The Silent Patient (2019) is a contemporary psychological thriller from author Alex Michaelides. It tells the story of Alicia, who killed her husband, Gabriel, six years earlier—and hasn’t spoken since. The bulk of the novel takes place in the present-day, narrated by Theo Faber, a forensic psychoanalyst who recently began working with Alicia at The Grove, the mental institute where she resides following Gabriel’s murder. The novel uses the epistolary technique, interspersing Theo’s narrative with excerpts from Alicia’s old diary, a written narrative from the past that recounts the weeks running up to Gabriel’s murder. These two narratives ultimately intersect in a plot twist that reveals that Theo and Alicia have a shared past that is far more personal than the simple doctor-patient relationship first presented.

Alex Michaelides is Cypriot-American author and screenwriter. He resides in London, where The Silent Patient is set. Upon publication, the novel went to the top of the New York Times bestseller list. This study guide refers to the Astramare Ltd Edition version, published in 2019.

Note: The novel deals with potentially triggering issues, including suicide, murder, mental/physical abuse, mental illness, and trauma.

Forensic psychotherapist Theo Faber, 42, narrates The Silent Patient by introducing its main plotline: the mystery of Alicia Berenson. Alicia is a painter who murdered her husband Gabriel Berenson six years earlier. She was 33 at the time. Gabriel was 44. Authorities discovered Alicia at the scene: She had shot Gabriel five times in the head and then slit her wrists. Alicia has not spoken since. The only clue as to her state of mind following the murder is a self-portrait she created, and signed with “ALCESTIS.” She was committed to a mental institution, The Grove.

The narrative moves in part through Theo’s present-day narration and in part through Alicia’s old diary, which recounts the weeks leading up to Gabriel’s murder. At the start, it’s six years after the murder. Theo is starting a new job at The Grove, a position he pursued with the aim of working with Alicia. Alicia’s high-profile case has captivated him for years.

In his first session with Alicia, Theo finds her heavily medicated by her primary therapist, Christian West. Determined to communicate with Alicia, Theo requests that they lower her dosage. In their next session, Alicia is more alert—and physically attacks him. Although The Grove’s manager, Stephanie Clarke, wants to shut down Theo’s sessions with Alicia, Lazarus Diomedes, clinical director at The Grove, intervenes and decides to give Theo six weeks to get Alicia to talk. Theo is determined to find out why Alicia killed Gabriel and why she won’t speak. Since he can’t communicate with her verbally, he resorts to playing the role of detective, interviewing her family, neighbors, and friends. He learns from Alicia’s neighbor, Barbie Hellmann, that Alicia had a stalker in the weeks before Gabriel’s murder.

Alongside recounting his investigation into Alicia, Theo also narrates details of his personal life, introducing a subplot regarding the infidelity of his wife Kathryn, or Kathy. Theo accidentally discovers the affair one night. The betrayal is earth shattering for Theo, who has struggled with his own mental health problems in the past (including an unsuccessful suicide attempt). In his private life, away from The Grove, he transforms into the clichéd jealous husband, obsessively checking Kathy’s emails and stalking her when she meets her lover to confirm his suspicions.

Back at The Grove, Theo learns that Alicia has stabbed another patient with a paintbrush. Christian has resumed Alicia’s medication and placed her in isolation. Lazarus tells Theo that he can no longer see Alicia for counseling. Theo pays Alicia a last visit—and she gives him her diary. It confirms what Barbie told Theo—that Alicia had a stalker in the weeks before Gabriel’s murder. From the diary, Theo learns that Alicia told Gabriel and her therapist—who Theo realizes was Christian, accepting off-the-books cash payments in exchange for secret private treatment—about her stalker. Neither man believed her. Christian prescribed anti-psychotic medication, which Alicia didn’t take in case it left her vulnerable to an attack. In the final diary entry, Alicia writes that her stalker is in the house. Theo returns the diary to Alicia.

Theo uses the revelations contained in the diary to confront Christian, as well as Alicia’s family and friends, including her cousin, Paul Rose, and her aunt, Lydia. Through this, Theo identifies that something Alicia overheard her father saying when she was a child resulted in Alicia’s psychological death, a transformative moment that resulted in her hatred of her father and in her subsequently being capable of murder. 

With this insight, Theo believes he understands why Alicia identifies with Alcestis: Like the tragic character, a man betrayed Alicia, a man who valued another life over hers. He confronts Alicia with his theory. Alicia begins talking and reveals the truth about the night of Gabriel’s murder. Her stalker broke in and tied her up. According to Alicia, when Gabriel came home, the stalker ambushed him, tied him up, shot him six times, and left. However, this story does not match the police’s evidence—someone shot Gabriel five times—and Theo doesn’t believe it.

Theo returns to The Grove the next day planning to confront Alicia about her dishonesty but when he arrives, he’s told that Alicia is in a coma—she overdosed. Theo believes that someone has deliberately given her a lethal dose of morphine and informs Lazarus. Lazarus calls the police, instructing Theo to find Alicia’s diary for evidence. The police suspect Christian (Theo has in the meantime revealed Christian’s past secret treatment of Alicia). In fact, Theo is the person who administered the morphine.

The narrative suggests up until this point that the subplot of Kathy’s infidelity is taking place in the present-day, in the background of the primary plot—Theo’s investigation into Alicia’s silence. However, the narrative reveals that the subplot of Kathy’s affair took place six years earlier—and that the man Kathy was having an affair with was Gabriel. Theo was Alicia’s stalker in the weeks before the murder. He followed Gabriel to his house, planning to kill him. That’s where he spotted Alicia.

A final diary entry of Alicia’s—written before the morphine took effect—reveals the truth. Alicia suspected as soon as he arrived at the Grove that Theo was her stalker. Alicia confirms her suspicion by Theo’s reaction to her false account of the night of the murder. She allowed Theo to give her a lethal overdose because she still feels guilty for Gabriel’s death. On the night of the murder, Theo tied up both Alicia and Gabriel. He then offered Gabriel a choice: either die himself or let Alicia die. When Gabriel chose to live, Theo fired a shot in the air and left. Unbeknownst to him, Theo had reawakened the trauma of Alicia’s feeling that her father wished she had died in her mother’s place. Mentally broken, she shot her husband.

Theo is unable to find Alicia’s diary and is unaware that this final entry exists, but he congratulates himself on having done the right thing by trying to help Alicia, whom he had not meant to end up insane and incarcerated. He receives a job offer as the director of another institution. Kathy is depressed at the death of her lover, but neither she nor Theo has admitted to the affair. The novel ends as the police arrive, armed with Alicia’s diary. Theo accepts that the time has come to pay the price for his actions. Ultimately, it is Alicia’s diary that reveals the truth and will bring Theo to justice.