Picture this. A lounge on a psychiatric ward with standard leatherette beige sofas and a couple of armchairs for good measure. Half a dozen inpatients sat around chatting, waiting for the creative therapist to come and start the session. Some look outwardly animated, others slump in silence, wrapped in the blanket of their own thoughts. The room is still in that strange way hospital rooms are: a mix of sterility and humanity, resignation and restlessness. In comes said creative therapist, who then asks the most normal, innocuous question that we all utter several times a day: “How are you?”
Most inpatients respond with the standard reply that we have all been taught to give: “Fine, thanks.” To me, this is the strangest question someone can ask in a psychiatric ward. This is an event that actually took place when I was an inpatient, not that long ago. However, I decided not to give the standard answer and replied honestly with some non-standard swear words. It was said in jest, and as a room we all laughed at the absurdity of it all together.
However, this absurdity persisted with me and became the basis of the article you are now reading. There is something about our everyday language that is completely enmeshed with society’s rules of etiquette, which doesn’t quite fit the psychiatric system. It says a lot about the socialisation of etiquette and language when individuals who are so mentally unwell that they are an inpatient on a mental health ward still answer the strangest question to ask in a psychiatric hospital with what is equally the strangest answer. Even the choice of words used to describe where we are—“mental health ward” versus “psychiatric ward”—carries its own connotations.
Did you notice I switched terminology earlier? Which phrase sits more comfortably with you? “Mental health” feels more delicate, milder, a little less stigmatised. “Psychiatric” communicates clinical, maybe even frightening. The labels themselves shape how we interpret the same environment. Language is not neutral.
We adhere to social scripts set out for us during childhood and carry them with us in all circumstances. It was unlikely that we would have the context for a social script for answering, “How are you?” in a psychiatric hospital. Instead, our social scripts tend to be overgeneralised and feed into our socialisation as children and adolescents. This question is almost ritualistic in scope, a reflex gesture when greeting someone. Social scripts are predictable, shared patterns of behaviour; a guidebook to social situations. In turn, the script requires us to simply reply with a non-committal “Fine, thanks”. The function is not to exchange real information but to signal recognition, acknowledgement, and a willingness to engage. Linguists refer to this as a phatic expression: communication that is less about content and more about establishing a relationship.
Inside a psychiatric hospital, the social script doesn’t fit the situation. The location itself undermines the entire premise of the question. Inpatients are in a hospital specifically because they are, by definition, ‘not fine’. The usual response then feels ridiculous and disingenuous. But, to say the truth, perhaps “I’m suicidal” breaks the unspoken rule that the exchange of conversation is intended to be light and socially lubricating, not a revelation of the very reason one is an inpatient. The discord exposes the fragility of social scripts.
The sociologist Erving Goffman described interactions in what he called “total institutions” such as prisons, care homes, and psychiatric hospitals. In these environments, the day-to-day performances we depend on in the outside world don’t work in the same way. In ordinary life, “How are you?” is part of the performance of being a socially competent individual. In institutions, however, language becomes stripped of casual function and instead is absorbed into bureaucratic systems. Words become tick-boxes, data points, entries on a chart.
Comparatively, patients in physical hospitals are rarely asked “How are you?” in the same sense. They are asked, “What’s your pain level today?” or “Are you managing to eat?”—questions that point directly to measurable, observable aspects of illness. Psychiatry, meanwhile, lives in the space between the measurable and the ineffable. And so the awkwardness emerges: the same casual question becomes charged with diagnostic weight.
The world of psychiatry has a whole separate language that shapes mental health settings, including psychiatric hospitals. “How are you?” becomes shorthand for ‘I need to tick this box’ as opposed to genuine curiosity. That is not to say that mental health professionals don’t care, but that for a patient to receive treatment, boxes must be ticked in relevant categories for diagnosis. The broader psychiatric lexicon is equally revealing. Terms like “service user,” “patient,” “client,” “high functioning,” “treatment-resistant,” or “remission” each carry layers of meaning, and often stigma.
Take “high functioning,” a phrase I intensely dislike as an apparently “high-functioning” autistic woman. It flattens out complexity, ignoring the reality that one can be academically successful and simultaneously unable to cook dinner, overwhelmed by the sensory chaos of a supermarket. The problem with this is that language constructs reality, and we all take part in the performance of social constructionism as described by Goffman. Therefore, language becomes even more critical.
From a social constructionist perspective, the strangeness of “How are you?” in a psychiatric ward does not lie in the words themselves but in the meanings attached to them. Language is never neutral; social norms, professional frameworks, and power relations shape it. Once admitted to hospital, a person is no longer just an individual but a “patient,” a role constructed through psychiatric discourse. Their words are filtered through diagnostic categories, risk assessments, and institutional priorities. What might be a casual greeting outside becomes, inside, a clinical tool—its meaning shifted by the very structures that govern the ward. In this sense, the problem isn’t just the question but the way psychiatric language reconstructs reality, often reducing human complexity to something legible for charts and reports.
