Mental Hospitals: A Guide For Call of Cthulhu GMs
And other people who play tabletop horror RPGs.
Call of Cthulhu and other horror games often have mental hospitals in them. Unfortunately, adventure writers, GMs, and players also often don’t really understand how mental hospitals work, so they can wind up writing them inaccurately.
Who am I to write this? I’m a severely mentally ill person with an excitingly long list of diagnoses. I have been institutionalized multiple times in wards aimed at both higher-functioning and lower-functioning people. I’m also an avid Call of Cthulhu GM and a huge fan of cosmic horror. I’m going to be talking about the modern United States here, because this is what I have experience with; I encourage people to post their experiences in their own countries in the comments. I’m also only going to be talking about the adult mental health care system, because I avoided the mental health care system as a child and adolescent. My general understanding is that child/adolescent wards tend to be way worse, often to the point of being abusive or traumatizing, and children and adolescents are much more likely to be institutionalized for dumb reasons. Again, I encourage people to share their own experiences in the comments.
Content Warnings
I don’t want to get into the debate about whether you should use content warnings for your horror games. However, if you’re using content warnings, you should content warn for institutionalization, especially if it’s involuntary. Involuntary institutionalization can be a deeply traumatic experience for many people, one which they don’t want to be reminded of when they’re trying to have fun playing a spooky horror game. Even if their institutionalization wasn’t traumatic, the circumstances which lead to institutionalization are almost always traumatic, and reminders of them can be upsetting and ruin a perfectly good game. The same thing is true for friends and family of people who were institutionalized. If there are mental hospitals and you’re using content warnings, content warn for them.
What Gets You Institutionalized?
In general, in the US, you’re institutionalized if you’re a danger to yourself or others. You can’t be institutionalized just for being weird, believing things that other people don’t believe, or talking a lot about the rise of Nyarlathotep or the reign of the Great Old Ones. All mental health professionals are legally obligated to institutionalize you if they consider you to be a danger to yourself or others.
The threshold for institutionalization varies a lot depending on the doctor. On the extreme end in one direction, some mental health professionals are morally opposed to involuntary institutionalization or think it’s not therapeutically indicated for certain clients (such as people with borderline personality disorder). So they will refuse to institutionalize patients unless the client literally says “I am planning to attempt suicide as soon as I leave your office and I refuse to make any sort of safety plan.” On the extreme end in the other direction, some mental health professionals will institutionalize anyone who admits to having suicidal thoughts or hallucinations. In general, those professionals are extraordinarily rare outside of hospitals. (If you admit to being suicidal in a hospital, you will wind up in inpatient.)
What’s a reasonable expectation? Most mental health professionals in my experience will institutionalize for immediate plans or intentions to seriously hurt oneself or other people, or if the person is so psychotic that they could possibly hurt themself or someone else by accident (such as by jumping out a window because they think they can fly). They won’t institutionalize someone if they can clearly articulate reasons not to hurt themself or others, if they don’t have a plan for how to do so, or if they say they’d never want to go through with it. They’re generally less likely to institutionalize for plans to do nonfatal self-harm than for suicide. People who have eating disorders and are seriously underweight may wind up in inpatient. People who are broadly speaking connected to reality won’t be institutionalized for psychosis, even if they think the Great Old Ones are talking to them or see things that aren’t there.
What about the cult institutionalizing investigators? Well, it’s difficult, because presumably the investigator is going to see a randomly selected mental health professional who isn’t a cultist. But if a cultist is using Dominate or the investigator has failed their Luck check, there’s absolutely nothing stopping a therapist from lying and saying that the investigator threatened to hurt themself or other people. The investigator can in theory sue but most people don’t bother and the mental health professional almost always wins.
What Is Being Institutionalized Like?
Boring. Boring, boring, boring, boring, boring.
The bad old days of Nurse Ratched are mostly over. (Although you may be restrained, physically or with drugs, if you break the rules, and restraint is extremely traumatizing for many people.)
The best way to imagine a normal mental hospital is to imagine a combination of the DMV and your worst middle-school teacher. Think about every single stupid rule that exists for no reason, every nonsense bit of bureaucracy, every procedure that seemed like a great idea in the meeting of a dozen middle managers none of whom will ever have to put it into practice, all of the time you spend staring at a clock waiting for all this to be over as the second hand draaaaaaags like each moment takes an hour, and the cheery inspirational posters about how Making Mistakes Is The First Step To Learning. That’s what a mental hospital is like. (Except there aren’t usually posters, the cheery inspirational content comes from social workers at group therapy.)
You spend a lot of time watching TV.
In principle, you receive group therapy in the hospital. In practice, hospitals vary a lot in terms of how much group therapy they provide and how much time is spent watching TV. You will generally see a social worker, a psychiatrist, and a medical doctor, all of whom will quickly screen you for various mental health problems. You will not get individual therapy.
You can justify literally anything as regards medication. I’ve known a person who were put on antipsychotics without informed consent even though they weren’t psychotic. I personally was denied my mood stabilizer. Many people get their prescribed medication on a regular schedule. In my experience, mental hospitals are weirdly free with handing out benzodiazepenes for sleep and behaving in a way which disrupts the hospital. You are allowed to refuse consent for medication, but a lot of mental hospitals don’t really bother with informed consent. Instead of explaining all the costs, benefits, and side effects of a medication, they’ll just be like “it’s for sleep.” And, of course, many people worry that being resistant to medication will keep them from being let out.
