psychiatry – History of The Human Sciences

Review: Outrageous Reason

Peter Barham, Outrageous Reason: Madness and Race in Britain and Empire, 1780-2020 (Monmouth: PCCS Books, 2023), 248pp, £21.50, softcover.

by Michael Romyn

In July 1981, Winston Rose, a 27-year-old father of two was choked to death by police officers in a neighbour’s back garden in Leyton, east London. Concerned for her husband during a period of poor mental health, Rose’s wife, Thora, had sought the advice of the social services, setting in motion a series of destructive actions by a range of state agents, including his GP, psychiatrists, and finally the police: 11 officers in total, some carrying riot shields, were sent to apprehend a visibly fearful Rose for psychiatric detention. Like the murder of George Floyd by a police officer in Minneapolis almost 40 years later, Rose’s fate was abetted by the spectre of violence his blackness supposedly portended. Rose, to be sure, stood little chance of being treated by the authorities with the care his situation necessitated. Rather, he was seen and dealt with as someone whose humanity was obscured by the myth and presumption of black dangerousness.

As Peter Barham shows, Rose’s life and death are a window onto the enduring entanglements of race-making and madness under the hegemony of white reason: mapped onto racialised bodies in broad swathes, madness and the dysfunction, deviancy, and dangerousness it signifies has made up a key dimension of the constitutive outside against which white liberal ‘rationality’ constructs and defends itself. This is a story Barham traces from the hold of the transatlantic slave ship to the hold of the police in contemporary Britain, demonstrating the way in which ideas about race and madness continue to flow along channels created by and for empire. The concept of the ‘hold’ certainly appears frequently across Outrageous Reason’s 14 chapters. For Barham, it can mean the deadly grasp applied by police officers and hospital wardens to black people like Rose and George Floyd, as well as Sean Rigg, Jimmy Mubenga, and numerous others, but also a ‘physical, ideological or, sometimes, figurative space, one of traumatic memory, in which persons, or the traces of persons such as records, are sheltered or stored, or, more commonly, held captive.’ (5).

Here, Barham’s objective is to retrieve a number of these subaltern persons or their traces through case studies and vignettes, some of which utilise personal narratives and other testimonial sources that place us squarely in the historical terrain. For example, we are plunged into the miserable depths of Kingston Lunatic Asylum in post emancipation Jamaica via the observations of Henrietta Dawson. Admitted to the asylum in the late 1850s, Dawson, who, like every patient at Kingston, was a woman of colour, was subjected to and witness of all manner of arbitrary violence, humiliation, and routinised punishment at the hands of staff, including the sometimes lethal practice of ‘tanking’, whereby patients were dunked and held underwater. Drawing on works by an array of scholars of slavery and postcolonialism, Barham argues that the conditions Dawson described were not a localised aberration in the hinterlands of British Empire, but that the asylum was an ‘engine room of colonial modernity’ (61); while cloaked in principles of benevolent governance, the Kingston asylum ‘scandal’ exposed the constitutive violence and racist differentiation at the heart of the imperial project. With the case of Orville Blackwood, who died in appalling circumstances at Broadmoor high-security psychiatric hospital in August 1991, Barham illustrates the disturbing continuities between Dawson’s experience and the treatment of black patients in contemporary spaces of ‘care’. As is made so clear in the book’s final chapters, the systematic negation of the colonial subject – to the status of ‘savages’, ‘beasts’, ‘barbarians’ and so on – continues to seep into and pollute our institutional cultures in both quotidian and cataclysmic ways.

The question of what care has looked like for the poor and racialised is posed at the outset of the book through the episode of the Zong slave ship massacre of 1781, where more than 130 captive Africans were thrown overboard by the crew in a chilling piece of financial calculus. While likely a simple error of re-painting, Barham argues that the earlier renaming of the ship, from the Dutch Zorg, meaning ‘care’, to Zong, augured the horrific events on the vessel to come. But he also sees it as a symbol of the way in which care has been routinely ‘abjected’ or ‘transformed into something else’ (57) when it comes to those deemed ‘mad’ or ‘damaged’ by the arbiters of white reason. The case of Alice Rebecca Triggs, a white domestic servant who spent the last four decades of her life in a mental institution after receiving a diagnosis of ‘moral imbecility’ in 1919, makes a wider point about how such delimitations of care and understanding not only imperilled black lives, but also the lives of the ‘lower or inferior orders’ in Britain who posed ‘a threat to the vitality and stability, and hence to the future, of the white race’ (102).

There is another aspect of care to consider here: early on in the book Barham writes that he is ‘trying to feel my way, challenging and exploring diverse forms of “knowing” and drawing as much as I can on the exercise of…“negative capability”’ (6). Certainly, he treads the complex and multiple intertwining pasts of race, class, and madness and their troubling resonances in the present with considerable care and empathy, and in a way that forces us to think about and contend with our own cultural assumptions. In doing so, Outrageous Reason marks an important step in what Barham describes as a ‘gathering discourse, or convergence of voices’ (213) that enjoins a revaluation of conceptions of pathology and dysfunction, as well as the hegemony of whiteness that upholds them.

Michael Romyn’s first book, London’s Aylesbury Estate: An Oral History of the ‘Concrete Jungle’, was published by Palgrave Macmillan in 2020.

Review: Disalienation

Review: Camille Robcis, Disalienation: Politics, Philosophy, and Radical Psychiatry in Postwar France (Chicago: The University of Chicago Press, 2021)

Janina Klement (University College London)

In January 1940, the Catalan refugee psychiatrist Francesc Tosquelles who had just arrived in France, was recruited to work with the French psychiatrist Paul Balvet. Since 1937, Balvet had been the director of a dilapidated and overcrowded asylum in the village of Saint-Alban-sur-Limagnole in Lozère which, situated 1000 metres above sea level in the mountains, counted itself among France’s most impoverished regions. In a giant communal effort that included the local villagers, they prepped the asylum for the war, piled food reserves and planted and harvested produce together with the patients, ultimately saving the asylum population from starvation. Next to its main function as a sanatorium, Saint-Alban became an assembly spot for persecuted intellectuals who began participating in the therapy of the mentally ill, and soon pushed for theorisation of their practice. In 1941, a manifesto with first principles emerged but only eleven years later, in 1952, the term “institutional psychotherapy” first appeared in a journal article.

With Disalienation, Camille Robcis delivers the first history of the French institutional psychotherapy movement for an anglophone readership. The book’s work is to position institutional psychotherapy as a set of ethics of everyday life and experience, and to read it as a political theory (with the ambition of contemporary applicability) of alienation, the unconscious and institutions, more so than to assess its therapeutic merits. Prior to its denomination and introduction to medical literature, institutional psychotherapy was a humanitarian and intuitive act of care during war-time. The bookcover blurb’s claim that Saint-Alban was the only asylum that ‘attempted to resist’ the Vichy regime’s “soft extermination” programme of the mentally ill through supply shortages conceals a dispute among historians (which remains unrectified by the book itself) whether many psychiatrists across France tried the same thing, but ultimately failed to rescue most of their patients. The clinic’s favourable geographical location in the mountains as well as Balvet’s good relationship with the Pétain administration arguably helped Saint-Alban to escape the occupiers and collaborators’ ruthless supervision.

