ etc) [was] another magical device to avoid harm.” 95 One Syrian radio show ridiculing such practices mentioned that an elderly woman ignorant of medical practices hoped to ward off evil disease by proclaiming, “God is one!” 96 It is possible a patient in Ibn Sina described in chapter five who mumbled to himself “ya Latif” (oh Gentle One) and “ilhamdillah” (thank God) hoped to protect himself in this way. 97
The blue bead Racy mentions is connected to a widespread association throughout the Mediterranean of the color blue with protection from evil eye and ill health. One folklorist remarked in 1951 that he had seen “horses and camels in Morocco and Algiers with great blue buttons on their harnesses” and that children in Greece and Armenia wore “blue ‘eye beads’ conspicuously on their clothing.” 98
Vernacular practices using amulets, incantations, cautery, and visits to saint shrines frequently surface in historical fiction and semiautobiographical works about the early and mid-twentieth century. Hanna Mina’s semiautobiographical Fragments of Memory describes one particularly difficult episode in his early childhood that refers to incantations and amulets as well as a “fear cup” or magic bowl ( tasit al-ra ʿ ba or tas al-ri ʿ b ) after a terrible fright from a snake he encountered when playing alone on a sandbank by the shore. 99 Born in 1924 to a low-income Christian family in the seaside town of Latakia, Mina wrote of his early childhood made harsh by dire poverty, disease, and homelessness. 100 Whether because of stigma associated with practices that educated Syrians might now consider backward or superstitious, or because the whole ordeal was one the family wanted to keep private, Mina risked rebuke from family members for the way he publicly wrote of these and other family moments in his widely distributed novels. 101

His mother had warned him against visiting the sand bank “because there were lots of scorpions and snakes . . . and there was no antidote for their sting.” 102 But his fascination with the sea and ships overpowers his fear of a snake or scorpion bite, until he does see a snake and he screams, “frozen with fear.” He runs until he stumbles, convinced the snake is about to strike. His physical reaction and the treatment that follows evidence a vernacular approach to what psychiatric healers may have otherwise seen as a psychological issue:
I rolled around in the sand emitting sharp, sobbing sounds that were heard by a fellah who ran to pick me up. When I calmed down in his arms, he was able to take me home with tears streaming down my sand-covered face. Father did not beat me. Running to me with the tasit al-raba Mother made me drink three times, splashed the rest of the water on my face, then lay down with me as I shivered in her arms. She told me afterwards that I was sick for a few days and that a sheikh came to recite incantations over me. He wrote an amulet for me, which mother hung around my neck. I never went back to the sand bank, not out of fear alone but due to the family moving. 103
In this instance, occurring likely in the late 1920s or early 1930s, the family’s response to Hanna’s shock is to treat him with imbibed water from the popular “fear cup” ritual, and to put the remaining water on his face, rather than on any other part of his body. Presumably the location of the contact with this water is significant—it may have a connection to the idea that a jinni entered through his eyes, ears, or mouth since his encounter with the snake included seeing it and screaming. The visit from a sheikh, the recitation of incantations, and the writing of an amulet are all vernacular treatments.
