The Silent Patient: An Analysis

by Alex Miceli 

The Silent Patient is told from the written perspective of Dr. Theo Farber, a talk therapist, who changes jobs to be able to work with the famous patient, Alicia Berenson, a painter who had shot her husband, Gabriel, several times in the face and then never spoke again. Instead of going to prison, she was committed to the failing psychiatric unit, the Grove. There, Theo faces internal resistance to his attempts to help Alicia. The novel also explores Theo’s own psychological issues and is partly told from Alicia’s diary leading up to the murder of her husband.

The Silent Patient is Michaelides’ first novel and won the Goodreads Choice Award for Mystery & Thriller. I hadn’t finished it by the time it won this award, so I did not vote for it myself. But I can see the appeal.

I don’t read a lot of mystery novels or watch a lot of mystery films because it is typically far too easy for me to guess the answer to the mystery. I have watched a lot of mystery television because I can sustain interest for an hour while still knowing the answer to the mystery, even with all the red herrings thrown up, but the actor you recognize theory tends to hold up on TV shows. It’s a lot harder to sustain that interest in a film, especially when they go about their reveals so slowly, trying to make it as dramatic as possible. Meanwhile, I’m bored out of my mind. In a novel, it is even worse, especially if I’ve guessed the mystery some fifty-odd pages before the reveal. That was my experience when reading The Woman in the Window. All this is a lead up to the delightful fact that when reading The Silent Patient I only guessed the answer a few pages before the reveal. Now, with that tidbit to tide you over until the spoiler section, I’d like to talk about some other things.

Yuri is an interesting character in that he gives Theo the creeps. He gave me the creeps too. When he helps Theo meet with Alicia in private, I got the sick feeling that Yuri believed this meeting was sexual. It was something about what he said and the smile on his face. It freaked me out. Of course, that’s not what happened with Theo and Alicia at all, but I got the impression that Yuri would help a coworker rape a patient. I wish that had been a little more explored because I think it could have worked well with the idea of the power people like Christian, Stephanie, and Theo have over the patients. I’m not saying I wanted a patient to be raped in the book, but I felt like the theme of mental healthcare providers as having all the power could have done with some more insidious exploration.

Patients are often taken advantage of and that is a theme of The Silent Patient. Maybe it would have been interesting to find out more about Yuri in how he related to the patients than what we got in the novel.

I’ve read and continue to read a lot of non-fiction books on psychology by a lot of different therapists and psychiatrists. That’s pretty clear from by comparative blog review about Doctor Strange, wherein I go into extreme detail over how Stephen Strange as presented in the movie has narcissistic personality disorder, while Tony Stark is just arrogant and impulsive. But one of the disorders I’ve read the most about is borderline personality disorder, so the use of the word borderline in The Silent Patient really threw me. It was used more to describe a patient that was a complete loss, one for whom progress would be impossible, and if anything would only damage those who tried to help them. I thought maybe BPD doesn’t exist in England. So I looked it up, and no, it does. They even practice the common therapies of DBT and CBT in the UK with these patients. The reason why I found this so annoying is that of all the personality disorders a patient can have, BPD is the one most likely to become manageable with treatment.

Now, if just one of the professionals in the novel went off the archaic definition of the term and they argued about those definitions as opposed to the argument they had about labels, I would have let this slide, but all of them used the term to mean the same thing. I can’t imagine it’s very helpful to any readers out there suffering from BPD to read its problematic use in The Silent Patient. It felt unresearched. It was like the book was written pre-Dr. Linehan and unfortunately feeds into the stigma surrounding this condition. This may seem minor, but with a main character as a therapist and a bunch of other mental healthcare providers as characters as well, it’s not great. Alicia isn’t suffering from BPD. If anything, she’s suffering from PTSD.

The Silent Patient doesn’t hide the fact that more is going on then the press and court system knew. When Theo describes the murder as it is understood from an external perspective at the beginning of the novel, I couldn’t help but notice that because Alicia had to be taken to the hospital immediately that in all likelihood there was no gun power residue test done on her hands. Typically, a suspect’s hands would be tested as soon as possible, but with her wrists slashed this would have been impossible. In fact, it didn’t seem they tested her clothes either, mainly because evidence in general was never brought up by Theo. Meaning I thought that it was obvious that more went on that night. Something far more insidious than what the press or the court system would have the average person believe.

People’s belief that Alicia’s silence and painting following the murder were both an admission of guilt was so frustrating. It wasn’t frustrating because they believed she’d done it for those reasons. It was frustrating because their judgement was so real. The case against Lindy Chamberlain-Creighton is a good example of people erroneously believing someone’s guilt based on how the defendant behaved. And there was the UK case against Sally Clark, wherein she was found guilty and imprisoned for the murder of her two infants who had died of SIDS all because an “expert” witness, Professor Sir Roy Meadow, a pediatrician, gave evidence that statistically it was unlikely two such infants could die of SIDS, when he was not an expert of statistics. And people believed him. So from the very beginning of the novel, I was ready to believe Alicia’s innocence. Her silence was an obvious sign of trauma and her painting was an attempt at self-healing, and any thought that these were signs of guilt was bullshit.

Now I’m going to talk spoilers, because I kind of must at this point. Skip ahead to get my final thoughts.

~~Spoiler Section~~

Beware! Do not read beyond this point unless you’ve already read the book or don’t mind it being ruined!