After the war, institutional psychotherapy was carried forward as a practice, subjected to multiple reinventions while transgressing its original geopolitical context. By organising the chapters around four key institutional psychotherapists, Tosquelles, Frantz Fanon, Félix Guattari and Michel Foucault, Robcis achieves to write a biography of a movement, tracing the intersecting yet distinctive practical and intellectual contributions that brought it into being, and that kept it in circulation for the better part of the second half of the twentieth century.

The first chapter knits together the story of how Francesc Tosquelles, a well-read experimental combat psychiatrist, anarchist, and co-founder of the Catalan federalist and anti-Stalinist activist group POUM (Partido Obrero de Unificación Marxista), became François Tosquelles, inventor of institutional psychotherapy and inspirational figure for the French health reform, that implemented the Catalan inspired concept of “sector psychiatry” nationwide in the 1960s. Institutional psychotherapy is born when after the war, Tosquelles’ équipe tore down the walls surrounding Saint-Alban to create an “asylum-village” allowing for more contacts with the local population. Moreover, the German psychiatrist Hermann Simon’s idea of a “more active treatment in the asylum” inspired the creation of a “healing collective” that actively involved patients in the structuring of everyday life in the hospital to treat the institution more than the individual. According to Jacques Lacan’s doctoral thesis, which first received recognition and practical application in the context of Saint-Alban, psychosis had to be grasped in its ‘phenomenal totality…the entirety of its historical existence’ (p. 38). Thus, as Robcis argues, the idea that the social and the psychic were intimately connected and had to be transformed collectively to escape alienation was the fundamental lesson that Tosquelles and his équipe transmitted to future generations of institutional psychotherapists.

The second chapter uncovers the early steps of Frantz Fanon’s hitherto lesser examined medical career, as Robcis seeks to ‘restate the significance of Fanon in the genealogy of what is generally called “Western radical psychiatry”’ (p. 51). The institutional psychotherapists’ dogma to treat the social and the psychic at the same time resonated with Fanon’s understanding of subjectivity as structural and therefore ‘fundamentally shaped by the social and political context’ (p. 59). The chapter follows him from medical school in Lyon to his brief internship in Saint-Alban, where he was involved with various art and ergo therapies, wrote pieces for the hospital newsletter and advocated together with Tosquelles for a limited use of electroshock therapy, to facilitate personality reconstruction. Yet his subsequent arrival at the Algerian psychiatric clinic of Blida-Joinville was marked by an initial ‘total failure’ (p. 66) to apply Saint-Alban-style social therapy. Arabic staff and patients were equally repulsed by the innovations forced upon them, and only the European patients responded positively to Fanon’s reshuffling of social roles and expectations in the hospital. Fanon retreated for a journey through Algeria which prompted him to reflect on his own complicity with colonial regimes, discovering the necessity to “decolonise” institutional psychotherapy. Upon his return he restructured institutional psychotherapy to the effect that Muslim patients began to enjoy socialising in the hospital space, for example through performances of Muslim singers and professional storytellers, and popular Algerian table games at the hospital’s new “Café maure”.

In this chapter the book is at its most romantic. Robcis masterfully narrates Fanon’s intellectual and personal trajectory beyond cultural and language barriers which he successfully overcame through self-sacrifice and careful introspection. By its finale, he has shaken off the European grip on institutional psychotherapy to arrive at ‘a truly disalienated and disalienating psychiatry’ (p. 68). The absence of patient perspectives in the book is quite noticeable here, as despite Robcis’ initial insistence that her interest is not to write a hagiography (p. 9), her narration tends strongly in this direction throughout the book and is furthermore reflected in her decision to focus on the contributions of four celebrated male practitioners to the movement.

Chapter three is a remarkably condensed and accessible tour de force of French intellectual history surrounding the events of May ’68 and the arrival of institutional psychotherapy in Paris, through figures such as Jean Oury, Félix Guattari and Gilles Deleuze. Robcis shows how institutional psychotherapy was radicalised at Oury’s “Clinique de la Borde,” on the premise of an “anti-oedipal” politics that sought to disalienate ‘the unconscious, the familial, the social, and the political, all at once’ (p. 78). The chapter’s main contribution to existing historiography is its attentiveness to how Guattari pronounced institutional psychotherapy’s potential to transform and express group desire, pushing the discourse into nonmedical contexts, especially urban planning, left-wing organising and working groups, among others on feminism, health policies, pedagogy and theatre.

The book’s final and arguably strongest chapter circles around Michel Foucault’s role in the development of institutional psychotherapy. Anyone who thought Foucault’s contribution is best explained by starting with his analysis of power is offered a captivating new reading (as well as a picture of him with a full head of hair). Although he never actually practised institutional psychotherapy, Robcis reads Foucault as a ‘fellow traveller’ (p. 110) of the movement. She convincingly argues that the question of psychic causality figured as a centre of attention to Foucault in his student years at the École Normale and the hospital Saint-Anne, and is further developed in his first book Maladie mentale et personnalité (1954). Crucially, for Robcis, Foucault arrived at a similar conclusion to the institutional psychotherapists, proposing that cure requires the relationship between the individual and its milieu to be intact. The chapter also traces how Foucault mediated exchanges between British antipsychiatrists and the French institutional psychotherapists around Guattari, suggesting that Foucault’s engagement with R. D. Laing’s and David Cooper’s work marked a decisive moment of his intellectual development away from the question of the institution and into the realm of the “disciplinary”.

Despite this recognition of transnational influences and sympathies, Robcis’ book largely remains faithful to the institutional psychotherapists’ own version of history. This is particularly evident in her portraits of British anti-psychiatry, which are partly based on judgments of the “French side”, which deliberately wanted to distance itself quite clearly from its British counterparts, whose work somewhat anticipated institutional psychotherapy, and was in many ways more similar to theirs than they liked to admit.

While the book makes an important contribution to the intellectual history of a neglected movement, it leaves the question of alienation that its title provokes largely untouched. Sure, we learn that ‘… institutional psychotherapy insisted on the role of institutions in the process of alienation and disalienation of the political, the social, and the subjective’ (p. 73), but a historization or discussion of alienation outside of the protagonists’ framework would have been instructive. The question arises whether alienation, for example from fascism, which marked the birth of institutional psychotherapy as a resistance movement, cannot be thought of as a positive and generally desirable experience.

In many ways, the history of institutional psychotherapy is more convincingly communicated through visual materials than words. Readers in New York City can visit a major exhibition about Francesc Tosquelles that includes hours of film and outsider art produced in French institutional psychotherapeutic milieus at the American Folk Art Museum until 23 October 2023.

Janina Klement is a final year PhD student in history of psychiatry at University College London and an affiliated member at the Birkbeck Centre for Interdisciplinary Research on Mental Health.

Interview: Ohad Reiss Sorokin on Alfred Binet, ‘intelligence’ and failed experiments

Ohad Reiss Sorokin, is a postdoctoral fellow at the Institute for Advanced Studies in Culture at the University of Virginia who recently completed a PhD at Princeton University. He received a commendation in this year’s History of the Human Sciences Early Career Essay Prize for his essay ‘Intelligence’ before ‘Intelligence Tests’: Alfred Binet’s Experiments on his Daughters (1890-1903)’. We spoke to him about his interest in Binet and other research.

