Given the unprecedented amount of crises that continue to unfold in Lebanon over the last two years, it is not surprising that the subject of mental health has been gaining long overdue traction. The events of the 17 October uprising exposed many to the trauma of a violent police state[1]; the COVID-19 pandemic and ensuing response, like most other countries in the world, left many, and in particular vulnerable groups, battling with mental health conditions including anxiety and depression[2]; the Beirut explosion followed, exposing an already precarious population to acute trauma[3].
The immense social, economic, and political collapse facing the country has left countless suffering with no discernable end in sight. It is as though dust and debris barely have time to settle before being kicked up again by another subsequent disaster. As persons living in Lebanon scramble to recover from the last blow and brace themselves for the next, institutions and outlets continue to warn of a mental health crisis that is descending steadily upon us.[4][5]
But in order to analyze the current crisis—and consequently, a response to it—it is necessary to critically examine how mental health is experienced, negotiated, and understood in the context of collective social suffering and systemic violence and injustice. How can we understand mental health within its cultural frameworks, including within the framework of Western biomedicine, the dominant paradigm which dictates the parameters of health and of interventions while positing itself as neutral, objective, scientific truth? How do we reconcile the experiences of mental health—in illness and well-being—with the context of injustice and systemic oppression?
Responding to the rubble
One of the main indicators of the worsening burden of mental health on people in Lebanon has been the increase in reported suicides in the country.[6] One event in particular, the suicide of a 61-year-old man on the main street of the Hamra district in the summer of 2020, gained considerable media attention after the man left behind his clean judicial record and a suicide note saying “أنا مش كافر [I am not a heretic]”, thought to be a reference to the Ziad al Rahbani song of the same title, in which the lyrics continue: “I am not a heretic, but hunger is heresy […] poverty is heresy, humiliation is heresy”.[7] The incident sent shockwaves through the country, and a popular protest against deteriorating living conditions was organized on the same day.[8] Meanwhile, civil society and NGOs scrambled to respond with awareness campaigns on suicide prevention over traditional and social media, including branded slogans, televised and printed interviews, and the distribution of information about the national suicide prevention hotline.
The mental health response to the Beirut explosion unfolded on a larger scale. Following the explosion, NGOs, civil society groups, and health institutions saturated social media feeds and airwaves with neatly bulleted lists that designated what, according to the World Health Organization and other well-renowned institutions, constituted normal and abnormal reactions to trauma. Households in the neighborhoods affected by the blast were visited by team after team of NGO representatives in succession, including those performing mental health assessments. Once again, services such as free clinics and the suicide prevention hotline were signposted, and individuals were urged to be proactive in relieving the burden of trauma that had rippled through society.
Both these responses followed similar formats: largely coordinated by NGOs (owing mostly to the lack of a robust public health infrastructure in general), reliant on scientific guidelines generated by institutions centered in the West such as the World Health Organization and the American Psychiatric Association, and, most importantly, reliant on the efforts of the individual sufferer to seek services and care.[9]
Within the paradigm of Western biomedicine, practices of mental health proudly tout the slogan of “bio-psycho-social.”[10] The theory refers to the interplay of biological, psychological, and social factors at the root of all mental health conditions. And yet, despite the glaring role of political, economic, and environmental factors in precipitating the public mental health crisis we face today, the responses to this crisis have often taken place on the individual front. Although the determinants of our current mental health burden are acknowledged to exist on the societal scale—capitalism, patriarchy, explosion, pandemic, collapse—interventions are largely limited to individual actions: reading lists of symptoms and assessing one’s mental states and the states of loved ones, seeking care at free clinics or over national hotlines, practicing “self-care,” all the while consuming the goods and services needed.
The practice of individualizing and pathologizing social suffering is one that is deeply rooted in the history of mental health in Lebanon, and even more deeply within the institution of psychiatry worldwide. Through examining the approaches towards mental health as they apply to the most disenfranchised in Lebanon—women, refugees, the impoverished, migrants, the displaced, and those subjected daily to systemic violence and exclusion—we can begin to understand how these approaches to social suffering and trauma have become a form of backfilling that erases narratives of history, dominance, and injustice under the guise of apolitical scientific and clinical guidelines and knowledge. Through placing the responsibility of seeking care upon the individual, the social component of this practice is buried under layers of backfilling that more often than not take place in isolation, far from the realities of collective suffering at the hands of systemic and structural violence. This allows for the commodification of mental health and well-being through the dominance of the self-care industrial complex at the hands of capitalist neoliberal expansion and in turn threatens to suffocate attempts to plant the seeds of solidarity and mutual support.