Other glimpses into vernacular treatment are visible in the memoir of Armenian Lebanese psychiatrist Herant Katchadourian. In retelling an incident from 1942 when he was a nine-year-old boy recovering from a long illness with relatives in Kessab, “the only Armenian village in Syria” that sits on the Syrian-Turkish border south of Antakya, Katchadourian remembers the following: “One of the guests told a story about a man who was ‘married’ to a female jinni. I wasn’t sure what that meant, and some of the other guests sounded skeptical. The storyteller persisted and claimed that the malevolent spirits, who were the relatives of the ‘wife,’ had finally come to claim the husband. No one else could actually see them, but the man kept pleading that they were taking him away. He died of fright, even though the doctors claimed it was a heart attack. The story haunted me for a long time.” 104
The anthropologist Aref Abu-Rabia, conducting ethnographic research among Negev Bedouin in the 1980s and 1990s, studied healing practices around saint shrines and belief in the evil eye. 105 He found that mental illnesses were among a range of afflictions the evil eye and jinn could bring. Connected to local notions of the magical power of jealousy, the evil eye could fall on a victim when “conveyed by a strange gaze, or by admiration without a blessing.” 106 It could cause many health problems, including “impairment of sexual activity, impotence, sterility, disorders in menstruation, problems in pregnancy and childbirth, deficient breast milk, mastitis, [and] a baby’s refusal to suckle.” 107 The evil eye and spirit possession could affect anyone and anything—children, adults, livestock, and possessions. It was especially dangerous to those who attracted jealousy the most: the young, the wealthy, and the beautiful. Victims exhibited all manner of discomforts, from drowsiness and fatigue to restlessness, lack of concentration, muscle pain, headaches, and even convulsions. 108
Though he disapproved of some vernacular practices, Racy encouraged psychiatrists to study and consider the usefulness of some approaches. The use of charms and the zar rituals showed individuals took treatment into their own hands. He noted, “despite ignorance, prejudice, superstition, and the operations of the unconscious mind, a large body of ‘primary psychological data’ is available to the common man as a basis of action—more perhaps than in the areas of infection, malnutrition, and metabolic derangement.” 109 Racy felt that, unlike medical sciences treating physical disease, treatment for psychiatric and psychological afflictions could benefit from incorporating vernacular practices. He stressed, “native systems for the sustenance of mental health must hold significant lessons for scientific medicine. . . . Yet the lessons to be found in Folk Psychiatry will be lost if they are based on nothing more than speculation. They beg for serious study.” 110 Vernacular treatments of mental illness, what he called “possibly the oldest medical ‘specialty,’ ” was one that deserved the intellectual curiosity of biomedical professionals.
Syrian psychiatrist Dr. ʿAbdul-Massih Khalaf noted in 1980 that “traditional healers” in Syria catered to the needs of their communities using “a jumble of traditional techniques” from beliefs held by Syrians of a variety of ethnic and religious backgrounds. 111 Their techniques, which included prayers and advice to the patient, sometimes included requests of the patient’s family that encouraged emotional involvement, and occasionally vernacular healers even suggested that the family take the patient to a medical doctor. 112 Though he referred to the late 1970s, the hybridic practices Dr. Khalaf described were also popular in the early and mid-twentieth century, as saint worship and the use of amulets and “fear cups” or bowls were popular among Muslim, Christian, and Jewish communities as well as among Armenians and Arabs living in Syria. 113
The “still unresolved conflict” between vernacular and biomedical practitioners, in the cities and in the countryside, prevented most people from living what biomedical experts called “a fully westernized urban existence” in 1960s Lebanon. It may have been lack of faith in the curative powers of psychiatric treatment coupled with an economic choice: it was often cheaper to visit a shrine than a doctor. A 1957 census in Lebanon showed a ratio of 1,260 trained doctors to 1.75 million inhabitants that improved to 1 doctor per 700 inhabitants in 1970, and “although foreign medical skills have been available in Beirut for over a century . . . a large percentage of Lebanese are not convinced that modern medical skill is wholly effective in dealing with infant sickness.” A 1965 poll in Lebanon found 80 percent of urban female respondents “held that certain types of infant illness were caused by the evil eye of a jealous or malignant person.” 114 Some Lebanese women felt it would be inappropriate for a woman to be examined by a male doctor, so where a female doctor was unavailable, nurses, midwives, and local women administered treatment. 115
For “incurables,” the treatment in Ibn Sina Hospital was not any more effective than treatment at a shrine to St. George or al-Khidr, or at the “micro-asylum” of a family member’s home. 116 There was no clear line between physician and charlatan when it came to healing illnesses patients and families perceived to be connected to jinn that doctors perceived to be biological but also socially constructed. 117 After all, for an “incurable” at Ibn Sina, what use was a psychiatrist’s approach to him or his family? This is not to suggest that there were no physicians seeking more efficacious treatment or attempting to better understand the chemical and cultural factors in mental illness at the time. But very little of that research, and the resources to implement them, made it to Ibn Sina. In any case, some of the most cutting-edge research and tools in Europe and America led to rather questionable conclusions. A survey of research projects in 1935 suggest a scientific environment deeply embedded in the stereotypes and gender dynamics of the time; one American study found that “alcoholism more often results from pampering by mothers than from alcoholism in fathers,” and one doctor in Boston noted “suggestion combined with electric currents or anesthesia effected almost instantaneous cures of hysterical paralysis similar to the ‘miraculous’ cures of faith healers.” 118
Medical pluralism has a long history and has garnered attention in Middle Eastern case studies in recent decades. 119 Supernatural connections to insanity prominent in Islamic societies for centuries “cannot be ignored” by historians. 120 In the field of transcultural psychiatry, “psychiatric pluralism” suggests that multiple approaches could be therapeutic, and that hegemonizing and universalizing strands of biomedical psychiatry can harm communities in which psychiatrists work. 121 The availability of multiple therapeutic options made patients more likely to find a treatment that worked for them. 122 Social workers have come to similar conclusions about spirit-based treatment among Bedouin in Israel. 123 Though these are recent studies, their premise is one psychiatrists like Racy and El Mahi found relevant at least as early as the 1950s.
