Mental health asylums, once pivotal in shaping our approach to mental health treatment, cast a persistent shadow over modern understandings of mental illness. Although often relegated to the realms of thriller movies and historical footnotes, their legacy profoundly influences current perspectives. The development of these institutions was deeply intertwined with historical, political, and social factors that are frequently overlooked or sanitized. This lack of critical reflection has led to a desensitized view of mental health, reinforcing negative public perceptions and outdated treatment methods.
The harsh realities of mental health asylums—characterized by inhumane practices and deplorable conditions—have left a lasting impact. Despite advancements in science, medicine, and societal attitudes, the lingering stigma surrounding these institutions continues to affect marginalized groups, including women, migrants, and people of color. This empathy gap impedes our understanding and stifles the necessary curiosity and critical examination of how historical injustices continue to reverberate in today’s mental health landscape. While progress has been made in treatment and societal views, the deep-seated negative perceptions of mental health institutions persist, particularly impacting disempowered communities.
1910 – Full view of Asfuriyeh, Lebanon Hospital for the Insane. Photo from the ‘Album of Asfuriyeh,’ digitized by the Borthwick Institute for Archives, on Wellcome Collection (CC BY-NC 4.0), modified.
‘Asfuriyeh: The Western origins of mental health institutions in Lebanon
In Lebanon, the historical development of mental health asylums –or what was known as “lunatic asylums” – began with Asfuriyeh, otherwise known as The Lebanon Hospital for the Insane. It was initially founded in 1896 to offer care and various services for ‘mentally afflicted’ individuals from Lebanon, Syria, and other South West Asian countries. Soon after, Asfuriyeh was attributed as a religious foundation: It initially offered accommodation for 10 individuals, later expanding to house up to 150 individuals who were considered to be ‘troubled’. This sudden expansion has resulted in increasing criticism and obstacles related to issues such as insufficient resources for proper treatment, overcrowding, multiple human rights violations, and negative perceptions towards mental health. Soon after, Asfuriyeh closed its doors in 1982 as a result of the violence of the 15-year-long civil war in Lebanon. Asfuriyeh was influenced by Bethlehem Hospital, also known as Bedlam, one of the oldest institutions to house the ‘insane’ in the United Kingdom. Although this asylum was not a big part of medieval society with initially only six ‘insane’ individuals, in 1403, one commissioner report stated that there were four pairs of shackles that were used to torture these individuals including 11 chains, six locks, and two pairs of stocks.
1896 – Bethlehem Royal Hospital, London, as seen from Lambeth Road. Photo originally published in The Queen’s London: A Pictorial and Descriptive Record of the Streets, Buildings, Parks and Scenery of the Great Metropolis, on Wikimedia Commons.
A plea of madness to organize society
Similar to our current understanding of ‘insanity,’ “madness” in the times of Bedlam and Asfuriyeh was a poorly defined category in society. It encompassed individuals who became an inconvenience to –and incompatible with– the social and economic order. They were the ones who did not conform to societal norms and the socially ‘natural’ way of living, and thus were classified as perverse, deviant, and abnormal. Although “madness” was once perceived as a biologically stable and God-given category, history has proven that “madness” has been socially constructed with the abnormal demands of the capitalist system. With the way society is constructed, refugees, women, and all sorts of marginalized groups who are at an economic and social disadvantage, often end up in the vast realm of “mental instability.”
1858 – Eliza Camplin, a patient at Bethlem Royal Hospital, during an episode of acute mania. Photo by Henry Hering, from the Bethlem Royal Hospital Museum of the Mind Archives on Wikimedia Commons.
1858 – A.B., a patient at Bethlem Royal Hospital, during an episode of acute mania. Photo by Henry Hering, from Bethlem Royal Hospital Museum of the Mind Archives on Wikimedia Commons.
1858 – Harriet Jordan, a patient at Bethlem Royal Hospital, during an episode of acute mania. Photo by Henry Hering, from the Bethlem Royal Hospital Museum of the Mind Archives on Wikimedia Commons.
Gendered “insanity”
In the historical context of mental health asylums, women who exhibited traits such as ‘bad wives,’ ‘hatred of spouses,’ ‘witchcraft,’ and ‘hysteria’ were often labeled as ‘mad,’ ‘troubled,’ or ‘insane,’ leading to their involuntary institutionalization. Adrienne Rich’s work on compulsory heterosexuality sheds light on how women’s autonomy was constrained by societal expectations, creating dependencies on men for economic stability and social acceptance. These intersecting systems of oppression not only limited women’s choices but also contributed to the medicalization of their issues within mental health asylums. “Normal” experiences such as menstruation or expressions of emotion were pathologized, perpetuating stereotypes of women’s emotional fragility and undermining their agency in mental health care systems. Thus, the historical legacy of mental health asylums reflects deeply rooted issues of sexism and the broader societal attitudes towards gender, mental health, and power dynamics. Women faced strict rules, surveillance, and dehumanizing treatments, resulting in a loss of autonomy and agency over their lives. The medicalization of women’s issues further reinforced stereotypes and hindered progress towards equitable mental health care for all.