Burying (and buried by) the social
Burying the social—and, as a consequence, erasing the narratives of injustice—is a consequence of the over psycho-pathologization of mental health, which is central to the paradigm of Western biomedicine. In Lebanon, as in many other countries where this paradigm is dominant, the history of mental health care has involved various forms of burying and silencing. Today, long-stay institutions resemble what anthropologist Joao Biehl describes as traditional “zones of social abandonment”: spaces where the unwanted, deviant, or those who could not be cared for go.[11] Lebanon’s current legal code fails to protect the rights of the “mentally ill,” with some legislation including legal definitions of “the idiot [السفيه\ة]” and “the insane [المجنون\ة].”[12] These definitions, dating back to the Ottoman legal code, have often been legal grounds for guardianship abuse. As well as contributing to further marginalization and stigma, outdated laws also allow for existing systems of oppression to be organized and reproduced within the framework of “neutral” or “objective” science and medicine. In this way, those living with mental illness themselves become backfilled or buried.
On the other hand, we see the role of the clinical and pathologizing approaches to mental health themselves as tools in the practice of backfilling the social. Through focusing on clinical diagnoses, the spectrum and nuance of social experience is often reduced to diagnostic categories. Constellations of symptoms become bound into discrete pathologies, which, in turn, are demarcated by itemized checklists.
In Lebanon, this is common practice with disenfranchised and marginalized groups. A 2013 survey of migrant domestic workers admitted to psychiatric hospitals found that the demographic in question (mostly of Ethiopian nationality) were more frequently diagnosed with psychosis in comparison with Lebanese patients, implying an increased vulnerability to mental illness of this particular group.[13] The study found that this group was also subjected to higher doses of antipsychotic medications, citing possible pressure from employers, as well as higher incidents of the use of physical restraints, citing possible communication challenges arising from language barriers. However, psychiatrist Kerbage (2014) takes the analysis further, suggesting that differential treatment of migrant domestic workers as well as the increased use of coercion and restraints are also likely due to the pre-existing structures of racism, discrimination, and the power structures playing out within psychiatric practice.[14]Kerbage also points out that reports of abuse are often omitted by medical teams for the sake of medical neutrality. Moghnieh (2017) argues that these diagnoses often obscure the factors of institutional racism and that approaching the experience of these workers from a purely clinical lens only feeds into the cycle of their marginalization.[15] Structural factors, such as systems of racism, discrimination, and exploitation, not only act as determinants of mental health for migrant domestic workers, but also affect the very clinical practice assessing their mental health when it comes to this group, rendering them more vulnerable to coercive practices and psychiatric detention.
We often see this kind of backfilling—obscuring structural determinants of mental health under the veil of psychological categories—in our region, in the approach to Post-Traumatic Stress Disorder (PTSD). Anthropologists of global health have argued that PTSD became a disorder that was often “exported” to areas of humanitarian crisis, and that the diagnosis often became caught up in the aid and relief industries.[16] Kerbage (2014) criticizes the use of PTSD as an overarching diagnosis for Syrian refugees in Lebanon, arguing that relying on decontextualized scales and checklists for diagnosis often obscured the very real determinants of well-being faced by refugees, including the lack of basic necessities, food insecurity, and poor and insecure living conditions.[17] Kerbage also argues that over-reliance on standardized scales risks pathologizing normal experiences of grief and loss following the events of war and displacement.