One of the issues at the heart of this persistence of supernatural understandings of illness is that there are two separate (but not necessarily mutually exclusive) truths at play here. There is the religious belief in the existence of jinn, and the cultural belief in the existence of the evil eye. There is also the scientific belief in the existence of mental illnesses that may be diagnosed and treated within the psychiatric framework. These beliefs need not be binaries. For some scholars of the Islamic world, the truth of jinn existing and the truth of medical science were not mutually exclusive. One fourteenth-century scholar of Prophetic medicine, Ibn Qayyim al-Jawziyya (d. 1350), had “pragmatic boundaries to resolve the contradiction” that creatures outside the natural world (like jinn) could perhaps influence disease etiology and transmission when he wrote that “as the jinn fall outside the realm of knowledge of medicine, it is possible that these creatures play a certain role . . . which does not contradict scientific findings.” 124 It would be controversial in the Islamic world to deny the existence of jinn entirely.

The validity of Quranic support for a causal relationship between jinn and mental illness, however, is contested. In a 2014 study, kinesiologist Farah Islam and sociologist Robert Campbell (based in Toronto and Nova Scotia) studied English translations of the Quran to dispel the notion that there was a Quranic basis to connecting insanity to jinn possession. 125 Islam and Campbell aim to “discredit the suggestion of any linkage of supernatural possession and mental illness being implied” in the Quran. Their search in Quranic “themes related to the terms jinn, Satan and madness” demonstrated “no direct connection between spirit-possession and mental illness. When people were spoken of as jinn-possessed or crazy in the text, this was done so in reference to the ignorance of pagan insults or to spiritual insanity, as a result of sin. No person of spiritual authority in the Qur’an ever expresses this belief.” 126 They published this study in the Journal of Religion and Health to dispel the deep stigma of mental illness, mistrust of medical professionals, and stereotypes of Canadian Muslim communities, but the phenomena they studied is widespread among Muslim communities in the Middle East. “We need to start a conversation on mental illness,” they stressed, “that brings together the best that medical science and healthcare systems have to offer, while at the same time respecting the fundamental precepts of Islam. Muslims express a great deal of distrust towards mainstream mental healthcare services.” This, coupled with “marginalization and isolation . . . in Western society and the community shame associated with mental illness” has led Muslim communities in Canada to “severely underutilize mental healthcare services,” a fact the clinical researchers found especially disappointing because of “how treatable mental illness is.” 127
A wide array of practices exist in the region, in a system some health researchers call “traditional Arabic and Islamic” medicine. This medicine developed over centuries of cross-cultural contact and is a hybrid of multiple healing traditions, including traditional Chinese medicine, Ayurvedic medicine, and Perso-Arabic medicine derived from Unani (or Yunani) medicine influenced by Galenic humoral theory and ancient Greek practices. Practices that some physicians attribute to “Islamic religious influences” draw from the Quran, ahadith , and medical practices familiar to the seventh-century Hijaz (the western edge of the Arabian peninsula where Mecca and Medina, the two holiest cities in Islam, are situated) that are known today as part of Prophetic tradition. 128 This system involves “herbal medicines, spiritual therapies, dietary practices, mind-body methods, and manual techniques” and includes Quranic healing and Prophetic medicine ( al-tibb al-nabawi ) as well as approaches scholars refer to alternately as folk, vernacular, or popular healing. 129 Figure 1 in the appendix gives more detail on the overlapping systems.