History of the Human Sciences: First of all, I wonder if you could briefly introduce your broad research interests, including your PhD project “‘I [Suffer] Unfortunately from Intellectual Hunger’: The Geistkreis, Desire for Knowledge, and the Transformation of Intellectual Life in the Twentieth Century”?

Ohad Reiss Sorokin: I wrote this essay a few years ago before I started working on my dissertation. The only thing that ties them together is that the dissertation is also a history of the human sciences but from a very different perspective. My dissertation deals with the ‘Geistkreis’, which was an intellectual circle that was active in Vienna between and 1921 and 1938. It was a meeting place of young philosophers, economists, lawyers, sociologists, psychologists, and art historians. What I argue in the dissertation is that they created this Geistkreis, in order to combat the reigning intellectual environment of Vienna at the time, which is known to be the “mandarin” culture. They tried to create a more open discussion culture that does the human sciences in a way that is not subjugated to the natural sciences, on the other hand, and is not completely metaphysical and out of touch with the empirical evidence, on the other.

HHS: Now to move on to your essay, ‘Intelligence’ before ‘Intelligence Tests’: Alfred Binet’s Experiments on his Daughters (1890-1903)’: who was Alfred Binet, for what is he most famous and how does your article on his work depart from the existing scholarship?

ORS: Binet is a very very famous figure in the history of the French psychology and in experimental psychology. He is most famous for the Binet-Simon test, which became the blueprint for the modern IQ test. That would be his main contribution. But that’s just one aspect of his work. He wrote so much, his bibliography is huge and he worked on many aspects of psychology. He did work with geniuses and people who could make complex calculations in their head to see how they thought. He was also a playwright. My work focuses on the 1903 book [L’Étude expérimentale de l’intelligence [“Experimental Study of Intelligence”], which was not exactly ignored but I argue that there was something very significant there that people have missed.

HHS: From what scientific contexts did the concept of ‘intelligence’ first emerge as a scientific object?

ORS: That is not an easy question to answer because we have a concept of intelligence from at least the Renaissance or even earlier. I focus on a very, very specific concept of intelligence that we talk about now, when we talk about intelligence, which has to be with intelligent tests, it has to do with the ranking of people according to their potential for intellectual achievement. This concept was created in an intellectual context in which empirical psychology became a lot more important in the late mid to late nineteenth century. It was a context in which such a concept was needed in order to sort students in a much more democratized education system.

HHS: And how did Binet understand ‘intelligence’?

ORS: The concept of intelligence I just described, that Binet developed in his 1903 book, has to do with personality, it’s called the personality type psychology of intelligence, which is like types of functions, holistic intellectual affinity/taste capabilities that can be described but cannot be ranked on a hierarchical scale. This is the kind of work that Binet does with his daughters in the 1903 book. He later developed a scale and its goal was to differentiate between what in English is called the ‘feeble minded’ and students who could actually succeed. Later on when he thinks about what was done with his intelligence test, especially in the United States, he never meant to create a number that you can sort people according to, but a scale to be used only in a specific context. It’s plausible that he never meant to do it, but he did nonetheless give the tools that allowed other people to do it.

HHS: What was the significance of Binet’s experiments on his daughters and, specifically, of the failed experiment you discuss?

ORS: The book is is quite interesting. There are definitely other books like that but it’s definitely not something you would see today in any of the natural sciences of psychology. It’s a big collection of experiments described from beginning to end, with all the details included, that he conducted with his daughters for many years. And, at least the way he presents it, he didn’t have a specific goal in mind, other than to study the intelligence of his daughters – whatever this means – and he tries many things. What I emphasize is that a failed experiment can teach us sometimes more than a successful one, especially if the experimenter reflects on the failure, then he can explain to us what he was looking for, he can explain what he didn’t get with the results. Then we can better understand the epistemic object or the thing that he was after that he did not discover. This is, to my mind, the key to understanding the most successful experiments which we just hear were successful.

HHS: What were the implications of Binet conducting experiments outside a laboratory setting – including his discussions of ‘outside noise’ and ‘distractions’ – for his understanding of intelligence?

ORS: I think the interesting thing is that he does not reflect so much about that, if I remember correctly. At the time he was working and was eventually the head of the experimental psychological laboratory in the Sorbonne so he had access to all the machines and instruments that were required but he does not reflect much about the effect of taking those instruments outside of the laboratory. He does, however, get very much annoyed by the fact that he doesn’t have adequate conditions in his home. So I would say as an answer to the question is that he has two subjects that can sees roughly every day, for many, many years which is something that it’s really difficult to duplicate in a laboratory setting. He has all the instruments and he exposed all the norms of laboratory science by remarking on the infringements of the norm that happens because he was working outside the laboratory. If it was just in a laboratory we wouldn’t know, for example, that sound isolation is important to measure intelligence because it’s not obvious, it hasn’t come from the concept that you need to isolate the subject. So in this book he makes these norms explicit and that’s what I found interesting about it

HHS: Why did Binet part ways with British associationism?

ORS: British associationism was, at the time, one of the leading theoretical frameworks for understanding the mechanics of the mind. Binet, who was an autodidact, read all the major works by John Stuart Mill and others, and at first took after them. During the time he was working with his daughters he discovered a number of phenomena that he could not square with the assoociationists’ passive understanding of consciousness, most important among them is, of course, “attention”, i.e., our mind’s capability to willfully focus on certain inputs and ignore others. This break with the British tradition helped him to articulate the need for a theory of the active mind. Intelligence is one way to think about it.

HHS: What role did time measurement devices play in Binet’s research?

ORS: I use the analysis done by Jimena Canales in the book Tenth of a Second. Canales argues that measuring things to the 10th of a second became such a crucial element of science in general in the late nineteenth and early twentieth century. It became like a symbol for science in a way. What I argue in the article is that at the beginning of that book it seemed like Binet measured things just out of duty. He’s a scientist so he needs to have a number somewhere. We know that in modern psychology that the mind is tied with time, it happens in time not in space so therefore it follows to measure time. There are tools for that and there’s a concept for that. But you can find time marks for tests that have nothing to do with time. He doesn’t comment on the time, he doesn’t explain why it is important that some took longer or shorter amounts of time.

But then, at some point, he changes, and I argue cautiously that the change is not necessarily a conscious one. At some point he asked the girls to write sentences. He defined the sentence according to their quality, quality in terms of whether it was a descriptive sentence, a poetic sentence or an imaginative sentence and so forth. He measured how much time it took for them to produce each kind of sentence. But then it is a bit like comparing apples and oranges. He compares the different times it took to each girl to perform different tasks. He has time as a way to compare the performance, but he does it in a way that makes no sense, because he himself defines the tasks as diffrernt. He doesn’t explain why he does it but in the paper I argue that this is the blueprint for the notion that we have today that doing something faster is an indication for greater intelligence. I mean to cook an egg is faster than to write paper. It says nothing about the persons cooking eggs or writing papers. That’s basically the argument.

