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attention to exercise and gainful activity. He suggested ‘removing the convalescent, and incurable insane, to convenient distances from large cities and towns, to well enclosed farms, properly adapted to the purposes of employing them with effect, in the different branches of husbandry and horticulture’.160 Over the following two hundred years, various developments in the practice of psychiatry (including the introduction of neuroleptic medication) were to tilt the balance away from this broad based, multi-modal approach to treatment recommended by Hallaran. The late twentieth century, however, saw the re-emergence of reenergised models of biopsychosocial psychiatry which emphasised the role of occupational therapies in the process of recovery,161 consistent with the approach outlined by Hallaran almost two centuries earlier.

      Developments in England,

      France and the United States

      As these developments and innovations in treatment were unfolding in late eighteenth- and early nineteenth-century Ireland, especially in Hallaran’s establishments in Cork, they coincided, to greater or lesser extents, with significant shifts in practice elsewhere. In England, the asylums that emerged during the 1700s were mostly highly custodial places and, although there were inevitably pockets of enlightened practice, there were also clear, systematic problems across the emergent system. At Bedlam in London, there were continual reports of abuse and poor conditions, albeit accompanied by contrasting reports of good treatment at times, with the result that Bedlam was subject of interminable speculation among journalists, politicians and the public, to whom it provided endless cause for concern and morbid fascination.162

      More broadly, the asylums of eighteenth-century England included a range of different establishments including, for example, St Luke’s Hospital in London, which accepted its first patients in July 1751.163 In what would be a remarkably consistent pattern across institutions and across countries, numbers at St Luke’s rose steadily following its opening. Battie, its founding medical officer and the leading asylum doctor of his day, duly wrote in strong support of confinement as a key element in management of the mentally ill, stating that confinement was always necessary and sometimes sufficient to effect a cure.164 Battie’s uncompromising stance strongly reinforced the emphasis on asylums in the treatment of the mentally ill over the following decades.

      In addition to its allegedly unique therapeutic potential, the asylum was also, according to Battie, essential for the education of physicians.165 England’s first provincial subscription asylum was duly established in Newcastle in 1765, and many others followed (e.g. Manchester in 1766, York in 1777). While regulations governing various specific practices were in place in these establishments, restraint, coercion and punishment still featured strongly, at least until evidence of abuses in Bedlam and York were later exposed.166

      The most palpable sign of change appeared in the 1790s, when William Tuke (1732–1822), a Quaker tea merchant, founded and opened The Retreat at York following the death of a Quaker woman in York Asylum.167 The Retreat aimed to provide care for the mentally ill in a humane and nurturing setting, and patients were allowed access to the grounds, housed in comfortable settings, and generally treated with sympathy.168

      Tuke was an admirer of Dr Philippe Pinel (1745–1826)169 of the Salpêtrière Hospital in Paris, who published an influential textbook promoting principles similar to those that underpinned Tuke’s initiative.170 Many of Pinel’s proposals were later championed by Dr Jean-Étienne-Dominique Esquirol (1772–1840) in Charenton, Paris and at the Salpêtrière. Pinel was an inveterate reformer, rejecting the established practices of bloodletting and purging, and concluding that mental disorder stemmed from heredity or ‘passions’ such as sadness, fear, anger or elation.

      Most famously, Pinel became known for removing the chains from female patients at the Salpêtrière in 1800, some three years after his assistant, Jean-Baptiste Pussin (1746–1811), had done so for male patients at the Bicêtre. In fact, Pinel’s initiative commenced in the early 1790s and built steadily over the following years.171 More broadly, it was Pinel’s sympathetic writings about the mentally ill, portraying them as unfortunate persons deserving of respect and sympathy, that likely had the greatest impact on public perceptions of the mentally ill in France and other parts of Europe.172

      These shifts in approach, exemplified by Tuke in England and Pinel in France, resulted in greater recognition of the idea that mental illness was a problem for which society had responsibility, and that the mentally ill should be treated with dignity. This idea did not rest easily, however, with the traditions of coercion, punishment and poor treatment that had evolved in many eighteenth-century English asylums.

      In Ireland, Hallaran, like Tuke and Pinel, was a key figure in developing progressive, humane approaches to the mentally ill, warning strongly against reliance on simple force, and promoting the idea of speaking with each patient as an individual human being:

      Maniacs, when in a state to be influenced by moral agents, are not to be subdued ex officio, by measures of mere force, and he who will attempt to impose upon their credulity by aiming it at too great a refinement in address or intellect, will often find himself detected, and treated by them with marked contempt … I have in consequence made it a special point on my review days, to converse for a few minutes with each patient, on the subject which appeared to be most welcome to his humour. By a regular attention to the duties of this parade, I am generally received with as much politeness and decorum as if every individual attached to it, had a share of expectancy from the manner in which he may happen to acquit himself on the occasion. The mental exertion employed amongst the convalescents by this species of address is very remarkable, and the advantages flowing from it are almost incredible.173

      Hallaran’s engagement with each patient on the subject the patient wished to speak about was entirely consistent with the more humane, respectful approach recommended by Tuke and Pinel. In retrospect, Hallaran’s approach is also consistent with twenty-first century ideas about engaging with patients’ symptoms in direct ways,174 as reflected in, for example, the increasing use of cognitive behaviour therapy (a talking therapy focused on thoughts and behaviours) for psychosis in the late twentieth century, focusing on understanding and interpreting symptoms, with patients and therapists working together to co-create a shared dialogue.175

      In parallel with developments in Europe, the 1700s also saw several significant moves towards organised care for the mentally ill in the US. In 1729, the first identifiable psychiatric ward was created in the Boston alms house when persons with mental illness were separated from other inmates.176 The mid-1700s saw the establishment of the Pennsylvania Hospital in Philadelphia, which took its first admissions in 1752 and was devoted to the care of the sick and mentally ill.177 Conditions for the mentally ill were, however, generally poor and an admission fee was charged for members of the public who wished to visit the insane wing of the establishment as spectators.

      The first hospital devoted exclusively to mental illness in the US, Virginia Eastern Lunatic Asylum in Williamsburg, was established in 1770, and the first patients admitted three years later.178 Notwithstanding these developments, most of the care and support needs of the mentally ill in colonial America were still met by families and communities, albeit increasingly backed up by the alms houses and hospitals that emerged in the later 1700s.179

      Subsequent developments in the US during the 1800s, especially the drive to establish mental hospitals, were driven by a range of diverse factors, including demographic changes, growing awareness of the social problems presented by the mentally ill, the philanthropic impulses of various elite groups, and developments in psychiatric practice in Europe and elsewhere. In France, for example, the 1700s had seen care of the mentally ill chiefly located in general hospitals, workhouses and hospices,180 although the Salpêtrière and Bicêtre in Paris would later lead the way in reforming conditions for the mentally ill. Clearly, a time of substantial change had arrived in France, the US, England and Ireland, focusing – chiefly and regrettably – on well-meaning institutional provision for the mentally ill.

      Asylums for the Mentally Ill: Inevitable, Inexorable, Unstoppable?

      Given these developments in Ireland and elsewhere during the late 1700s and early 1800s, and the long standing, unresolved problems presented by the mentally ill, it is useful to pose the question: was there any alternative to the asylums that emerged so

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