While medieval practices found roots in the Quran and sayings of the Prophet as well as systems of thought across the Silk Road regions, with the use of works by Ibn Qayyim al-Jawziyya and other fourteenth-century scholars like Shams al-Din al-Dhahabi (d. 1348) and Ibn Mufli al-Maqdisi (d. 1362), they also drew from treatises by leading intellectuals of centuries earlier. Tenth-century scholars Muhammad b. Zakariyya al-Razi (d. 923), Thabit b. Qurra (d. 901), and Qusta ibn Luqa (d. 910 or 920), as Justin Stearns notes, built on ideas around contagion in the Islamic Middle East to include some epidemic diseases, and even though scholars of the premodern period did not view mental illness as contagious, there were at least two tenth-century scholars who declared melancholy to be hereditary and one (Ibn Luqa) who considered certain psychological states such as sadness and arousal to be contagious. 130
In a study published in 2007, psychiatrist Elie Karam found that “demonic possession” was one of the factors community members cited for “a mass psychogenic incident” the previous year as well as for diagnoses of multiple personality disorders in Lebanon. 131 A case reported in the May 2000 issue of The Arab Journal of Psychiatry of a woman that psychiatrists diagnosed with bipolar affective disorder raised grave concerns about “traditional” treatment. 132 It noted that “a few days after her [hospital] discharge, her family decided to stop the prescribed medicine and took her to a faith healer.” While in a lucid state, she disclosed to her psychiatrist that she had “faked” jinn possession to save her own life since “in all these visits, she was physically tortured by the healers” during treatment that traditional healers considered an exorcism. 133 While the data from this patient suggests a level of abuse at the hands of a faith healer that a court might find criminal, psychiatrists who dismiss supernatural worldviews altogether, or who view all faith healers as charlatans and abusers, alienate the local populations that find meaning in attributing certain human behaviors to intervention by disturbing spirits. 134
There are no clear hierarchies among Syrian and Lebanese religious healers writ large, though saint shrines associated with long-standing Sufi orders or with Shiʿi imams hold extra meaning for visitors who see themselves as members of those communities. 135 More generally, however, a religious leader ( shaykh ) or even a family member may perform ruqiya on a patient (reading Quranic verses or prayers and then “ ‘blowing a puff of air’ on the wound or ill body part”), while a male healer known as a katib (literally, a writer) might be consulted along with a shaykh for hijab (an amulet a patient might wear containing Quranic verses and written prayers “to ward off evil spirits.”) 136
Several years after Lebanon’s independence, Asfuriyeh Hospital staff still occasionally complained of the “vast barrier of prejudice and ignorance concerning mental disease” that led potential patients to “lay competitors” endorsing “medieval methods . . . such as branding and exorcism.” 137 In a 1961 interview, Ibn Sina medical director Dr. ʿAzza al-Roumani similarly despaired of the treatment of “sorcerers and fortune-tellers” and of the persistent widespread lack of understanding of medical causes of mental illness. 138
Doctors at Ibn Sina and Asfuriyeh tried to address with chemical and biological innovations the symptoms of people suffering from terrible mental and at times physical anguish. These physicians failed to garner the trust of families of patients who believed deeply in the spirit-based nature of these symptoms in the early and mid-twentieth century. Treatment with amulets, fear cups, religious incantations, cautery, visits to saint shrines and participation in zar cults were more popular with the majority of people in Syria than treatment with electricity, insulin, or sedatives. If cultural psychiatry emerged as a field for “how to effectively market medications” and to “[reconfigure] other forms of suffering in ways that suit the interests of the pharmaceutical industry,” as Laurence Kirmayer noted, it failed to meet these goals in Syria. 139
The persistence of vernacular practices drew concern from local hospital administrators as well as international health organizations. Sudanese psychiatrist Tigani El Mahi, born in 1911 south of Khartoum and a graduate of the Kitchener School of Medicine in Khartoum in 1935, became mental health advisor to the World Health Organization Regional Office for the Eastern Mediterranean based in Alexandria, Egypt, in 1956. He wrote frequently on cultural variance in mental health practices in the 1950s and 1960s. 140 According to Racy, El Mahi felt “modern psychology and psychiatry” did not accord enough weight to the ways in which culture “arises from and responds to psychological needs and is thus a factor in molding character and behavior.” 141 For example, El Mahi believed that it was a popular misconception among non-Arab and non-African psychiatrists that psychiatric disturbances were rare in what he called “traditional cultures.” He believed the low incidence of certain illnesses among communities was a result of the way certain groups perceived symptoms, and that people “lost in magic and religion” had a higher threshold than communities in Europe and the Americas for tolerating “psychic disorganization,” while “modernization” brought “a greater sense of individuality” and subsequently a lower threshold for tolerating such disorganization. 142 Yet El Mahi’s description is not malicious or condescending in the way other psychiatrists in his period wrote. 143 He was not averse to working with spiritual elements in mental health treatment, and even felt (as Racy did) that religious healers in the Middle East and Sudan were “often remarkably effective” and “in a position to use suggestion and persuasion based on an intense religious transference” to treat patients. 144