1945 – Casebook record for Frances Arundell Coode at Holloway Sanatorium, documenting her diagnosis of acute mania and the associated medical observations. Photo on Wellcome Collection.
In contemporary mental health care, women continue to experience misdiagnoses with disorders that are historically, socially, and politically proven to be sexist. For instance, the concept of hysteria, originally attributed to women and their emotional distress as a result of a ‘wandering womb‘ or female biology, has evolved into diagnostic categories like somatic symptom disorder, conversion disorder, and dissociative disorders within modern psychiatry. Despite attempts at clinical precision and evidence-based approaches, these diagnostic replacements often serve the same underlying biases.
Furthermore, multiple disorders such as Borderline Personality Disorder (BPD) and Histrionic Personality Disorder (HPD) have faced criticism for their gendered biases, with women historically being disproportionately diagnosed more frequently than men. The diagnostic criteria for BPD and HPD stem from societal stereotypes of women’s emotional expression, leading to over-pathologization and generalization of women as emotionally erratic and uncontrollable. For example, traits associated with HPD, such as seductiveness and exaggerated emotions, perpetuate gender stereotypes about women’s behavior, reinforcing notions of women as overly emotional, attention-seeking, or manipulative. These gender biases in diagnosis and treatment are rooted in normalized gender-based inferiority and violence, restricting women to traditional roles as caretakers and family-builders, under the mercy of their male counterparts. These biases are deeply entrenched in a broader patriarchal and societal context which upholds and perpetuates a notion of female inferiority, viewing women as less capable, competent, and deserving of the same opportunities that men are offered. Therefore, the go-to description of women in Lebanon and around the world as crazy, hysterical, or delusional for any action or reaction they engage in is not innocent, but comes after centuries and decades of patriarchal indoctrination in society and women’s unjust stays in mental institutions.
The historical development of mental health asylums, particularly in their treatment of women and marginalized racial groups, underscores the intertwined nature of sexism and racism within mental health care systems.
Is race a defining factor of madness?
Mental health asylums and mental healthcare have also been inherently racist to people of color including refugees, immigrants, migrant workers, and black and brown folks, who are disproportionately admitted to inpatient psychiatric facilities. A recent study on disparities in the use of the 2021 Mental Health Act in the UK among ethnic groups found either no explanation for the variation in risk of detention or insufficient evidence to support explanations such as “higher comorbid drug use in ethnic groups, language barriers, poorer detection of mental illness, and greater stigma of mental health issues.”
2021-2022 – Ethnic disparities in detentions under the Mental Health Act in England. Chart courtesy of the Mental Health Services Data Set, Ethnicity Facts and Figures, GOV.UK (CC BY-NC-ND 2.0).
According to a 2023 report by the UK Government, white people were nearly five times less likely than black people to be detained under the Mental Health Act, with 342 detentions per 100,000 people compared to 72 for every 100,000 white people. Additionally, the report indicates that the black ‘other’ ethnic group had the highest rate of detention (760 per 100,000 people) while the White Irish, Chinese, British, and Indian ethnic groups had the lowest rates of detention (62, 64, 69, and 75 per 100,000 respectively).
Furthermore, nation-state borders have also been used as political tools and exclusionary factors to dictate and produce “madness.” Many people who are directly or indirectly forced to cross borders in an attempt to find refuge and safety have experienced conflict and persecution in their home countries, and endure life-threatening journeys. They often become second-class citizens in the countries they migrate to, denying them access to housing, healthcare services, freedom of mobility, and educational and employment opportunities. This situation leads to a high prevalence of mental health distress among asylum seekers, with refugees being five times more likely to have mental health needs than the rest of the population. Migrants and their children are also significantly more likely to meet the criteria for post-traumatic stress disorder, particularly when children are separated from their parents. This heightened distress is exacerbated by the hostile environment perpetuated by different governments, reflecting racist and discriminatory social fabrics that create a constant state of fear and precarity.
2015 – Hundreds protested at Yarl’s Wood Detention Centre, Bedfordshire, exposing systemic abuses including indefinite detention, poor conditions, and mistreatment of immigrant women and adult family groups. Photo by Eye Dj on Flickr (CC BY-NC-ND 2.0).