HHS: How is the difference between the two concepts of intelligence Binet outlined in 1903 and 1905 conventionally characterised and how do you understand the relationship between them? Why do you claim that the concept of intelligence outlined in his 1903 book should be seen as a ‘major ontological leap’?

ORS: These are two separate questions, I think. The first one is easier to answer because usually scholars treat the 1905 publication as introducing Binet’s concept of intelligence because in this iteration of the concept intelligence becomes measurable and hierarchical. Those two components are “missing,” or better, not yet in existence, in 1903.

For the most part scholars either treat the1903 concept as a deficient concept on his way to create the, “fully developed” 1905 concept. Or they ignore it altogether because they don’t think about it as a work about intelligence, but as a work about “personality types”. I don’t remember seeing a good account that explained why he called it intelligence nevertheless in 1903.

I was trying to draw attention to the fact that there are some similarities between the two concepts. It’s difficult, I don’t think it’s impossible, but it’s difficult to find in other major works on intelligence from the time period. It is the idea that intelligence is subjective, in the sense that we measure or look at the intelligence of each person separately. It is not about a philosophical or general concept of intelligence. It’s immaterial – not about the size of the brain or the density of the brain or anything like that – and yet it’s empirically observable.

It’s not something that you learn from a conceptual analysis of any sort. Instead you need to take people to the lab or make an empirical examination or make them take a test. The combination of those characteristics is already there in 1903.

I wouldn’t be the first to argue that Binet has a very eclectic method. This constellation of characteristics is the result of his eclectic method and it’s an ontological leap in the sense that it creates in the world an object that did not exist before. The idea that we each have a specific thing that was like an organ but immaterial and yet is observable with particular methods.

HHS: I began by asking you about your PhD project and wondered if in conclusion you could say something about where you hope your research might lead in the future.

ORS: I’ve been working on the dissertation about the ‘Geistkreis’ for four years now and with time I realized that what I found so attractive about this circle is that they are almost an embodiment of the idea of desire for knowledge. I’m interested in how knowledge and desire survive together in the realm of professional humanities, in the twentieth and early twenty-first century. I’m about to start a postdoc position in the Institute for Advanced Studies of Culture at the University of Virginia and I hope to follow this thread.

Review: Closing the Asylum

Peter Barham, Closing the Asylum: The Mental Patient in Modern Society (London: Process Press, 2020)

Steffan Blayney, University of Sheffield

When the first edition of Peter Barham’s Closing the Asylum was published in 1992, it attempted to describe the historical underpinnings of a protracted upheaval in mental health provision which was still very much ongoing. While the dismantling of the Victorian asylum system had been the professed aim of successive British governments dating back at least to the 1959 Mental Health Act – and while the overall asylum population had been declining steadily since its peak in 1954 – still in the early 1990s deinstitutionalisation remained an unfinished project. By the time of the book’s second edition in 1997, with the majority of hospitals open a decade previously now closed, this seemed harder to argue, yet by this point characterisations of ‘care in the community’ as a failure were already becoming mainstream. This new edition, published in 2020, arrives in the wake of the 2018 Independent Review of the Mental Health Act amidst ongoing debates about the extent of coercion and legal compulsion within the mental health system.

Barham’s original text, reissued here with a new prologue and preface, situated twentieth-century debates over deinstitutionalisation within the longer history of how modern societies have dealt with the ‘problem of insanity’. This has always been a social question at least as much as it has been a medical one. In nineteenth-century Britain, and particularly after the New Poor Law of 1834, the public asylum emerged – alongside the workhouse and the prison – as a means to deal with surplus populations produced by industrialisation. Idealistically imagined by their founders as spaces of care and rehabilitation, the Victorian asylums quickly became little more than overcrowded repositories for incurables and undesirables. The segregation of the mad was given legitimacy by an emerging psychiatric profession whose own optimism about the possibility of cure quickly ceded to essentialising views of mental patients as inherently ‘broken’ or ‘flawed’ individuals, who for the most part would remain incapable of participating in society and undeserving of recognition as fully human. While such conceptualisations were never without their critics, Barham argued, the eventual movement towards asylum closure that emerged in the twentieth century failed to seriously challenge the underlying ideological structures which continued to produce madness as a social problem and the mental patient as a second-class citizen.

The resulting story of deinstitutionalisation was one in which the hopes held by many for the full liberation of hospital inmates would always be secondary to more cynical policy motives. Focusing primarily on mental health law and policy in England and Wales, and weaving historical and sociological analysis with the views of service users and campaigners, Closing the Asylum described how hopes entertained by reformers from the mid-twentieth century for progressive alternatives to the authoritarian psychiatric hospital were repeatedly frustrated or co-opted. Too often, talk of patient freedoms or more enlightened approaches to care functioned as little more than ideological cover for governments eager to cut expenditure by avoiding the costs associated with long-term custodial care. Hospitals emptied, but the services which would allow former inmates to live meaningfully independent lives fail to materialise, with new developments in psychopharmacology enabling the management of symptoms without the need for costly social or psychological therapies. For some who would formerly have been hospitalised, the institutions of the criminal justice system expanded to fill the vacuum (a growing prison population since the 1990s includes an increasing proportion of inmates identified as suffering from a mental health condition). For many more, especially those already from deprived backgrounds, newfound freedoms were undermined by persistent poverty, insufficient welfare support, and the stigma of illness leading to discrimination in housing and employment. Where the mental patient is still viewed by society as a problem to be solved rather than a full political subject, Barham demonstrated, ‘community care’ can function just as effectively as the asylum as a technology of social exclusion and marginalisation.

Another aspect of the old regime which failed to disappear along with its physical architecture was its use of force and legal compulsion. While it might have been expected that the move away from the rigid hierarchy of the asylum would lead to greater liberty for patients, evidence from the last three decades, which Barham details in the prologue to the new edition, shows that the opposite is true. The use of constraint and coercion, justified by the supposed risk posed by patients to themselves or others, has not only persisted through deinstitutionalisation but is increasing. Despite falling numbers of long-stay patients, the total number of people being detained involuntarily almost tripled between 1988 and 2015. This combined with drastic reductions in the overall number of psychiatric beds through years of austerity means that half of all psychiatric inpatients are now detained under the Mental Health Act – compared to around 10% in the 1970s. Moreover, with the arrival of Community Treatment Orders (CTOs) in 2008, mandating compulsory outpatient treatment under threat of detention, formal coercion is now no longer limited to the hospital setting. The violence of the system, it might be added, is not evenly applied: black patients are more than four times more likely to be involuntarily detained than their white counterparts, and more than ten times more likely to be subject to a CTO. Nor is the ‘shadow of coercion’ (8) which extends over the mental health system limited to those against whom the provisions of the Mental Health Act are directly mobilised. As service user activists (and some psychiatrists) have argued, in a system where patients and doctors know that the threat of compulsion is always available, it becomes difficult to see any treatment as fully voluntary.

While sharply critical of the way deinstitutionalisation has played out in practice, Barham has remained neither nostalgic for the asylum nor pessimistic about the prospects for more progressive services in the future. As he makes clear in the prologue to the new edition, ‘though the book is consistently critical and questioning of the way in which policies of community care have been implemented, it nonetheless holds steadfast to a positive view of the capabilities of the diverse range of people who are assembled under the banner of the “mentally ill”, and to the promise of community-led, above asylum-led lives for enhancing their life prospects.’ Deinstitutionalisation in this context should be seen not as an irrecoverable failure but as an unfinished ‘emancipatory project’ (28).