El Mahi realized the vast majority of people in North Africa, East Africa, and the Levant were familiar with such systems and he sought to disseminate knowledge in both directions—from folk healers to psychiatric experts as well as from psychiatrists to practitioners of such rituals as the zar in Egypt, Ethiopia, and the Sudan. 145 “It is essential to make it clear that the concept of mental health is not exclusively a medical one,” he reminded World Health Organization (WHO) leaders in 1960 after a visit to hospitals in Tripoli, Libya, and “the sum-total of Mental Health comprehends a wide sphere of social, economic, spiritual as well as the purely medical issues.” 146 He felt psychiatry best served populations when it took into account wide-ranging influences on health. A major difference between the vernacular system and that of biomedical and psychiatric practices in the region is that the former was more holistic, while the latter (at least in the ways it was understood by Lebanese and Syrian patients in the twentieth century) was significantly detached from holistic approaches. It was a system to heal only one dimension of the body, or in the case of mental illness, the brain—but it ignored the soul and, in some senses, the mind.
The World Health Organization committee that convened in 1959 and subsequent WHO studies in the 1970s drew attention to the issue of prevalence and treatment of schizophrenia and its symptoms globally, particularly “the effect of culture on the form and content of schizophrenia” and its comparability across cultures. 147 It was an opportunity to advance research in ways that, the WHO staff hoped, challenged racialized or climactic understandings of disease at a time when cross-cultural comparative studies on schizophrenia “using the same methodology [were] virtually non-existent.” 148 A support system for counseling services beyond hospital walls was practically non-existent for most people as “teachers, parents, religious leaders, physicians, and wise uncles . . . [did] the best they [could]” with the tools they had. 149
In a 1959 interview, Ibn Sina Mental Hospital medical director Dr. ʿAzza al-Roumani took the opposite position of El Mahi and other WHO experts. For Roumani, the “magic and religion” practiced by “sorcerers and fortune-tellers” ( al-sahara wal- ʿ irafin ) could do no healing at best and serious harm at worst. 150 Charlatans extorted “large amounts of money for exorcism meetings that neither hurt nor helped,” because elders exploited “the people’s foolish trust in [the belief] that madness is caused by evil spirit possession that reside in the body of the sick person and cause his illness, and the person cannot recover until the spirits are extracted” by supernatural means, such as exorcisms, incantations, and the like. 151 John Racy lamented the “poor pay and poor academic standing” of psychiatrists in the countries he studied (Egypt, Jordan, Lebanon, Syria, Iraq, Kuwait, Saudi Arabia, and the Sudan) and echoed El Mahi’s comment that “a job poorly paid is a job poorly done.” 152 The ideas underpaid psychiatrists fought to dispel were the purview of “seers, fortune-tellers, mind-readers, and clairvoyants,” men and women Racy occasionally found indistinguishable from “out-and-out charlatans and quacks.” 153 In a French translation of the Arabic 1977 publication, Syrian physician and novelist ʿAbdul-Salaam al-ʿUjayli related in short story form his experiences traveling in the Syrian countryside, and he was particularly critical of these pseudo-medical practitioners. 154 In “Les charlatans sont a des degres divers,” al-ʿUjayli cautioned readers against the manipulative methods these healers used to fool patients into believing their treatments were effective, extorting fees from patients as they “healed.” 155
Healers like al-ʿUjayli did not reach all who could have benefitted. In the 1994 English translation of Daughter of Damascus , Syrian writer Siham Tergeman remembered unwashed mentally ill people wandering the streets of mid-twentieth century Damascus like “crazy Ikram and her mother,” “the crazy man Dabdabit” (a name that referred to an approaching storm) who was nicknamed as such because he walked about town hoping to find free food at anniversaries of someone’s death, and Abu Daʿas who roamed the quarters of old Damascus singing while holding in one hand a small toy bird (a symbol of insanity discussed in chapters three and four) to solicit pocket change from passersby. 156 This depiction is one of desperation and poverty among individuals who needed social support and curative treatment but received neither.