For example, a 2021 report by the UK Government highlights the significant suffering caused by Britain’s immigration detention system, incarcerating people deemed to be ‘illegal.’ The report notes that 32,000 people entered the UK immigration detention system in 2015, with abusive treatments such as bunk bed installations, removal of bodily autonomy, guards, cell lock-ins, and exposed toilets that mimic conditions found in prisons and mental health asylums. Studies by the Royal College of Psychiatrists in 2021 also indicate that people detained in immigration detention facilities are most likely to experience symptoms of anxiety, fear, hopelessness, insomnia, self-harm, and suicidal ideations and behaviors including passive and active suicidal thoughts. This highlights the detrimental impact of immigration policies on mental well-being and how mental health systems and immigration systems overlap and collude with one another to serve the interests of the state. For example, doctors in the UK who admit patients to the psychiatric inpatient unit are encouraged to inquire about patients’ immigration status, resulting in reluctance among people to seek mental health services for fear of immigration enforcement action. Similarly, in countries like the United States (US) and Canada, individuals can be denied entrance or a US green card if they are deemed to have a clinically diagnosable ‘physical or mental disorder’. This demonstrates how sanity becomes intertwined with the construct of the ‘good’ and submissive nation-state subject, serving the interest of protecting capital.
2020 – The short film ‘Mekdas: When Will I Look Back at Now‘ explores the dire conditions faced by migrant domestic workers under Lebanon’s Kafala system. Directed and produced by Firas El Hallak. Video courtesy of IDWF on Flickr (CC BY-NC-ND 2.0).
Within the Lebanese context, one can understand the intersection of race and claims of insanity when looking at migrant workers and refugees in Lebanon. Around 250,000 migrant workers are believed to be currently working in Lebanon, most of which contracted under Kafala, a modern-day slavery system. The conditions of their arrival and “training” are murky, with many being subjected to physical and mental abuse, meant to teach them how to become “docile” and “subjugated” before being sent off to employers. According to Lebanon’s intelligence agency, two migrant domestic workers die every week on average, with some “falling” from the apartment building during escape attempts, and others by suicide. These situations are almost always under-investigated, with employers and security personnel deeming the migrant workers as “insane,” “crazy,” and “hysterical.” The migrant worker’s economic, social, and personal situation are almost never discussed, even when she is subjected to physical, verbal, and sometimes sexual abuse at the hands of her employers.
A similar pattern can be perceived when it comes to the refugee population in Lebanon. Apart from the pain of being forcefully displaced from their homelands, and/or dealing with traumatic war-time events, Palestinian and Syrian refugees face several legal, economic, and social barriers, which affect their quality of life, and as such, their mental health. Over the past few years, several cases have emerged in which Syrian refugees have committed or attempted to commit suicide, due to the harsh living conditions they endure as refugees in Lebanon, or due to the threats of deportation back to Syria.
Instead of exploring the systemic causes behind such events, officials or mainstream narratives always approach suicides or suicide attempts from an individual perspective, resorting to calling the migrant worker or refugee “insane,” and assuming that this event is a one-off thing.
2022 – Syrian refugee Hisham Al Rawi, 38, in a UNHCR center for torture victims and mental health support in Beirut, battles severe depression and panic disorder, worsened by systemic neglect and discrimination. Photo by Prospects ILO on Flickr (CC BY-NC-ND 2.0).
A political legacy
Finally, it is essential to note that mental health has been and continues to be seen as existent within a vacuum, eradicating the intersecting effects of various systems of oppression in diagnosing someone’s mental health condition. The mental health asylum system is only symbolic of how the whole mental health field is inherently discriminant towards marginalized groups of people. The historical legacy of mental health asylums and their intersections with gender, race, and immigration policies, reflects deeply rooted issues of sexism, racism, and systematic discrimination. Furthermore, institutionalization, in various ways and forms, continues to shape our views on certain individuals, behaviors, and groups of people, instructing us on what “madness” is constructed to be in a world that makes it easy to be insane.
Serge Nasr
Serge Nasr is a dedicated professional with a degree in Psychology and Human Behavior and an ongoing master's degree in Interdisciplinary Gender Studies. Serge's work is centered on bridging the gap between mental health advocacy and intersectional queer and gender interventions. With a deep commitment to addressing systematic discrimination, he emphasizes the need for comprehensive strategies and targeted advocacy to foster more inclusive and equitable mental health support. By integrating insights from both psychology and gender studies, Serge aims to create innovative solutions that address the unique challenges faced by marginalized communities inside and outside the mental health sector.
- Serge Nasr
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