Lessons learnt from the importance of placing mental health and clinical diagnoses within their social and cultural contexts can help us turn a more critical lens towards the public health responses to the mental health crisis we face today. Services such as the suicide prevention hotline and temporary mental health clinics (such as those that sprung up following the Beirut explosion) may be therapeutic, but in their focus on the pathological can often fail to address—and even risk obscuring—root causes of exploitation, trauma, and suffering. Today, the public mental health crisis facing Lebanon is not one that stems from purely psychopathological causes, nor should it be treated solely on the level of individuals. While people living with pre-existing mental health conditions have historically been the subject of backfilling, the mental health disorders rising among the population are a product of acute socioeconomic circumstances, and their treatment as individual conditions has contributed to the burial and backfilling of a collective social suffering and a system of exploitation and abuse.
Individualization of social pain: when backfilling becomes an individualized process
Backfilling in mental health occurs not only through pathologizing social pain, but also through individualizing it. The individualization of social pain is not a chance phenomenon. Rather, this individualistic ideology is a product of the neoliberal hyper-focus on individuals and is best encapsulated in the rise of the self-care industry.
Self-care has historically been used by rights-based movements, including feminist and disability rights movements, as a radical tool to maintain mental health during struggles for liberation and justice. More recently, self-care has been co-opted by the neoliberal ideology of individualism and has become a means to ensuring that maintaining health and well-being remains the responsibility of the individual.[18]
By framing mass social suffering as an individualized experience, perpetrators of oppression and systematic violence are absolved of responsibility, including the responsibility to address and remedy structural determinants. Instead, the responsibility to address mental health is funneled through the self-care industrial complex.
As a result, the mental health effects of a systemic, public, and social root cause have become our own personal issue–we are expected to evaluate and assess our mental health according to “objective” and “scientific” indicators, and based on those, to seek services, practice self-care, call lifelines, consume pop psychology through television and social media. In the scramble to return to work and economic productivity, for example, employers are also absolved of the responsibility to provide an accommodating environment that takes into account the effect of the public mental health burden on workers. Instead, it becomes the personal responsibility of the worker to seek individualized solutions for herself on her own time; and in many cases, she may find her livelihood threatened if she fails to do so and return to full productivity.
Great moral value is also ascribed to qualities such as resilience and adaptability, often in reference to the ability to sustain economic productivity. These qualities are, in turn, seen as markers of strength of individual character. It is also interesting to note that though these very terms are also used to describe markets in times of crisis, the use of “resilience” has been challenged especially in situations of injustice. It is here that lessons can be learned from the work of Rita Giacaman, who reflects on her encounters with the word “resilience” as a healthcare practitioner and researcher in Palestine: “From our perspective, it does not make sense to offer humanitarian aid, alleviate daily suffering and support Palestinian resilience so that they can cope, adapt and accept unacceptable conditions without also calling for justice to Palestinians […] This recognition of injustice and working towards its removal is a key component of ‘resilience’ building in the Palestinian and other contexts of injustice worldwide.”[19] Through this critical view on resilience, it becomes clear that any attempt to address mental health while burying these social contexts and structures will always be incomplete.
Mental health is built from and builds the social. It is backfilled or used to backfill. Through pathologizing and individualizing social pain, we have become burdened with the responsibility to backfill trauma into ourselves, and by doing so, we quietly erase and obfuscate the social reality of our psychic distress. By individualizing our suffering, we are also forced to cut ties with the collective, thus muffling our claims to intersectional solidarity. In Lebanon, systemic sources for the mental health burden demand political, systemic changes: individualized therapies and interventions may bandage the psychological wounds, but do not address the wounding factors. On an immediate level, the collective social suffering facing our society cannot be treated without deeply rooted systemic and structural change. More importantly, it cannot be faced by each of us alone: in order to truly heal we need to recognize that our individual experiences with mental health stem from a collective suffering, and thus healing becomes rooted in collective action.
[1] Barkil-Oteo, Andres. “Depressed? You Might Be Suffering from Oppression: On Malaise, Alienation, and Solidarity” The Public Source, 02 Apr. 2020, https://thepublicsource.org/depressed-suffering-oppression-malaise-alienation-solidarity. Accessed 4 May 2021.
[2] Fouad, Fouad M., Andres Barkil-Oteo, and Jasmin Lilian Diab. “Mental Health in Lebanon’s Triple-Fold Crisis: The Case of Refugees and Vulnerable Groups in Times of COVID-19.” Frontiers in Public Health 8 (2021): 1049.
