Forensic Psychiatry and The Silent Patient

The Silent Patient is a New York Times bestseller and has been optioned as a movie. Alicia Berenson, the titular character, who had appeared to be a happily married woman, shot her husband five times in the face prior to becoming mute. She was admitted to a forensic psychiatric hospital after trial, and the reader learns her thoughts through diary entries. While The Silent Patient was a page-turning thriller, it often portrays an inaccurate picture regarding forensic topics, leading to concern that it propagates misunderstandings about forensic psychiatry and forensic patients.

Forensic psychiatrist characters have long been portrayed in fiction, and different types have previously been identified, including Dr. Evil, Activist, and Jack-of-All-Trades. For example, Dr. Hannibal Lecter, a Dr. Evil character, used his vast psychiatric knowledge for his own evil ends.^1,2 Another recent Dr. Evil is Dr. Peter Teleborian, the forensic child psychiatrist from Stieg Larsson's The Girl with the Dragon Tattoo.³ An Activist forensic character has been described as going far beyond their job description, instead using cases as vehicles for another agenda. The Jack-of-All-Trades forensic psychiatrist engages in behaviors that are outside our role such as investigating crimes or acting as a policeman.^1,2 Dr. Evil, Activist, and Jack-of-All-Trades forensic psychiatrist characters are all seen in The Silent Patient.

The Silent Patient provides an inaccurate view of forensic psychiatric topics. Testimony at trial was presented by Professor Diomedes, a professor of forensic psychiatry, who was also clinical director of the secure forensic unit in North London. This professor “argued that Alicia's refusal to speak was in itself evidence of profound psychological distress—and she should be sentenced accordingly” (p 11). After Alicia's plea of diminished responsibility was accepted, she was admitted to the forensic hospital under the care of the same psychiatrist “whose testimony had been so influential with the judge” (p 12). Theo Faber, the narrator and forensic psychotherapist, alerts the reader that “if her silence was merely an act, a performance for the benefit of the jury, then it had worked” (p 2). He noted that if Alicia recovered, she would be discharged from the hospital within a few years. One wonders what mental illness her silence suggests or whether it is merely a vehicle for storytelling. Given the well-known public misinterpretations of the insanity defense, such as feigning mental illness to escape criminal responsibility, and of the purposes of psychiatric forensic hospitalization, this book further feeds into those misunderstandings.

The Silent Patient describes a multitude of boundary violations. Theo changed jobs to work at the forensic hospital where Alicia was. Theo proclaims, “Alicia needed help—and only I knew how to help her” (p 315), perhaps an Activist or perhaps a narcissist. He also notes a less honorable intention: “working with her might lead to a book or publication of some kind” (p 20). Theo, acting as a Jack-of-All-Trades, visited Alicia's family members and neighbors on his own time in the evenings. Another forensic psychiatrist, Dr. Christian West, explains to Theo, “You're going about this the wrong way. You're asking questions, searching for clues, like it's a detective story” (p 129). Though instructed not to make additional visits, Theo continues undeterred. Theo learns that Dr. West had treated Alicia privately as an outpatient prior to her crime, but he had not testified at trial. Theo confronts Dr. West, who says, “I wasn't really Alicia's doctor—I mean, not officially. I only did it as a favor to Gabriel [Alicia's late husband]. We were friends” (p 230), explaining that he had seen her at his girlfriend's house for cash. Similarly, in the recent popular film Side Effects, Dr. Jonathan Banks unusually acted both as the defendant's treating psychiatrist prior to her offending and as her forensic psychiatrist once hospitalized.⁴ As progress is made in psychotherapy and the silent patient begins to speak, Theo notes “we talked about Alicia's childhood—and mine. I told her about my father, and growing up in that house; she seemed curious to know as much as possible about my past …. I remember thinking, there's no going back now. We were crashing through every last boundary between therapist and patient. Soon it would be impossible to tell who was who” (p 265). It is worrisome if the general population perceives mental health providers to be intrusive or manipulative. Theo also becomes angry with Alicia for lying to him about the offending, stating “I was annoyed that she had lied, badly and pointlessly, to my face” (p 281). Real forensic mental health providers are not surprised by people lying about offending.

The Silent Patient further propagates inaccurate perceptions of mental health providers, psychiatric treatment, and hospitalization. Dr. West describes Alicia as “a lost cause. A total bitch” (p 235). Dr. West understandably “looked irritated” when Theo asks, “If she's [Alicia's] faking, then how can she be borderline?” (p 72), as Theo's comment implies that a person cannot have more than one diagnosed condition at a time. Though the reader is repeatedly reminded that the novel takes place in a forensic hospital, the characters do not appear to be engaging in any specific forensic activities. Alicia's muteness is treated unusually, with risperidone 16 mg daily. Theo says of seclusion: “it isn't just cruel—it's barbaric” (p 200), which further stigmatizes and mystifies the highly regulated practice. Additionally (spoiler alert), The Silent Patient features a person seemingly experiencing delusions, which are later revealed to be reality-based beliefs. This lends credence to the idea that forensic psychiatrists inappropriately treat reality-based beliefs as if they were delusions. All of these inaccuracies further stigmatize forensic psychiatry in the mind of the general public.

It is important that forensic mental health providers are aware of popular culture references to our field because these are often the only source of education that the public has about forensics and the patients we serve. Fiction can paint a picture that can be perceived by the reader as reality, and it can be challenging to recognize when fiction ends and reality begins. Overall, although The Silent Patient is a captivating read, it risks stigmatizing forensic psychiatry for patients, legal professionals, and society.

• © 2020 American Academy of Psychiatry and the Law