The ‘real questions’ that societies need to answer, as Barham maintained in 1992, have never been ‘about dismantling the mental hospitals as such, but about the prospects for manufacturing the social and political will adequate to the task of bringing back and reassimilating into society what had been thrust into the mental hospital’ (151). For Barham this means reaching a point where individuals are treated not primarily as ‘patients’, defined in law by their diagnosis, but as ‘persons’ entitled to full rights as citizens. Drawing on ideas advanced by the psychiatric survivor movement (the new edition includes a preface from the veteran campaigner Peter Campbell) he advocates a shift from managerial or paternalistic conceptions of care, underpinned by coercion, towards a focus on empowerment and autonomy for service users. This will not be achieved through legal or medical fixes, but only by reckoning with the centuries-old legacies of a system which has created the ‘mentally ill’ as a class apart.

Review: On the Heels of Ignorance

Owen Whooley, On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing (Chicago, IL: University of Chicago Press, 2019), ISBN: 9780226616384

Ahlam Rahal, McGill University, Montreal

Positioning himself in psychiatric knowledge as a researcher, Owen Whooley starts On the Heels of Ignorance by describing memories from his childhood, which planted the seeds that grew into his writing about psychiatric ignorance. As the son of a man with a mental illness, young Whooley had daily experienced questions related to his father’s mental health problems. His attempts to understand his father’s depression and drug addiction had always been surrounded by ignorance, uncertainty, and inscrutability. As the author explains, both he and mental health professionals failed to grasp his father’s inner world or to define clearly the characteristics of his mental illness. This experience impacted Whooley’s thoughts and provided the impetus to study historical ignorance within psychiatric knowledge.

Unlike earlier scholars, who critically investigated the profession of psychiatry and the sociopolitical interests that underlie health professions (e.g., Foucault, 1976; Fromm, 1955), Whooley investigates both challenges in psychiatric knowledge and power interests that proliferate within the psychiatric field. The biggest challenge, according to Whooley, is ignorance, which hampers our grasp of mental illness.

Ignorance, Whooley argues, is related to two self-reinforcing dimensions: ontology and epistemology. The ontological dimension refers to descriptions, causes, and the nature of “insanity”; whereas epistemology involves the assumptions, investigations, and inquiry approaches that grasp the essence of the mental illness. Whooley argues that the multiple definitions of the nature of the mental illness that psychiatry has offered throughout history have influenced the investigation of mental illness, and therefore, created incoherent psychiatric knowledge. Explaining these attempts to redefine and reinvent psychiatric identity, Whooley suggests that psychiatry has aimed to maintain its prestigious position, professional authority, and social control over the population and other health fields through the recreation of its discourse. Through writing this book, the author attempts to answer the following question: How has psychiatry dealt with its knowledge’s challenges, securing itself as a prestigious profession, and restoring professional power?

To answer these questions, Whooley traces the historical development of psychiatric discourses. The author uses qualitative methods of inquiry, collects data from multiple sources, including the American Journal of Psychiatry over its entire run, professional journal articles such as the American Journal of Psychoanalysis, institutional documents, and interviews with thirty mental health professionals. Through this data, Whooley reconstructs the knowledge of psychiatry, illuminating both crises that have emerged within its body of knowledge and the strategies psychiatry has used to deal with unknown fields (i.e., ignorance).

The book is divided into five chapters. In each chapter, the author discusses the reinvention of psychiatric knowledge in a specific period, ontological assumptions regarding mental illness, dominant therapeutic modes, and psychiatric institutional infrastructure. Each chapter ends with a remaining unknown field in psychiatry, which threatens psychiatric authority, and therefore motivates policymakers and practitioners to reinvent the body of psychiatric knowledge.

Considering the multiple transformations that psychiatry has undergone and the wide range of literature the book embraces, readers might get frustrated by seeing the incohesive forms of knowledge and different tactics that psychiatry has used in an attempt to overcome ignorance. After reading about psychiatric knowledge in each period, I pause for a breath, thinking of the varied tactics that policymakers, directors and regulators in psychiatry have used to restore psychiatric authority in each era. As the book details, these tactics mainly include cultural and institutional strategies. Culturally, officials have redefined the nature of the mental illness, starting with adopting religious morals in early times, continuing through embracing biological and psychoanalytical principles, and ending with borrowing knowledge from medicine and neuroscience. Institutionally, psychiatry has concealed its ignorance by attaching itself to a secured and prestigious doctrine that dominates the science of each period. In current times, psychiatry has attached itself to the fields of medicine and neuroscience.

This book not only provides mental health professionals with rich information about the historical development of psychiatric knowledge, but also stimulates readers’ thoughts about psychiatrists’ interests in changing their professional knowledge. Readers who might have been diagnosed with mental illnesses might also benefit from reading this book to rethink the appropriateness of the treatments they receive. Do those treatments meet their needs? Do psychologists understand their clients’ inner worlds? Should clients be hesitant to trust mental health professionals?

Whooley devotes a great deal of effort to exploring challenges and debates within psychiatry but pays less attention to external social events that played a role in reshaping psychiatric knowledge. An example of that is the economy. In the last chapter, Whooley shows that, when psychiatry has turned to diagnosis and medications, pharmacological companies have benefited from this transformation. But it remains unclear how the financial benefits of such companies have motivated changes in psychiatric knowledge, supporting its scientific power in turn. But incomplete answers in this book might provide readers with opportunities to study the political-economic forces that have reshaped psychiatric discourse. Such studies might grasp the understanding of how psychiatry has dealt with its ignorance in light of internal and external power relations.

Review: Psychedelic Prophets

Review: Paul Bisbee, Cynthia Carson, Erika Dyck, Patrick Farrell, James Sexton, and James W. Spisak (eds.), Psychedelic Prophets: The Letters of Aldous Huxley and Humphry Osmond (Montreal: McGill-Queen’s Press, 2018) lxxix and 644 pp. ISBN: 978-0-7735-5506-8

Charlie Williams, Queen Mary University of London

Humphrey Osmond is best known as the man who turned Aldous Huxley on to mescaline in 1953. Following a brief correspondence, Huxley invited Osmond, a psychiatrist based in Saskatchewan, Canada to come and stay with him and his wife in Los Angeles. In another letter, he suggested that Osmond might bring some mescaline. Huxley’s mescaline trip was described in detail in The Doors of Perception (1954), a book which would introduce countless psychic wanderers to the powerful subjective experience of mescaline and the ‘labyrinth of endlessly significant complexity’ discovered in the folds of Huxley’s grey flannel trousers. Their meeting in California was also the beginning of a close friendship, now captured in this recent edited collection of their correspondence, Psychedelic Prophets.

