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After all these years Tommy C. is much the worse for wear. Even after we have cleaned him up and dressed him in freshly laundered clothes he still looks bedraggled. He lost most of his teeth and he appears quite a bit older than his 37 years.

I think he's tired of life on the streets of New York or being in various psychiatric hospitals and jails. Tommy never functions very well, but intermittently, he becomes seriously mentally ill. For us on the Bellevue Psychiatric Hospital Forensic Psychiatric Service, he is something of a "special patient" because of his technique for gaining admission to our service.

Often in the past, when he would feel himself slipping into psychosis, he'd dial the local telephone number of the United States Secret Service and make threats against the life of the president. He would give them his location and they would promptly and dutifully pick him up and bring him to our unit. However, after fifteen years this isn't working anymore. Now when he is arrested (and this is quite frequent) he tells his history, threatens to hurt himself and is usually sent to us. He is presently on our unit, quiet, pleasant, smiling all the time. He likes it here. He likes being cared for.

I'm not surprised at his attitude because the Forensic Psychiatry Service at Bellevue is considered a model facility with an excellent program. We are able to treat the sickest and most difficult patients. While a significant proportion of our patients are sent to us because they may be suicidal or homicidal, most are simply afflicted with serious, long-term mental illness.

For us, a more typical patient is Mr. Allen H. It seems that he is suffering from multiple personality disorder and under stress can become one of several different persons. This, as you can imagine, makes it rather difficult for him to participate in the legal process. On our service he is calm and composed.

Robert S., on the other hand, is always a clear and present danger. In addition to a severe, chronic mental illness and some mental retardation, he is of enormous size. He was and is a body builder and when provoked, he can become dangerous and destructive. Unfortunately, this usually happens when he is taken to court. Robert was first sent to us after he "broke up" a courtroom and frightened everyone. He was so clearly impaired that we were able to obtain a court order to medicate him involuntarily. Six weeks of medication and verbal therapy and he is truly almost a different person, gentle, responsive and responsible.

In truth, most of our patients are more like Tommy C. than they are like Robert S. In more than twenty years working on the Forensic Psychiatry Service of Bellevue Hospital, I've found that the vast majority of the mentally ill, even those in the criminal justice system are not violent and not dangerous. I will go further and say that even the patients on my ward -- a select few from the vast population of the city's jails -- are rarely dangerous. I and my staff feel quite safe and at ease as we walk about the ward. Violence and dangerousness are as a rule "situational." The notion that these people are always violent or dangerous is just wrong. It is a well-known cliché that the most dangerous people, certainly in terms of those most likely to commit a crime, are those people just released from prison! Except in the rare instance where a patient is totally "out of it," most patients respond to the therapeutic environment (the caring "milieu" of the ward). Indeed, it is specifically designed that way.

As I have traveled around the country I have found that in the minds of many, "Bellevue" is synonymous with "the criminally mentally ill." For many years, New York tabloids have related some horrible crime, usually in the Times Square area, and then stated that the perpetrator "was taken to Bellevue." While this has provided Bellevue with considerable name recognition, it is an unfortunate bad rap. In truth, Bellevue is a very large general hospital with a much smaller psychiatric division, of which the Prison Ward is only a small part. But Bellevue, whose history goes back more than 250 years, has always cared for this population.

Bellevue traces its origins to a small building on the site that is now the City Hall, which housed the sick, the insane and the criminals of New York City. And as the facility moved to larger quarters it always had a place for patients both medically and mentally ill who were in the criminal justice system. When a brand new facility was built exclusively for psychiatric patients, it contained a separate ward for prisoners. This was the origin of the Forensic Psychiatry Service.

We are becoming more sensitive to the problems that result from lumping together the mentally ill and the criminal populations. While this may have been done for management efficiency at first, it is now a source of considerable stigma. Many people, unfortunately, continue to associate mental illness with dangerousness. In ancient days the violent mentally ill were labeled "furioso." Even the use of the term "the mad" implies dangerousness.

Of course, as one of the best such services in the world, we naturally get a large share of dangerous and "notorious" patients. But, for the most part, our patients are not dangerous, just very sick and very much in need of help. We do our best under the circumstances to help them. One of our major problems, however, is that when our patients have "pulled themselves together," they must generally return to the deplorable conditions of the jails.

Our awareness of the conditions that prevail in the other facilities hangs over us like a dark, ominous cloud. We are always trying to keep our eyes on a vision of better care and more humane conditions. We struggle against the ever-mounting numbers of inmates in our jails and the stigma the mentally ill still carry, especially when they have been involved in acts that are both violent and dangerous. We are encouraged by the recent development of advocacy groups that specifically focus on the mentally ill in jails and prisons and we see them as glimmers of light and hope in a very dark situation.