It’s also worth considering why the question is being asked in the first place. Outside in the ‘real world’, “How are you?” is a throwaway expression, ritualistic rather than inquiry. Inside, however, its purpose is murkier. Is it a genuine attempt at connection, an opening to conversation, or is it simply a procedural requirement disguised as small talk? In psychiatric settings, every question carries weight: it might be risk assessment, a diagnostic probe, or a way of measuring whether the treatment plan is “working.” Patients learn quickly that their answers can have consequences, which changes the dynamic entirely. What looks like kindness on the surface can, in practice, function as surveillance. To ask “How are you?” in this environment is not neutral—it is bound up in power, policy, and the uneasy marriage of care and control.
Then there is also the double bind for patients if they are too honest. It could potentially trigger an intervention, but then again, if the patient is not truthful, they could stay invisible.
If the standard “How are you?” falls flat in a psychiatric setting, what might work better? It doesn’t need to be complicated, but it does require looking at things from a different perspective. Rather than relying on reflexive small talk, mental health professionals could ask questions that acknowledge ups and downs and show genuine interest in how someone is truly doing. Something as simple as, “How’s today compared to yesterday?” can feel more honest and human. This is a deceptively simple change, but it opens space for nuance. It recognises that mental states shift hour by hour, day by day. A patient may not be “fine” or “unwell” in any definitive sense, but they may be feeling worse than yesterday or even better. By formulating the question comparatively, it eliminates the pressure to provide a definitive judgment on one’s overall state of being.
Another helpful alternative is, “What’s helping you get through right now?” This gently queries and encourages patients to reflect on their own resources and coping strategies. This may include medication, therapy or both. For others, it may be the comfort of music, talking to a loved one, or perhaps the structure that the ward’s daily routine provides. It’s not about focusing on malady, it’s more about acknowledging the resources we lean on—the small things that, even in our lowest moments, can help us stay constant.
Equally valuable is the question, “What feels hardest today?” Unlike “How are you?”, which implies a tidy, socially acceptable response, this question validates struggle. It assumes that hardship is present and creates a space for it to be communicated. It doesn’t ask someone to pour out their whole life story, or to shrink their pain into a neat clinical phrase. It provides that space to be honest about what feels hard in the moment.
Even gentle openers like “What would make today a bit easier?” or “What do you need more of right now?” can make a massive difference. They look ahead without adding more pressure, emphasising that people still have some say in their care and that even minor modifications can make a difference. They invite collaboration between the patient and mental health professionals rather than compliance.
At the heart of all these alternatives is one principle: they move beyond surveillance. They resist turning the patient into a data point for a form. Instead, they treat conversation as relational care. They affirm that the person in front of you is more than their diagnosis, more than their risk profile, and more than their “functioning” label. They emphasise that communication can itself be care, especially if we are ready to ask different questions, and more importantly, to really listen to the answers.
As human beings, we find comfort in routine and familiarity. Despite the strangeness of asking the question “How are you?” whilst in a psychiatric hospital, it is familiar like a habit, thus comforting. It is the same phrase spoken at bus stops, in offices, and at the school gates. It connects the patient, however briefly, to the wider social world from which hospitalisation has cut them off. There is a duality in how the question is both frustrating and reassuring at the same time. Albeit flawed, being asked the question at all is still a human connection. Being asked “How are you?” is sometimes less about the content and more about remembering that the individual is still a person worth asking. Even if the reply is part of a social script, the ritual still matters.
If we zoom out, the psychiatric ward simply makes visible what is true everywhere: much of our everyday conversation is absurd if taken literally. “We must catch up sometime” rarely means we will. “I’ll give you a ring” often means nothing of the sort. The difference is that in psychiatric settings, language is loaded with consequences. The wrong word can mean medication, confinement, or discharge. Words that in the ‘real world’ mean politeness inside become instruments of power.
Ultimately, asking the question “How are you?” whilst in a psychiatric hospital feels strange because it exposes the massive gap between everyday etiquette and authentic lived experience. It highlights how the words we use daily out of habit can feel hollow when spoken in the wrong context. However, even with its strangeness, this fundamental question holds value. It is evidence that someone is trying to reach out.
Perhaps, we should be asking the question with more genuine care, rather than stop asking it altogether. Possibly, this will open the way for more authentic and congruent conversations. A way of care on the ward that sees the person and not just the patient. Because sometimes it isn’t the question itself that is meaningful, but the active participation of another human being reaching out.