As a preface to the collection tells us, both men were prodigious letter writers. Huxley is estimated to have written 10,000 letters in his lifetime. Osmond, was both an ardent letter writer and a meticulous archivist, keeping copies of both sides of the transaction. Thus, the volume is said to represent a complete set of their correspondence (apart from one or more missing pages from a letter written by Osmond on April 30, 1956). Consisting of over 275 letters, Psychedelic Prophets begins formally, with a letter addressed to “Dear Mr Huxley” on March 31, 1953 and ends ten years later with tones of much deeper affection – “My Dear Aldous” – one month prior to Huxley’s death on November 22, 1963. Their discussions follow the arc of a close friendship and a rich intellectual connection, taking deep dives into questions of psychopharmacology, schizophrenia, parapsychology, mysticism, cybernetics, Jungian psychology and psychoanalysis, alongside never-ending intrigue about the effects of psychedelic drugs. The letters also feature their impressions of numerous notable figures they encountered over this period, including Timothy Leary, Norbert Wiener, Abram Hoffer and Gerald Heard.

The most famous moment contained within this correspondence involved a question raised by Osmond about what to label psychoactive pharmaceuticals such as mescaline. In a letter dated March 15, 1956 Osmond wrote that he felt the widely used term “psychotomimetic” (psychotic mimicry) did not do justice to the full range of experiences these drugs could produce. Various candidates for an alternative were put forward including “psychophrenics”, “psycholytics” and the accurate yet clunky “euleutheropsychics” (260-263). Huxley was keen on phanerothyme (soul revealing) and signed off his letter with a short rhyme: “To make this trivial world sublime, take half a gramme of phanerothyme” (266). But they eventually settled on Osmond’s suggestion “psychedelic”, combining “psyche” – the Greek for “mind” – and “delos” – meaning “to manifest” or “bring to light”. Osmond even penned his own ditty: “To fathom Hell or soar angelic, just take a pinch of PSYCHEDELIC” (267).

It was certainly an artful piece of branding. “Psychedelic” met their criterion of having a clear meaning, being easy to pronounce and being unlike any other name. It captured their idea that the consciousness altering experience of psychedelic drugs was no mental aberration but instead facilitated a widening of the doors of perception, an opening up of the self and the possibility of furthering human potential beyond the limits of everyday consciousness. It was an idea that would not only shape early approaches to psychedelic therapy, but also carry through to popular culture as LSD became a symbol of rebellion and cultural change in the 1960s. More recently, Nicholas Langlitz has shown how the idea derived from Huxley and Osmond that psychedelics remove some kind of vestigial filter on the mind or brain remains influential in psychedelic culture and research today, despite conflicting neurophysiological evidence (2012, 125-127).

In the last two decades proponents of psychedelics have championed a so-called ‘psychedelic renaissance’ (Sessa, 2012). Strict regulations that all but put an end to legitimate research in the 1960s have been cautiously lifted and psychedelic drugs are once again being touted for their potential to treat various common and chronic mental conditions. This resurgent biomedical interest has also been accompanied by a wave of scholarship in the humanities and social sciences, much of which has shown how difficult it is to decouple contemporary psychedelic research from its turbulent history (Dyck, 2008; Richert, 2019; Evans, 2017; Langlitz, 2012; Hartogsohn, 2020).. Despite remarkable progress in the decriminalisation of psychedelics for clinical use, Ericka Dyck, an editor of Psychedelic Prophets, points out that the latest phase of psychedelic research shares much in common with its historical beginnings – ‘enthusiasm and awe, and hyperbolic claims about the drug’s potential impact on a wide range of medical concerns’ (2017). Navigating this hyperbole, Dyck suggests, requires attention to the same fault lines and epistemological problems that psychedelic research has tripped up on in the past. In Britain today, ketamine therapy for depression is available on the NHS and advocates hope that psilocybin, MDMA and LSD will all be added to the roster of widely prescribed pharmaceutical therapies within the next five to ten years. But the popularity of microdosing, retreats and informal encounters with psychedelics also show that self-medication and experimentation are how the majority experience these drugs, suggesting that psychedelic therapy will continue to traverse the boundaries of the medical establishment even as these drugs become part of more orthodox therapeutic interventions.

Other scholarship has focused on the question of how cultural meanings of psychedelic drugs influence how an experience plays out in a lab, clinic or recreational setting. During the first wave of psychedelic research both Osmond and Huxley were well aware that the psychedelic experience was influenced by social and environmental factors often referred to as ‘set’ and ‘setting’. Set may be understood as any factor that an individual brings to the experience, including their personality, motives, previous knowledge or experience, mood and preparation. Setting refers to both the physical and social environment in which the experience takes place. More recently, researchers have referred to set and setting under the more general umbrella term “context” (Carhart-Harris et al, 2018). If context is key to the effectiveness of psychedelics in therapy so is an understanding of the history of ideas that surround them. In his account of post war LSD research, Ido Hartogsohn argues that the principles of set and setting may be applied historically to understand the ‘psychosocial construction’ of drug effects through an examination of the complex interactions between psychopharmacological effects and broader socio-cultural factors shaping drug experience (2020; see also 2017). Hartogsohn (2017), for example, suggests that early 1950s experiments which studied psychedelics under the pretext of inducing psychosis were far more likely to foster negative experiences and instigate ‘the very responses they expected to find’. Many of the epistemological challenges encountered by psychedelic researchers, including set and setting, are dealt with in Langlitz’ Neuropsychedelia: The Revival of Hallucinogen Research Since the Decade of the Brain (2012). Langlitz suggests that the age of psychedelic research offers a unique opportunity for empirical research scientists to apply the kinds of approaches associated with the medical humanities and science studies scholarship.

Much of the history of psychedelics, particularly those that incorporate a more diverse understanding of the actors, places and cultures that have lent psychedelics their meaning is still to be written. But between 1956 and 1963 Osmond and Huxley found themselves in a unique position, with access to many newly synthesised or recently “discovered” psychoactive substances and amongst a network of influential intellectuals interested in how these drugs could reshape not only therapy but society more broadly. Their history as well as that of psychedelic research is mapped out in the comprehensive introduction and epilogue to Psychedelic Prophets. But for historians, scientists or anyone else interested in delving deeper into the foundational ideas that have driven psychedelic culture, this huge volume of Huxley and Osmond’s correspondence contains rich pickings.

Review: ‘Aṣfūriyyeh: A History of Madness, Modernity, and War in the Middle East

Chris Sandal-Wilson, University of East Anglia

Joelle M. Abi-Rached, ʿAṣfūriyyeh: A History of Madness, Modernity, and War in the Middle East (Cambridge, MA: The MIT Press, 2020)

In 1982, after more than eight decades of operation, the Lebanon Hospital for Mental and Nervous Disorders officially closed its doors. Seven years into the Lebanese civil war, as hospital employees – who had braved bullets and shells to continue providing counselling to the increasingly anxious population outside the hospital’s walls during the war – desperately sought to overturn the decision to close and to secure the salaries they were owed, the archives of the hospital were abandoned. It was through the initiative of Hilda Nassar, director (until 2013) of the Saab Medical Library at the American University of Beirut, and the work of the archivist Linda Sadaka that the archive of this remarkable institution was saved, as Joelle Abi-Rached tells us at the start of the equally remarkable history that she has woven out of both this and an impressive number of other archives.

