A Day In A Mental Hospital, A Dream Of Life Outside

WEST BRENTWOOD, L.I.— It is 6 A.M., and behind the barred windows at Pilgrim State Psychiatric Hospital a young woman blinks awake. Outside, it is chilly, but inside the locked hospital doors, steam heat rushes through metal pipes as shouts of ''Time to get up'' echo through the halls.

The woman, clad in a pink flannel nightgown, steps out of bed and into slippers. She is 32 years old, well groomed, from a middle-class family and schizophrenic; she has been here many times before.

Some people with her illness live on the street, panhandling for money, rummaging through refuse, sleeping in doorways. But in part because of luck, in part because her family helped her, in part because she was willing to be helped, she found her way here, to New York State's largest mental hospital. Returning to Outside World

On this day, the woman will be among 2,577 patients fed, medicated, clothed, counseled, monitored and tended in ways they are unable to do themselves. They are among the sickest of the mentally ill, those for whom medicine has not worked, those who have had the most difficulty adjusting to life in the outside community.

Still, from the moment she and the other patients awaken until the moment they go to sleep, if one message resonates through their care, it is that they must return, that the outside world is where they belong.

At one time, Pilgrim State had 16,000 patients and was the largest psychiatric hospital in the world. And, like other hospitals, it became a symbol of mental illness, a last stop for a disease that medicine could not treat and society preferred to ignore.

Patients arrived, were assigned beds and stayed until they died. There are 18,000 numbered cemetery plots on the grounds.

But today, two decades after the advent of effective drugs and a change in commitment laws resulted in the release of tens of thousands of mentally ill people from hospitals, Pilgrim has a new mission: to treat acutely disturbed people and prepare them for the world outside.

It is a quixotic mission, one that a dedicated staff arduously pursues despite the fact that many patients leave only to return, either because they are not ready for the world or because the world is not ready for them. To spend a day at Pilgrim State and to meet its patients is to see just how difficult the transition can be and how overwhelming a task it is for the hospital, for the patient and for society.

It is 6:20 A.M., and the 32-year-old woman is in the shower as other patients brush their teeth and comb their hair.

The vast majority of patients here suffer from schizophrenia, a disease of the mind that afflicts one in every 100 Americans. The most acute symptoms -voices, hallucinations, suicidal thoughts, delusions of grandeur - can be controlled, but it is a chronic condition and symptoms can recur without notice.

This woman, for example, goes through periods when she is convinced the police are about to cart her off. At better times, she is often agitated and anxious. Talking, she stands so close she can almost touch her listener's nose. She will repeat the question ''How are you?'' for hours. She is given to strange clothing and bizarre makeup.

A few of the patients are considered dangerous to others, but she is typical of the majority, who are mainly a danger to themselves and at times unable to wash, to feed themselves, to engage in basic social interactions, to earn a living. Many have been in and out of Pilgrim their entire lives. She has been admitted eight times since age 18.

As the patients in Building 11 get ready for the day, in a central office at the other end of the hospital, the nursing staff prepares its report on the previous night. Three patients were admitted. Two patients did not return from afternoon leave; they have been reported as missing. A 23-year-old man who had talked about killing himself was transferred to an area where he could be watched more closely.

All in all, it had been a quiet night. 7:20 A.M.: A Fiery Dream

It is 7:20 A.M. in the day room on the ground floor of Building 11, a spacious area of metal chairs clustered around a television.

A middle-aged woman is talking quietly to herself as she makes tiny pirouettes in place. Another woman sings in Korean. A third walks around carrying a stuffed rabbit attached to a Bible.

Back in the ward, another patient is arguing with a hospital aide. ''I dreamed that the house was burning down,'' she shouts.

''You still have to get up,'' the aide says.

''Yeah, but I didn't sleep,'' the patient insists.

This woman, who is 30 and has been in the hospital about one year, frequently rebels against getting up on time. All patients must get up, dress, make their beds and eat breakfast. Then they must report to assigned activities, from group therapy to clerical training to part-time work meant to prepare them for the outside world.

''How are you feeling today?'' the building's supervisor, Janet Specht, asks a dark-haired woman.

''O.K.,'' the woman replies. ''I'm sorry about what I did last week.''

The week before, this 21-year-old woman had argued with her mother on the telephone and then tried to slit her wrists with the tab to a soda can.