In another literary reflection, Dr. al-ʿUjayli despaired of the widespread belief among people of the countryside that an injection is all they needed to cure them of illness. 157 For al-ʿUjayli, this was an unfortunate side effect of the medical theatricality of previous decades, where physicians hoped to spread trust in biomedical tools and treatments by displaying the instruments as powerful, seductive, and mysterious. 158 Administering medicine was a way for healers to “win loyalty, prove ethnographic accounts, confirm the categories of colonial knowledge, and justify the need” for their presence. 159 But this brought the potential danger that patients expected a quick fix of these new medical tools. “The doctors and pseudo-doctors who preceded me,” wrote al-ʿUjayli, “made the idea of an injection synonymous with effective treatment in the eyes of local people” and used such treatment as justification for their fees. 160
Concepts about mental illness and approaches to its treatment are constructed not in universal terms but in terms that are uniquely meaningful to a given social, psychological, and cultural environment. 161 To focus solely on psychiatric treatment and brain chemistry, as Ibn Sina Hospital’s staff tried to do, dismisses the social and cultural capital many Syrians invested in their own framework for understanding mental illness. In these pieces of historical fiction, social and cultural processes of early and mid-twentieth century Syria helped people identify behavior they considered to be problematic, abnormal, or divinely inspired.
Studies of health in modern societies, particularly of the role etiology plays in labeling illness and seeking and responding to treatment, should accommodate non-biomedical practices to better understand the role of the modern state in developing health care institutions with room for a range of medical and alternative options. “Culture-fair” approaches in Egypt and elsewhere in the Middle East suggest historians of psychiatry could better integrate “therapeutic rationales” in the accepted narratives of social control. 162 Joel Braslow’s term “therapeutic rationale” is useful here for understanding the ways in which physicians saw diseases and cures as “an almost inseparable unit that mutually legitimates and reinforces the other’s existence.” 163 Faith in psychiatric causes and courses of mental illnesses was the strongest weapon of doctors against what they believed to be superstition and ill-placed faith in supernatural approaches to mental illness. Consumption of this knowledge, evidenced in health-seeking patterns, suggests a therapeutic rationale in the early and mid-twentieth century that for many Syrian patients promoted vernacular over cosmopolitan biomedical intervention. Syrian psychiatrist Dr. ʿAbdul-Massih Khalaf noted in 1980 that “the use of healers and traditional medicine [remained widespread,] especially in rural areas and places far from major urban centers.” 164
Since treatment for illnesses such as schizophrenia was largely ineffective in the mid-twentieth century, mental health was one of the few arenas in modern medical care that left some room for other voices to challenge the hegemonic nature of biomedicine. Popular Middle Eastern beliefs about supernatural forces inhabiting particular objects, areas, or animals described in the Quran and ahadith led to some people’s unease near certain springs, alleys, or graveyards, fearing a demon in these areas might possess the innocent passerby. 165 It is unclear to what extent many Syrians felt that treatments involving Quranic tincture or exorcism, for example, effectively banished demons and rehabilitated a possessed person, but it is clear that such treatments were widespread.