ʿAsfuriyyeh: A History of Madness, Modernity, and War in the Middle East traces the rise and fall of an institution which started out life as the Lebanon Hospital for the Insane in the twilight years of the nineteenth century, became the Lebanon Hospital for Mental Diseases in 1915, the Lebanon Hospital for Mental and Nervous Disorders in 1950, and was in throes of a further transformation, this time into the Lebanon Psychiatric Institute in 1976, when war intervened. The hospital’s many names might be taken as indexing how the history of psychiatry unfolded in Lebanon across these decades, as the institution developed from a home for forsaken, impoverished, often chronic cases into the central node in a network of outpatient clinics which aimed to bring mental hygiene to the masses.

But the hospital could never shake off another name, derived from its original location to the east of Beirut on the foothills of Mount Lebanon: ʿAsfuriyyeh, the place of the birds. The name came – like Bedlam in the British context – to serve as a pejorative stand-in for asylums and madness in general, cropping up in novels, plays, and love songs, in spite of the institution’s relentless efforts to stress its scientific credentials and its relocation to a new site in the 1970s. It is a term which has regional currency, too, in a testimony to the hospital’s long history of treating patients and training medical students and psychiatric nurses from Syria, Palestine, Jordan, and beyond. Abi-Rached’s sympathy for this misremembered institution is clear. As well as rescuing ʿAsfuriyyeh from the myths and rumours which have grown to surround it, her concern is to remember the hospital at a time when its original site is at risk of being ‘developed’, like so much of historic Beirut, into amnesiac high-rises.

Weaving together a prodigious range of sources, including Arabic-language scientific and medical journals, missionary accounts, diplomatic correspondence, and hospital reports, Abi-Rached’s aim goes beyond simply narrating an institutional history. Instead, she treats the history of ʿAsfuriyyeh as a ‘sampling device’, or as ‘metonymy and metaphor’,[1] to reveal broader themes. Some of these will be of particular interest to historians of Lebanon and the wider region, but many of them have global resonances. In Abi-Rached’s capable hands, the story of ‘Asfurriyeh helps us think through the often complex relationships between the mind sciences and modernity; medicine, missionaries, and empires; war, conflict, and mental disorder; as well as a host of other crucial themes, including sectarianism, gentrification, memory, and ruination. ʿAsfuriyyeh’s six chapters proceed largely chronologically, with a pause near the middle of the book for a more synoptic exploration of the diagnosis and treatment of patients.

The opening chapter, ‘Oriental Madness and Civilization’, explores understandings of madness in the decades before ʿAsfuriyyeh was established, mobilising two distinct literatures to do so. The first half of the chapter draws on the writings of European and American travellers, missionaries, and medical doctors, who were concerned above all with the abusive treatment of ‘lunatics’ in the region, and the pathological nature of even the ‘normal’ local mind. The second half traces how the sciences of the mind were introduced and elaborated in the pages of Arabic-language scientific and medical periodicals like al-Muqtataf (‘The Digest’), which emphasised a naturalistic account of mental illness. Abi-Rached underlines the strikingly dissonant interests of these literatures and their authors: rather than accepting European accounts of the inherently pathological nature of the so-called ‘Oriental mind’, local intellectuals tied the question of insanity and the deterioration of care for the mentally ill to their wider programme for reforming the late Ottoman state and its people.

The second chapter, ‘The Struggle for Influence and the Birth of Psychiatry’, draws on diplomatic archives as well as the records of ʿAsfuriyyeh itself to reconstruct the history of the founding and early development of the hospital. Although founded by a Swiss Quaker missionary, Theophilus Waldmeier, Abi-Rached argues that the hospital needs to be understood not as a unilateral attempt at proselytization, but rather within the context of a complex struggle for power and influence in the region which involved local as much as international actors. Good relations with the Ottomans were key to the survival of the hospital, with its British medical director and matron permitted to remain on site during the First World War, when they were technically enemy subjects. Although avowedly non-sectarian and cosmopolitan in outlook, the hospital was perceived as ‘Protestant’ and ‘Anglo-Saxon’, both of which fuelled French suspicion of the institution once they replaced the Ottomans after the war, though their policies – covering hospital fees through the introduction of the assistance publique, for instance– indirectly benefited ‘Asfurriyeh.

The third chapter, ‘The Rise of ʿAsfuriyyeh and the Decline of Missions’, charts the transformation of the institution across the middle decades of the twentieth century, as the missionary zeal which had played a role in its foundation withered away and – contrapuntally – psychiatry’s domain was extended to encompass not just the obvious ‘lunatic’ but the everyday strains of industrial modernity. After the Second World War, a series of neuropsychiatric clinics were founded, as well as a forensic unit for prisoners, to bring mental hygiene to the home, school, factory, and military. If the impressive uptake at these outpatient clinics is any indicator, the wider population welcomed psychiatry’s expansionist ambitions. While in part encouraged by demand, these innovations were driven too by competition with a rival institution, Dayr al-Salib, a convent to the north of Beirut which had been converted in the 1920s by a Lebanese Capuchin priest into an asylum for elderly priests, and subsequently transformed into a psychiatric institution in the 1950s. Abi-Rached also stresses the role played by successive leaders in this period, above all Dr Antranig Manugian, medical director from 1962, whose transformational vision of ʿAsfuriyyeh as a modern psychiatric institute would be torpedoed by the outbreak of the Lebanese civil war.

The fourth chapter, ‘Patriarchal Power and the Gospel of the Modern Care of Insanity’, grapples with the backgrounds, diagnosis, and treatment of patients at ʿAsfuriyyeh right across its lifespan, notably through quantitative analysis of annual reports. This throws up interesting trends: peaks in admissions, for instance, to the hospital during the First and Second World Wars, as well as in the 1950s and 1960s at a time of growing economic prosperity, inequality, and substance use. While Abi-Rached makes some use here of patient case files – mostly from the hospital’s early years – she is reluctant to immerse herself in this archive, on the grounds that ‘the patients’ voices, personal narratives, and singular stories are buried in medical dossiers under the “tyranny” of their diagnosis’.[2] Instead, Abi-Rached largely limits herself to deploying these files to puncture myths surrounding the (in)famous case of Mayy Ziyadah, the influential feminist and poet admitted to the hospital in 1936. No one would deny that medical case files are tricky to work with, methodologically as well as ethically, and it may well be the case that these are amongst the files still in the process of being organised by archivists and so perhaps inaccessible. But they do seem to represent a rich, and here largely untapped, vein for researchers to explore further in future.

The fifth chapter, ‘The Downfall of ʿAsfuriyyeh and the Breakdown of the State’, was to my mind the most compelling and haunting of the book. Zooming in on ʿAsfuriyyeh between the start of the Lebanese civil war in 1975 and the hospital’s closure in 1982, Abi-Rached draws on the correspondence of the hospital’s medical director, Dr Manugian, to paint a deeply felt picture of a hospital which not only found itself in the midst of war, but a target within that war. Staff, students, and patients were kidnapped, injured, sexually assaulted, and killed, and every building hit at least once by shells. It is a harrowing story which Abi-Rached locates within a broader shift in the nature of political violence over the century towards targeting hospitals as a strategy of war – a strategy tragically familiar to us today, whether in Syria, Yemen, Gaza, Afghanistan, or elsewhere.