''I didn't mean anything by it,'' she says. ''I was just angry at her. I mean, I was trying to get even with her. I had to go for a shock treatment. I was scared. She said she was coming to see me and she didn't. She hates me. She doesn't want to see me.''

''But that's no way to tell her you're angry,'' Ms. Specht says.

The day staff is beginning to settle in. Back in the dayroom, an aide takes out a piece of chalk.

''Today is Wednesday,'' she writes on a blackboard. ''You are at Pilgrim State Psychiatric Hospital. The weather is sunny and cool.''

For most of the patients, who are not permitted outside, it is the only way for them to know. 10:30 A.M.: A Class on Life

Whether patients belong in the hospital and at what point it would be best for them to leave are questions that pervade all care here.

''At first, they don't want to be here,'' Peggy O'Neill, Pilgrim's executive director, said. ''Then they don't want to leave.''

Indeed, nearly half the patients at Pilgrim State have been hospitalized there for so long and have become so dependent on the institution that they now refuse to leave.

One such patient is a 68-year-old woman with long gray hair and deep-set blue eyes. She has lived here since she was 21. In many ways, she is a symbol of what administrators say they do not want younger patients to become.

One problem is that when people are judged ready to leave the hospital, they usually are still too fragile to live on their own. Most need some place where they can receive some supervision, particularly about taking the medications that control their symptoms. The trouble is, such settings are scarce.

Although an estimated 175,000 people living in New York State will be diagnosed as schizophrenic over the course of their lives, there are only 6,500 beds available in community residences, group homes that provide patients with supervision and support after they leave a hospital. Also, there are virtually no residential programs that cater to the seriously mentally ill who are also dependent on drugs and alcohol.

A recent study by the New York State Psychiatric Clinic estimated that 15,000 people living on the streets are severely mentally ill and should be in hospitals or supervised homes.

Still, the hospital staff wages its quest to return patients to the outside.

At 10:30 A.M., the woman with the long gray hair is sitting at a table with five other elderly women, nearly all of whom have lived in the hospital much of their adult lives. One, who is 69, has been here since 1953. Another, 77, has been here since 1955.

''Have you ever seen something like this?'' a psychologist, Esther Chang, asks the women as she holds up a vegetable peeler.

Three in the group say no. They also have never used a can opener, made coffee in a percolator or used a microwave oven. The plan is to teach these women how to shop for food and cook so they will eventually be able to move.

''When you talk to them about moving to a family-care home, they don't know what you're talking about,'' Ms. Chang said. ''They've never lived in a home.''

Two of the women - one of them 77, the other 70 - have already been transferred from the ward to their own apartment on the hospital grounds. It is their first taste of freedom in decades.

''We love it,'' the 77-year-old says. 1:40 P.M.: A Father's Plea

A 64-year-old physicist and his wife from Glen Cove have three children, all in their 30's. Two have successful careers in Manhattan. The third is a patient at Pilgrim State.

It is 1:40 P.M., and the father has been called in for a meeting. His 34-year-old son has become a behavior problem; the staff thinks he acts belligerent to secure the attention of his family.

''We're here to talk about your son's progress,'' Ellen Hertz, an administrator, begins as the father sits in a conference room with four social workers and assistants familiar with the case. ''He's doing better. Better than the last time we met.''

Her manner is unthreatening. She knows how difficult the situation has been for the family.

''We saw our son Saturday, and he was worse than at any time,'' the father replies. ''He was shouting at me. He was shouting at the aides. He was very bad. What can we do?''

''Perhaps you should tell him that if he continues to act that way, you are going to get up and leave,'' a social worker suggests. The father does not seem to hear. ''We cannot change the hospital,'' he says. ''What annoys him is the noise in the hospital. When the doors open and close, it goes bang. The patients are shocked every time they hear the banging.''

A second social worker suggests that the son may be doing things to make his family feel sorry for him.

Eventually the son is invited into the meeting. He is a tall, handsome man and greets his father with warmth.

''I blew my cool,'' he says, appearing to understand at once what the meeting is about. He acknowledges that he must learn to control his temper.

On hearing this, the father hugs his son and gives him a new Walkman to help drown out the hospital noise. 2:20 P.M.: Urge to Leave

There was a time when all patients at Pilgrim State wore identical gray uniforms. They slept in wards that contained 120 beds and not one mirror. A point of pride was the hospital's efficiency in performing lobotomies, brain operations that sever the nerves that control emotion.