While the social significance of labeling and treating illness varied across time and space, many methods people used to identify abnormality and the means to control it were similar. Influential figures (religious leaders especially) contribute to shaping of social norms, of boundaries for what they consider acceptable behavior and appropriate possibilities. People identify and subsequently ostracize individuals through labels and actions that suggest disability, criminality, or contagion of diseased bodies and minds. Such actions can lead to organized activities by hospitals and other groups that target the different people, the deviants from the norm. Groups might act on these beliefs in an effort to transform “social ills” of individuals and groups, as with public health campaigns against alcoholism, prostitution, vagrancy, and other behavior labeled immoral or criminal. There is medical significance to folk religious practice. Families continue to struggle with stigma, misconceptions, and harmful vernacular treatment regarding people living with mental and developmental disabilities. 166 Some doctors note it is “high time that psychology . . . be sensitized . . . to the role of culture in shaping the psyche.” 167 This was not the direction medical missionaries and legal reformers took in mid-twentieth century Lebanon and Syria.
This chapter argues that there was a continuity in widespread use of vernacular healing in early and mid-twentieth century Lebanon and Syria. The following chapter turns to the institutionalization of a medical modernism through late nineteenth-century Ottoman legislative reforms around mental health hospitalization, the establishment of medical schools with some psychiatric teaching, and the foundation of two asylums (eventually named mental hospitals) near the major urban centers of Beirut and Damascus. Later chapters focus on these two mental hospitals to show how the limits of anti-sectarian medical missionary work (in the case of Asfuriyeh) and medicalized discourse of nationalist physicians (in the case of Ibn Sina) inadvertently contributed to the persistence of vernacular healing. Ordinary Syrians and Lebanese did not accept the authority of psychiatric healing. The power of faith-based beliefs complicates narratives of healing that marginalize any religious approach as “unscientific” and therefore illegitimate. 168 What constituted “science” was changing, but magical healing was still a powerful and widespread belief. Significant proportions of hospitals’ target populations continued to see non-biomedical healing practices as legitimate and effective throughout the twentieth century.
The Origins of Greater Syrian Medical Institutions
Twentieth-century psychiatry grew out of a Western medical tradition with roots in the culturally cross-pollinated scientific landscapes of the ninth- to thirteenth-century Islamic Middle East. Galenic theory, Chinese and Ayurvedic concepts, empirical study, and innovation complemented medieval and early modern legacies refashioned by positivism as a mode of learning. 1 Approaches to mental health developed through concepts of the body and the spirit rooted in scientific, religious, and cultural frameworks. But technological innovation had limits; prior to the 1950s, when chemical treatment with chlorpromazine (marketed in Europe and Syria as Largactyl or Largactil, and in the United States as Thorazine) first seemed to effectively suppress psychotic symptoms, earlier treatments acted only as sedatives or “chemical restraints.” Patients and their families saw little evidence that psychiatric treatment could be as curative for minds as biomedicine appeared to be for bodies. 2 The material and structural limitations of psychiatric and pharmacological treatment in Syria and Lebanon left ample space for healing alternatives. Local families saw vernacular healers as more trustworthy in their long-cultivated community ties, familiar healing practices, and separation from colonizers’ medical training. Though modern medical institutions have existed in Beirut and Damascus for over a century, folk treatments continue to be part of health-seeking behavior in the region today.
Changes in understandings of madness and treatment produced reforms in the mid- to late nineteenth century across Europe, including in the Ottoman Empire. The Tanzimat or legislative reform era of the nineteenth-century Ottoman Empire brought reforms modeled on the 1838 lunacy law in Paris. 3 Though American and French missionary groups founded two universities in Beirut with medical colleges in the 1860s and 1870s, education had already begun to transform under Ottoman efforts to enforce public order, prevent the spread of epidemics, and advance secular notions of disease. Many Ottoman intellectuals hoped to “eradicate unscientific traditional knowledge and modes of thought,” convinced that “the increasing authority of science in the near future would be accompanied by a corresponding decline in religiosity in general and by the discrediting of theological explanations of natural phenomena in particular.” 4