The final chapter of the book, ‘The Politics of Health, Charity, and Sectarianism’, takes us past the official closure of ʿAsfuriyyeh in 1982 to develop some of the previous chapter’s reflections on non-sectarianism as the hospital’s deeply held – and ultimately, at a time of sectarian conflict, costly – ideology. Not only is it the case that health services, including mental health services, have been ‘sectarianised’ in Lebanon since 1982, but the very memory of ʿAsfuriyyeh itself is under threat of being sectarianised, with legal consequences: the Supreme Council of the Protestant Community in Syria and Lebanon is seeking to assert its control over this ‘Protestant’ institution in the courts. Abi-Rached vigorously contests this strategic misremembering of an institution whose executive committees, staff, and patients were always drawn from a range of backgrounds.

There is much here to digest for anyone interested in the histories of psychiatry, Lebanon, or the modern Middle East; certainly more than enough to guarantee the book a well-deserved place on undergraduate as well as postgraduate course syllabi, where some of its larger claims are sure to provoke reflection and discussion. At a time when re-institutionalisation is increasingly mooted in the West, Abi-Rached is at pains to emphasise that the closure of ʿAsfuriyyeh cannot be seen as part of any broader movement towards de-institutionalisation, as in Europe and North America. Instead, vast psychiatric hospitals continue to accommodate thousands of patients in Lebanon and the wider region: Dayr al-Salib, which historically rivalled and ultimately outlived ʿAsfuriyyeh, has a bedstrength of 1,100 today, a staggering figure which is nonetheless surpassed by at least two mental hospitals in Egypt and a further institution in Iraq.

Abi-Rached also takes issue with two components of Foucault’s account of the asylum: rather than replacing the leprosarium, Abi-Rached argues the asylum should be seen as emerging in the Middle East as a result of the decline of the bimaristan, charitable healing institutions with their own long history of managing the mentally ill; and rather than any ‘great confinement’, Abi-Rached argues that neither numbers, nor the routes by which patients arrived at ʿAsfuriyyeh, support this picture of the mass incarceration of the insane in Lebanon. While both these narratives have been roundly critiqued on empirical grounds not only in histories of psychiatry beyond Europe, but within it too,[3] one gets the sense that ʿAsfuriyyeh feels obliged to return to them, as the first English-language monograph on the history of psychiatry in the region, for its historiographical moorings.[4]

ʿAsfuriyyeh is a rich, original, deeply researched, and often moving work. Given its many strengths, I wondered whether it needed to be quite so pugnacious in its engagement with the few existing works on ʿAsfuriyyeh, which are criticised for being ‘still stuck in the Foucauldian and postcolonial frameworks’.[5] To give an example, in the otherwise excellent fifth chapter, Abi-Rached takes a tilt at Eugene Rogan for dismissing the hospital’s non-sectarianism as a mere public relations ploy. But Rogan doesn’t quite, at least in my reading, argue this.[6] At other points, a focus on rebutting these interpretations leaves some bigger, and more interesting, questions undisturbed. Responding in the fourth chapter to the claim that the Ottoman authorities embraced ʿAsfuriyyeh because it offered a means to cleanse the streets of lunatics, Abi-Rached marshals statistics to show that a majority of patients at the hospital were almost always private. But the more difficult question this leaves – as Abi-Rached recognises – is the degree to which coercion and dubious motives on the part of families, if not the state, may still have played a role in these admissions. Patient case records might have offered the beginnings of an answer.

In a sense, the book’s pioneering focus on the history of psychiatry in the modern Middle East means that Abi-Rached has to work hard to find bodies of scholarship with which to engage. While the connections she draws are almost always fresh and thought-provoking as a result, the invocation of a spectral figure of ‘Foucauldian and postcolonial frameworks’ at times jars. This does not at all detract from the accomplishment of this book, which not only provides a compelling history in its own right but generously offers future lines of inquiry an essential point of departure. In the opening pages of ʿAsfuriyyeh, Abi-Rached states that her goal is ‘to save this influential institution from oblivion’.[7] This is too modest a description of what she has achieved here, but it does capture a quality which I think characterises this remarkable history: a deep sympathy at its heart for ʿAsfuriyyeh, its reputation, and its people.

[1] Here Abi-Rached is drawing on Charles Rosenberg, ‘What Is An Epidemic? AIDS in Historical Perspective’, Daedalus 118, 2 (1989) and Michel de Certeau, L’écriture de l’histoire (Paris: Gallimard, 1975) respectively.

[2] Abi-Rached, ʿAsfuriyyeh, p.99. Here Abi-Rached is quoting Charles Rosenberg, ‘The Tyranny of Diagnosis: Specific Entities and Individual Experiences’, Milbank Quarterly 80, 2 (2002), pp.237-60.

[3] For example, in this journal, Andrew Scull, ‘Michel Foucault’s history of madness’, History of the Human Sciences 3, 1 (1990), pp.57-67. For colonial psychiatry and the ‘great confinement’, see Megan Vaughan, ‘Idioms of madness: Zomba Lunatic Asylum, Nyasaland, in the colonial period’, Journal of Southern African Studies 9, 2 (1983), pp.218-38.

[4] Happily this situation looks set to change in the near future, with forthcoming monographs by Lamia Moghnieh, Beverly A. Tsacoyianis, and this review’s author. For the history of psychiatry in Israel, see Rakefet Zalashik, Ad Nafesh: Refugees, Immigrants, Newcomers, and the Israeli Psychiatric Establishment (Tel Aviv: Hakibutz Hameukhad, 2008) [Hebrew] and Das Unselige Erbe: Die Geschichte der Psychiatrie in Palästina und Israel (Frankfurt: Campus Verlag, 2012) [German]; for the history of psychiatry in the Ottoman empire, see Fatih Artvinli, Delilik, Siyaset ve Toplum: Toptaşı Bimarhanesi (1873-1927) (Istanbul: Boğaziçi Üniversitesi Yayınevi, 2013) [Turkish]. For earlier histories of madness in the Middle East, see Michael Dols, Majnun: The Madman in Medieval Islamic Society, ed. Diana E. Immisch (Oxford: Oxford University Press,1992), and Sara Scalenghe, Disability in the Ottoman Arab World, 1500-1800 (New York: Cambridge University Press, 2014), esp. ch. 3. Much more attention has been paid to the career of psychoanalysis in the region: see in particular Omnia El Shakry, The Arabic Freud: Psychoanalysis and Islam in Modern Egypt (Princeton and Oxford: Princeton University Press, 2017).

[5] Abi-Rached, ʿAsfuriyyeh, p.18.

[6] The reference given here is to Eugene Rogan, ‘Madness and Marginality: The Advent of the Psychiatric Asylum in Egypt and Lebanon’, in Eugene Rogan, ed. Outside In: On the Margins of the Modern Middle East (London: I.B. Tauris, 2002), p.115. This is what Rogan has to say about ‘public relations’: ‘As a private institution without government support, the Lebanon Hospital dedicated tremendous effort to what would now be termed public relations. On the one hand, the hospital was entirely dependent on networks of private subscribers… On the [other] hand, they sought to preserve good relations with the Ottoman officials of the Mutasarrifiyya (governor general).’

[7] Abi-Rached, ʿAsfuriyyeh, p.xxvii.