I’d write about NPCs an investigator might encounter, but people tend not to talk to each other very much at the mental hospital. Most social workers, psychiatrists, nurses, and medical doctors tend to be businesslike and efficient, without a lot of fuss; again, you want to think more about a DMV employee than you do an outpatient therapist.
Group therapy social workers come in two types: some provide recreational therapy or art therapy, in which case they probably make small talk with their clients while generally supervising them; some provide actual therapy, in which case you can get a realistic experience by imagining they talk like a therapy worksheet. Most group therapists have strong and unshakable ideas of how recovery is supposed to work. You can get a good sense of the possible range by reading mental health Instagram. (Yes, this includes “you need to have a higher power in order to recover,” “the secret to good mental health is yoga,” and “actually all you need to do is take your meds every day.”)
In a higher-functioning ward, everyone is depressed or zonked out on drugs. You won’t go far wrong by imagining the average person as someone quiet, polite, and extremely bored who, if they actually open up about their life, will have a backstory written by a twelve-year-old in their wangst phase. In a lower-functioning ward, some people have psychosis or mania and might pace a lot, say weird things, talk constantly and very fast, etc. This is where you get most of your “stereotypically crazy” behavior. I’m not sure I can describe the way that psychotic and manic people typically behave in a short paragraph, but probably stereotypically crazy is fine as long as they’re not violent. Violence is very, very rare in mental hospitals, and the violent mentally ill person is a stereotype which causes mentally ill people a lot of harm. Not everyone is going to be stereotypically crazy; even in the lower-functioning ward, a lot of people are polite, bored, and traumatized.
In general, your mental hospital will feel realistic if you keep in mind the twin facts that it is very boring and full of lots of horrible bureaucracy.
How Do You Talk To Someone In The Hospital?
If the person hasn’t consented to hear from you, or if you’re in the ER, the hospital won’t confirm or deny whether the person is there. A friend once called all the hospitals in an area, all but one of them said “oh, that person isn’t here,” and the last said “oh, we can’t confirm or deny that that person is here,” so they knew that that was the one with that person; this might be something an investigator can do.
You can’t talk to someone who is on a psych hold in an ER. People are normally transferred away from the ER as soon as they’re stable, although last time I got stuck in the ER for three days because of covid reducing the number of mental hospital beds.
There are two ways to talk to someone in a mental hospital: phone calls and visits. Visiting hours are usually one hour a day in the evening; there are normally limits on how many people can visit at once. Phone calls are unlimited, although you may be unable to get through because someone else is on the phone or the person is in group therapy. The person has to consent to receive phone calls from you for you to be put through. They’ll also normally have a several-digit number which they can give out to people so that the hospital knows that they consented to you calling them. The phone calls are allegedly confidential but every mental hospital phone I’ve ever seen is located right next to the nurse’s desk, so people do self-censor.
How Long Is Someone Institutionalized For?
In theory, a person can be involuntarily institutionalized for three days, after which something something judges something no one I know has gotten to that part.
In practice, in mental hospitals, involuntary institutionalization is usually used as a threat. Most patients are “voluntary,” a term which here means that they’re here of their own free will but if they try to leave then they’ll be put on an involuntary hold for the next three days. For this reason, many allegedly three-day stays are longer than three days. If a person is particularly cooperative, and had the good luck to not be in the hospital over the weekend when fewer doctors are working, they may be let out in two days. You can reasonably justify anything up to a week or so, and maybe two weeks or so if it’s an unusually bad hospital.
You see what I mean by the cross between the DMV and your worst middle school teacher, though?
Normally, anyone can get out of inpatient mental health care by being cooperative, not self-harming, and repeating “I feel a lot better and I don’t want to hurt myself/other people anymore” to all mental health professionals.
If you’d like your investigator or NPC to have long-term mental health care that’s more intensive than a therapist, they’re not going to be in a mental hospital. They’re going to be in intensive outpatient or a partial hospitalization program, which means they go to therapy at a hospital six to thirty hours a week but return home to eat and sleep. (Partial hospitalization is more intensive than intensive outpatient.) Partial hospitalization and intensive outpatient programs usually involve medication management, group therapy, individual therapy, and a mix of evidence-based (cognitive behavioral therapy, dialectical behavioral therapy) and non-evidence-based (yoga, aromatherapy, art therapy) approaches. Inpatient treatment is still common for substance abuse and eating disorders, but I don’t have an ED or substance abuse, so I don’t know much about that.
I have a tiny bit of knowledge here (UK)- My dad was a big guy, a mental health nurse, and a monster. I grew up on stories of how he and other nurses piled on patients that were having issues, restraining them forcefully, hurting them deliberately.
If you were a "problem" patient then you might get an injected sedative, and if the nurses didn't like you then that syringe might be dragged along the wall to dull the tip.
Patients were force-fed pills if they refused to take them. If they were begging to see a doctor they'd be ignored. If they were hurt it wasn't a priority because "they probably did it to themselves".
Of course, I only have the word of one very bad man to go on, but every story had the same elements- Most of the nurses abused the patients and it was funny because the patients were less than human.
So yeah, UK mental health hospitals from the late 90s to around 2010 were not good places to be.
I would have thought most of these games are played in a pre-modern setting!