So Alicia did kill Gabriel. I still stand by the idea that she was suffering from PTSD, and I also feel like she was suffering a mental break at the time of killing him. To be honest, as much as I didn’t like Gabriel, mostly due to him having a friend medicate Alicia and his inability to trust her, oh yeah, and the cheating, I didn’t think he deserved to die for the non-choice he made. When Theo asks him to chose between himself and Alicia, he doesn’t actually answer. Saying “I don’t want to die” isn’t an answer. Not really. Of course, he doesn’t want to die. Most people don’t want to die. And despite what a lot of people say, dying for the one you love is fucking horrible. That’s not healthy. I don’t really consider it some grand romantic gesture. I don’t want that to be the mark of love. That’s the mark of obsession and a lack of self-preservation. I don’t want that in my life. That’s horrifying.

Theo’s psychological claim that she did it because it related to what her father had said and Alicia’s description of her state of mind at the time suggest that saying “I wish she had died instead of her mother” and “I don’t want to die” are the same. They are nowhere near the same sentiment. Also her father saying that in his first stages of grief isn’t fucking psychic murder. What even is that? People say shit they don’t mean when in poor states of mind. They even do things they otherwise wouldn’t, like, I don’t know, shoot their husband in the face several times. While I don’t think Alicia should have killed him for saying that, I also don’t think she was completely responsible for what she did that night. She was terrorized for weeks and then kidnapped and assaulted. I do think she suffered a psychotic break, so if I can think Poor Alicia when she murders someone, I can certainly think Poor Gabriel when he expresses his desire to live. Nothing about what Alicia did to Gabriel was justified, but nothing about what Theo did to Alicia was justified either. I consider Gabriel to be the victim the press and court system purported him to be.

Theo is far more responsible than he wants to admit, even to himself. His frequent claims to a desire for wanting to help Alicia were all bullshit. He even says that a cynic would consider what he did returning to the scene of the crime to clean up evidence against himself. But then the cynics are proven right when he attempts to kill Alicia. I don’t believe he ever wanted to help her. I believe he wanted to make sure he was safe. The ironic thing though is that had he not gotten involved, he would have been safe. What he did was also self-destructive. He kept digging and digging and pushing and pushing. He even told Stephanie and Diomedies that Alicia hadn’t overdosed. One could argue that he wanted to get Christian out of the way, but what threat was Christian really to him. If anything, he could have blackmailed Christian into compliance even without the diary as just the accusation of treating patients under the table could have been enough to ruin his career. The other thing that motivated Theo though was his desire to come off as a savior. He wanted to “save” Alicia when he knew her husband was cheating on her. And he wanted to “save” her from the trauma that night had caused. He wanted to be the good guy. It’s sick that a lot of the worst people in the world think they’re doing good, when in fact all they are doing is causing pain.

I only realized that Theo was the man following Alicia when he described her standing by the window. That was the moment I realized that Theo had played with the timeline of events. I had questioned it that same chapter when he described how much he was following her, because I couldn’t help but think, doesn’t he have a job to go to? Now this works because Theo is writing what we are reading. He gets to decide what order we learn things in. But we are only told once at the beginning of the novel that this is a written account and then reminded at the end. Theo omitted many of his thoughts from the account on purpose. I was a little off-put by the lack of hints in his internal thoughts as he was investigating Alicia’s life, but that was undone by his second reminder of this being his own written account. He’s trying to mislead his reader. I believe a couple more reminders would have been helpful, as there is quite a bit of narrative distance between these two tells, but mostly this works really well, as it solves many of the sticky narrative issues him being the man would have otherwise brought up. He writes, however, that he didn’t want Ruth to know what a monster he had become, but with this narrative set-up, it’s obvious she has to know by the end. He was going to be arrested for some serious crimes.

By the end of the novel, I realized I didn’t like anyone, but that especially, I hated Theo. No matter how much sympathy he tried to get out of me at the end, I had none to give because he knew damn well that what he’d done to Alicia both in the past and at the Grove were unforgivable. I maybe could have forgiven what he did in the past since he hadn’t killed anyone and had kind of lost it, but he’s so calm and so aware when he kills Alicia and afterwards, trying to maneuverer everyone where he wants them that he no longer has a mental break as a shield and he kind of knows it.

Ah, one last thought, I don’t find it believable that the trust would make him the head of the Grove but especially a new facility. He was too new to them. Unless they were seriously sexist, I would think they would have gone Indira. The only person maybe worth liking maybe.

Final Thoughts – Spoiler Free!

Overall, I’d say The Silent Patient was a very well-done mystery. It’s definitely worth reading. Especially if you like mysteries. As often is the case, The Silent Patient is more about Theo than it is Alicia. It’s interesting and the twists and turns are engaging and fun. There is a lot of depth here and much to talk about. But what did you think about The Silent Patient? Did you like it? Why? What didn’t you like? Who did you think was the least likable character? Did you figure out the ending beforehand? What tipped you off? Anything else you wish I would have brought up? Let me know in the comments below and please mark all spoilers.

Alex Miceli is a writer of prose, poems, plays, and reviewer of books, movies, and TV shows. Her play, The Two Halves of Andrew’s Brain, is published and licensed through Playscripts, Inc. and her short story “Surrounded by the Unreal” won the Charles Cagle Fiction Award Graduate Division. You can watch her play video games on her YouTube channel, or find all things Alex on her website.

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