Young people are changing face of mental health in Lebanon

Tradition, corruption and political negligence continue to stigmatise mental illness, but the new generation is transforming old taboos

“I’m bipolar,” Mohamad announces in a matter-of-fact tone. In his close-knit Lebanese community, admitting to having a mental health disorder could prejudice his chances of getting married and finding a job, but Mohamad proudly insists he has freed himself from “all that shit”.

He comes from a Muslim family with a long history of mental health issues, yet this has never been openly discussed. When he was 15, in the first attempt to understand the origins of his condition, he sought the help of a Sheikh. “He would only do like this,” Mohamad says, raising his hand to mimic a benediction, “and I would supposedly be healed”. Now he is 27 and, after years taking medications to numb the emotional roller-coaster, he feels ready to fight his demons without pills – or religion.

Lebanon’s young generation is challenging longstanding cultural taboos around mental health. They are helped by a growing number of NGOs and support groups, including The Institute for Development, Research, Advocacy and Applied Care (IDRAAC), a local non-profit organisation dedicated to raising awareness around mental health issues. The IDRAAC recently launched a multimedia campaign featuring five celebrities and the slogan “Wellbeing is a matter of mind. Think about it”.

“If awareness is the first step toward change, Lebanon’s young generation are starting a brave journey.”

Embrace, a support and awareness network, have created a YouTube video mocking typical Lebanese ways of cloaking mental health issues. Taking on statements like “he had a complicated life,” or “she lives on another planet,” they invite viewers to figuratively untie “the knot”, or the tangled perception that Lebanese society has of mental health. In recent years, movies such as Ghadi, where a child with Down’s syndrome is worshipped as an angel, have raised awareness around psychiatric issues.

But while Lebanese society is starting to break free of taboos around mental health, they still face obstacles. Spending on health care is largely out of pocket: not even private insurance companies cover admissions for psychiatric illnesses. The fee for a psychiatric visit ranges between $50 (£33) and $150 (£100). So young people have to be financially independent in order to gain psychiatric help, while their families often linger between denial and superstition.

The system also relies on the private sector, namely NGOs and three religiously affiliated psychiatric hospitals, which the government subcontracts. Even patients with the right to government aid still have to pay themselves then wait for a refund – a slow process.

What’s more, private practitioners are often more concerned with boosting the number of visits rather than giving a thoughtful diagnosis. “My visits lasted an average of five minutes, where I listed my symptoms and I was prescribed more pills,” Mohamad remembers. “I then went home and researched the medicines, as I was not even told what they were and why I was taking them”.

Lina Al Khouri, a mental health councillor for an NGO that helps drug addicts, argues the combination of the carelessness with which practitioners increase dosages and the pharmacies’ laxity in selling drugs is blurring the boundaries between mental illness and drug addiction. “As there is no supervision, private practitioners aim at maximising the number of visits to boost profits,” she says. “To make it quick, patients are prescribed a higher dosage if they still show symptoms, which often results in them spiralling into drug abuse”.

Despite all this, the stigma surrounding mental health issues is being challenged by the new generation, through NGO work, social networks and the media. They are challenging the gaps in the provision of mental health that are holding back a much-needed transformative process.

Changing the legislation

Lebanese legislation still lags far behind international human rights standards in protecting the rights of people with mental health disorders. The absence of a clear legal definition of mental disorder leaves room for interpretation based on social beliefs and cultural norms.

One of most severe abuses stemming from the lack of a legal framework is forced institutionalisation. Involuntary admissions are not monitored by a judicial third party but are left in the hands of psychiatrists and families. Experts have denounced episodes of corruption, in which family members pay practitioners to lock away a relative over inheritance disputes, for example. As the patient has no power over their own release, this can result in a life sentence.

In 2012 IDRAAC tried to end this by drafting a new bill, currently under discussion, in which the 1983 definition of mental health illness is replaced by a more explicit one. Elie Karam, president of IDRAAC and co-author of the first national study on mental health disorders, is confident the new legal framework will grant greater protection against abuse. Critics, however, dispute its clarity, claiming it fails to prescribe appropriate periods of treatment and make sure institutionalisation takes place in the least restrictive environment.

Regardless of its limits, the new proposal opens a public debate which some say the government is trying to prevent. According to NGO The Legal Agenda, the new bill has skipped several stages of parliamentary scrutiny for no apparent reason, a move that has reduced media coverage and limited opportunity to make amendments. The dubiousness of this fast tracking procedure and the near silence of mainstream media suggest a political unwillingness to limit the authority of the psychiatric profession, as well as a reluctance to discuss mental health.

Traditionally, psychological disorders were – and still partly are – perceived as “problems with the mood” that have to be confined to the private sphere. The first mental institution, the Catholic Deir-el-Salib, served as a place of seclusion for those experiencing mental illnesses. Patients were subjected to disputable procedures such as ice baths and electroconvulsive therapy (ETC). ETC is still in use today – in Lebanon and other countries – but anaesthetics are now administered to soothe the pain of broken bones resulting from the electrically induced seizures.

According to Mohamad, public acceptance is growing, but this can be a double-edged sword. “Kids are prescribed psychotropic drugs because they are perceived as socially inadequate,” he remarks, pointing out that nonconformist behaviours are being treated as symptoms of mental illnesses. “What we should focus on is not changing the way we look at mental health issues, but our society’s concept of ‘normality’”.

Breaking away from the myth of the Phoenix

Statistics are sketchy in a country that saw its last official census in 1932, but studies estimate one in four Lebanese people has experienced a mental health disorder, according to the World Health Organisation’s definition. Despite decades of vicious sectarian wars, the rate of mental health disorders is lower than that of the United States and lies within the range observed in the UK.

Yet in Lebanon there is a much higher percentage of people not receiving treatment. While in the UK around two thirds of people do not have access to aid, this reaches a staggering 90 percent in Lebanon.

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But according to Karam, the strong social ties still existent within Lebanon keep health disorders at bay – an idea he summarises with the word “resilience”, meaning the ability of a society to readapt to stress and hardships. “In Lebanon we suffered from organised violence, but here we feel safer in our own neighbourhoods than people in Western countries,” he says.

Lebanon has been described as the incarnation of the myth of the Phoenix, due to its never-ending cycle of destruction and rebirth. Studies have confirmed the importance of strong community ties in coping with clinical and sub clinical levels of psychological stress, due to the permanent anticipation of violent conflict. This is particularly so in a context where access to mental health aid is severely limited.

However, anthropologist Filippo Marranconi warns that drawing an automatic connection between mental health in Lebanon and war-related events carries the risk of falling into a self-fulfilling prophecy. He warns against “studies intending to spot PTSD…that do not take into account the complexity of a person’s experience.”

Such an approach might end up reinforcing the cliché of the war-torn country – a sexy topic especially for foreign NGOs working in Lebanon – while ignoring more nuanced social dynamics.

If awareness is the first step toward change, Lebanon’s young generation are starting a brave journey. The mobilisation of local NGOs and support groups, and the beginning of a public discourse on legal reform indicate that – under a more traditional political and social crust – a major shift is taking place.

First published by Open Democracy