[3] Tannouri, Sara. “I needed to make myself useful to overcome the panic” Voices from the Field, Medecins Sans Frontiers, 09 Oct. 2020, https://www.msf.org/lebanon-mental-health-needs-are-great-wake-beirut-blast. Accessed 24 Apr. 2021.
[4] UNICEF. “Mental Health as a Priority for UN in Lebanon during COVID-19 [Press Release]. 19 June 2020, https://www.unicef.org/lebanon/press-releases/mental-health-priority-un-lebanon-during-covid-19. Accessed 24 Apr. 2021.
[5] Hankir, Zahra, and Kareem Chehayeb. “Another explosion for Lebanon: The blast in Beirut made international headlines. Even before that the nation was in turmoil and it has only worsened the mental health crisis.” Index on Censorship 49.4 (2020): 8-13.
[6] Chehayeb, Kareem. “Broken Lebanon: Economic crisis takes its toll on country’s mental health.” Middle East Eye. 16 July 2020, https://www.middleeasteye.net/news/lebanon-economic-crisis-mental-health-toll-suicide. Accessed 28 Apr. 2021.
[7] “Broken Lebanon: Economic crisis takes its toll on country’s mental health.” Middle East Eye. 03 July 2020, https://www.middleeasteye.net/news/lebanon-suicide-economic-crisis-beirut. Accessed 28 Apr. 2021.
[8] “أنا لست كافرا لكن الجوع كافر.. انتحار لبناني في بيروت احتجاجا على سوء الأوضاع الاقتصادية” Al Jazeera. 07 July 2020, https://www.aljazeera.net/videos/2020/7/3/%d8%a3%d9%86%d8%a7-%d9%84%d8%b3%d8%aa-%d9%83%d8%a7%d9%81%d8%b1%d8%a7-%d9%84%d9%83%d9%86-%d8%a7%d9%84%d8%ac%d9%88%d8%b9-%d9%83%d8%a7%d9%81%d8%b1-%d8%a7%d9%86%d8%aa%d8%ad%d8%a7%d8%b1. . Accessed 28 Apr. 2021.
[9] Hijazi, Zeinab, Inka Weissbecker, and Rabih Chammay. “The integration of mental health into primary health care in Lebanon.” Intervention 9.3 (2011): 265-78.
[10] Hanlon, Charlotte, et al. “Interventions for Mental Disorders.” Global Mental Health: Principles and Practice, 1st ed., Oxford University Press, 2013, pp. 252–76.
[11] Biehl, João. Vita: Life in a zone of social abandonment. Univ of California Press, 2013.
[12] Kerbage, Hala, Rabih El Chammay, and Sami Richa. “Mental Health Legislation in Lebanon: Nonconformity to international standards and clinical dilemmas in psychiatric practice.” International journal of law and psychiatry 44 (2016): 48-53.
[13] Zahreddine, Nada, et al. “Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon.” Community mental health journal 50.5 (2014): 619-628.
[14] Kerbage, Hala. “Foreign Domestic Workers in Lebanon: The Missing Psychiatric Link.” (2014). https://english.legal-agenda.com/foreign-domestic-workers-in-lebanon-the-missing-psychiatric-link/
[15] Moghnieh, Lamia, and Filippo Marranconi. “Mental health strategy in Lebanon: an anthropological critique.” Mental Health 2017 (2017): 04-24./
[16] Breslau, Joshua. “Introduction: Cultures of trauma: Anthropological views of posttraumatic stress disorder in international health.” Culture, Medicine and Psychiatry 28.2 (2004): 113.
[17] Kerbage, Hala. ” The Risks of Pathologizing Syrian Refugees: Towards a Collective Social Suffering Approach.” (2014). https://english.legal-agenda.com/the-risks-of-pathologizing-syrian-refugees-towards-a-collective-social-suffering-approach/
[18] Ward, Lizzie. “Caring for ourselves? Self-care and neoliberalism.” Ethics of care: Critical advances in international perspective. Policy Press, 2015. 45-56.
[19] Giacaman, Rita. “Reflections on the meaning of ‘resilience’in the Palestinian context.” Journal of Public Health 42.3 (2020): e369-e400.