Lobotomies are no longer done here. There are no rooms for solitary confinement. Restraints are used only on acutely disturbed patients who are in danger of harming themselves or others.

The whole tenor of care has changed. Patients are encouraged to take pride in their appearance. They can buy clothing at a thrift shop. They can decorate their beds with stuffed animals. They can refuse medication. They are assigned their own lawyers.

Concern for patients' rights underlies many of these changes. This, plus a relaxing of commitment laws and the treatment possibilities opened up by neuroleptic drugs like Stelazine and Thorazine, helped reduce the population of New York State mental hospitals to 16,000 today from 93,000 in 1955.

''The question of the need for hospitalization is a legal question, not a medical question,'' said Ines T. Auell, the principal lawyer for patients at Pilgrim. ''The question is not whether a patient is mentally ill, but whether the patient has a mental illness for which hospitalization is appropriate.''

But defining what is appropriate draws heated debate, even among the legal staff. One staff lawyer argues that any patient who does not want to be in a hospital should be entitled to leave. All this, however, infuriates the doctors, who believe that they, not lawyers or judges, should make the decision.

On this day, it is 2:20 P.M. and a 35-year-old man says angrily that he has applied to the court to be released. Dr. Santokh Singh Ohson, his physician, is against it.

''All the lawyers are interested in is whether he is suicidal or homicidal,'' Dr. Singh says. ''This man has been in the hospital six weeks. The Angel talks to him. The Devil talks to him. God tells him to pray.

''I'm afraid to let him go to church. Who knows what he'll be told to do there? He broke a staff worker's nose two weeks ago. Just last week, he jumped a therapy aide.'' 5:30 P.M.: Soothing Talk

It is 5:30 P.M., and the young woman who was angry this morning because she did not want to get up appears at the door of Janet Specht's office. Clad in dungarees and a sweater, she stands quietly until Ms. Specht looks up and encourages her to come in.

''How are you doing?'' Ms. Specht asks.

The woman says nothing at first. Then, in disgust, says: ''I've had it with this place. I want to get out. When am I going to get out?''

''We all have to struggle a little,'' Ms. Specht replies, soothingly.

The young woman, who is schizophrenic, has been in the hospital for more than a year. Her parents, a professional couple living in Nassau, don't want to accept the seriousness of her condition; they keep asking her when she will go back to college.

''It's the little things that count,'' Ms. Specht says. ''And you build on those.''

''But will I ever work?'' the young woman asks, looking out the window. ''Will I ever be able to make money? Will I ever make enough money to live, to support myself, to be like everyone else?''

''You have to take it one step at a time,'' Ms. Specht says.

The woman nods. She has had the conversation before. She will have it again. But for the moment, anyway, conversation seems to be enough. 6 P.M.: Doors Locked

Night is the lonely time at Pilgrim State. The front doors - open by day to those patients who are allowed to go to jobs on campus - are locked at 6 P.M. Attendance is taken. Patients rest in their rooms until dinner.

In Building 12, for elderly patients, a woman puts on a necklace as she dresses for the evening meal. Another woman circles the hall anxiously, looking for someone to talk to. The patients move in slow motion toward the dining hall, where a man is refusing to eat. ''I don't want to eat!'' he cries. Meanwhile, a young woman is brought to the admissions office by the police. Convinced that her mother wanted to poison her, she had decided to burn down their house. She says nothing is wrong with her. She is led into Building 22, where other newly admitted patients are placed under observation for an average of six weeks.

On the second floor, a group of patients is sitting together, singing. ''Old Man River.'' ''Perfect Harmony.'' ''The Impossible Dream.'' They all seem to know the tunes. They conclude with ''You'll Never Walk Alone.''

''A bad day on the outside is better than a good day here,'' says Shelly Wolfson, an administrator who has worked at the hospital 17 days. ''I see it as a testament to the human spirit that they want to be free.'' 9:10 P.M.: Bedtime Drugs

It is 9:10 P.M., and patients stand in line at the nursing station for their final medications.

All in all, it has been a full day. There was a social in the community room. The woman who did not want to get up in the morning was placed on a waiting list for a community residence; she will probably have to wait six months. The young woman who had tried to slit her wrist went to see a gynecologist.

''That was terrific,'' she says, a big smile on her face, as if the visit to the doctor was the high point of her week. ''Why?'' she is asked. ''I went out,'' she says gleefully, as if stating the obvious.

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