Many nineteenth-century Ottoman reforms were efforts to protect the empire’s territories from internal and external threats. Ottoman control of far-flung provinces weakened as majority-Christian regions of the empire (notably Greek and then Bulgarian areas) fought for and won their own sovereignty. After the Ottoman Albanian general Mehmet ʿAli seized power in Cairo in the aftermath of the Napoleonic invasion of Egypt (1798–1801), Mehmet ʿAli grew so strong and independent of the Ottoman sultan that he sent his own loyal forces south into the Sudan, and northeast to occupy Syrian lands from 1831 to 1840, contributing to Maronite-Druze conflicts in 1841 and 1845 that eventually erupted in the massacres of 1860. 5 The bloody clashes in Mount Lebanon and Damascus led to the death or migration of hundreds of thousands. Ottoman officials sought to protect their interests by creating the semiautonomous state or mutasarrifiyya of Lebanon, a designation that lasted from 1861 to 1915 with special privileges for religious minorities and borders defined in collaboration with French, British, Russian, Austrian, and Prussian delegates. 6 This complicated foreign roles in regional religious and educational projects like medical schools as foreign interests aligned more directly with particular communities, such as the Maronite church with French Jesuits and the French government, and Protestant schools with missionaries from the United States and England. As part of Ottoman efforts to modernize the military and infrastructure to prevent further losses, one of the many fields that drew Ottoman imperial attention for legal reform was medicine and the sciences. 7
It was in this larger campaign for modernization and social order that Ottomans sought to establish government oversight of asylums and the instruction of “alienists” (the professional name for doctors of mental illnesses before “psychiatrist”) through clinical observation in asylums that drew heavily from the French Lunacy Law of 1838. The 1876 Ottoman Mental Health Hospitalization Act provided the basis for mental health hospitalization laws in a number of postcolonial states in the Middle East, including Syria. 8 Yet mental health issues were not a major concern for political administrators in the nineteenth century, focused as they were largely on matters of safety and public health. 9 They hoped to stem the tide of infectious diseases such as cholera, typhoid, tuberculosis, diphtheria, plague, and malaria through policing and instruction about hygiene and public safety. 10 These were concerns in urban centers throughout the industrializing world. Mental health laws focused not on rehabilitation but on controlling violent or rebellious individuals. An 1887 health law enacted in Istanbul, for example, noted that nonhospitalized mental patients were a hazard to society and order. 11 Their fears parallel rhetoric French politicians used in justifying the 1838 lunacy law in Paris as “simultaneously a law of philanthropy and general police” in that asylums might ease the suffering of people with “the most distressing of human infirmities” but also “preserve society from the disorders which these sick persons can perpetrate.” 12
The 1876 Ottoman law, which went into effect in March 1877, mandated that any institution dedicated to caring for mentally ill persons must receive Ottoman government permission to operate, that potential patients undergo a special medical evaluation by two physicians (one chosen by the government, the other by the family) prior to hospitalization, and that a government inspector visit all psychiatric establishments, both public and private. 13 This, like the French law, “changed the procedures for the confinement of lunatics and, by way of justifying this change, expressed an abstract commitment to the new medical treatment of them.” 14
While the 1876 law shows the growing importance the government placed on mental health treatment, the late nineteenth century also witnessed growing concern among physicians about the overlap between mental and physical health. Samir Jalakh, a graduate of the Syrian Protestant College, emphasized to physicians in 1881 that a person’s psychological state and level of nutrition were important to maintaining good hygiene, and that medical care was particularly necessary in situations that could otherwise leave room for potentially damaging alternative treatment. 15 Improved hygiene was one way doctors emphasized social differences as they deplored the work of “charlatans,” an act that marginalized certain groups in the doctors’ quests to create a urban medical identity that stood in marked contrast from rural, nonmedical identities. 16 Doctors hoped to bring all classes and religious groups, including marginalized ones, into a unified approach to illness. But this unified approach was one in which biomedical experts expected healers with nonmedical worldviews to submit completely to (rather than supplement or complement) biomedical approaches. 17
Mental health of elites was a more pressing matter for the Ottoman government than mental health of the general public. Government-paid treatment for elite Ottomans in European psychiatric hospitals in the Second Constitutional Period (1908–1918) suggests that the administration had a very narrow scope in addressing mental health domestically. They also sought to repatriate Ottoman subjects who had stayed in European psychiatric hospitals. As Fatih Artvinli has argued, “within the scope of these international transfers, it was not only mentally ill patients who began to circulate, but also families, diagnoses, psychiatric information and statutes.” 18 The circulation of ideas was not only between Ottoman and other European regions; during a brief period of semiautonomous rule on Mount Lebanon under Amir Bashir Al-Shihabi II (1788–1840), a few Lebanese students studied at Qasr al-ʿAyni, the first modern medical school in Cairo established in 1827.

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