‘The Silent Patient’ ends with a major twist. Should a savvy reader have seen it coming?

The Silent Patient is the gripping tale of Alicia Berenson, a happily married artist who murders her husband and never speaks again. Forensic psychotherapist Theo Faber sets out to unravel the mystery of Alicia’s notorious crime and quickly discovers that nothing about her case is as clear-cut as it seems...

Would you judge me if I said I did not see the ending of “The Silent Patient” coming? That I read all 323 pages of Alex Michaelides’s best-selling psychological thriller and did not deduce the twist until he wanted me to (page 304). And then I still did not understand the hows and whys until he fully explained, in elementary-my-dear detail, the convoluted psychology at play (pg. 312). Michaelides’s debut is being adapted as a screenplay from Brad Pitt’s production company. I'm excited to see it on screen. 

This is one I can assure you, that you won't want to miss...

Here is a great Q&A peak behind the author and the book: 

You did post-graduate work in psychology and worked in a secure psychiatric unit for two years. What drew you to the field?

It’s a bit like Theo, the narrator in the book, says: He was drawn to mental health to heal himself. In my case it certainly started like that. I had a lot of individual therapy for a long time, and then I became interested in studying it. I moved around to different places. I studied group therapy. I studied individual therapy. And then my sister is a psychiatrist and she got me a part-time job at a secure unit for teenagers, which was an incredible experience. I learned so much. I didn’t have the idea then for writing a novel about it, but I knew it was a formative, life-changing experience.

I ultimately left because I was reaching a point in my studies where I was about to take on long-term patients, and I felt I was really a writer not a therapist. But it was also more complicated than that. Despite meeting some really incredible people–at this unit, particularly–I did also encounter, while I was studying, lots of people who were supposedly very eminent, who were lacking in anything I recognized as empathy. Or common sense. So I sort of fell out of love with psychotherapy, even though it had helped me a great deal. That was definitely playing in my mind when I wrote the novel–that ambivalence. 

The Silent Patient is full of references to Greek myths and tragedies, especially the Euripides play Alcestis. How did the myths influence your writing?

Cyprus, where I grew up, is a very ancient country. It’s where Aphrodite was born. So you grow up with an awareness of the Greek myths. At age 13, you’re being taught The Iliad and The Odyssey, and the plays are always being staged. It’s in the culture very strongly. I’ve always been fascinated with Euripides and the tragic heroines he has. I think they’re really close to Tennessee Williams in lots of ways. The Alcestis was a play that captivated me since I was a child. There was something about this woman returning from death and never speaking again.

My next book also has a lot of Greek tragedy in it. It’s about a series of murders at a Cambridge college. It’s a little Grand Guignol, a little gruesome. There’s lots of that in Greek tragedy. I’ve been doing research about all the horrible things that went on. It’s fun exploring that. 

And there’s a great tradition of psychological suspense in British literature. 

I’m very into that tradition. I think the way Henry James shifts the POV in Portrait of Lady so you realize you’ve been looking at the triangular relationship in the wrong way is very close to what Agatha Christie does in Five Little Pigs or Death on the Nile. I love that feeling of reaching the end of a book and suddenly realizing you’ve been viewing the whole thing the wrong way up. And that it still holds water. I find that really fascinating. 

You’re also a screenwriter. Was that experience helpful in writing The Silent Patient?

The screenwriting helped a lot. Just in terms of keeping up the pace, keeping things moving. Someone like Billy Wilder has taught me so much. He has a book of interviews with Cameron Crowe that’s just incredible. He said any scene that doesn’t have a plot point in it is a bad scene. And so you just don’t write that scene because you’ll cut it. I’ve learned that from my experience in movies.

When I was working with Uma Thurman on the film The Con is On, she taught me a lot about writing. She said that every scene has to have an iconic image in it. It can’t just be two people talking. I had that in my head the whole time I was writing The Silent Patient. That was when Alicia became a painter, because Uma suggested it. 

The control that you have writing a novel must have been liberating. 

Really liberating. You’re on your own. When you make films, it’s a committee the whole time. The writer is the least important person. A friend of mine is a critic, and he said to me once–I thought it was really smart–that films are about contraction and books are about expansion. You can go down rabbit holes with books; you can explore tangents. It’s great to be able to go into someone’s thoughts, which you can’t do in films. I think that’s always held me back, slightly. I’ve always had a facility with plot, but this is the first time I’ve been able to marry it with something deeper.

 Was The Silent Patient always going to be a novel, or did it start as a film?

It was always going to be a novel. I wanted to try to write the kind of book I’d like to read. I wish I’d done it 10 years ago, because I wasn’t expecting people to like it as much as they have. It’s been a really amazing thing. 

Behind the Book Cover With Creative Director Anne Twomey: 

1. Was it a new challenge to design a cover for The Silent Patient, given one of the main characters is an artist? 
I dealt with something similar once before, when I designed a cover for Steve Martin’s novel, An Object of Beauty. The protagonist is an up-and-coming art dealer and the story is an observation of the art world in the late 1990s. As such, the production used a special stock that resembled canvas and a high gloss lamination was used over the painted type to attain a linseed oil quality.  

In The Silent Patient, the protagonist is a painter. I found myself drawn to continue exploring painting as a theme for the design. I could have tried to replicate the paintings as described in the book but felt that there needed to be some room for the reader’s imagination through the author’s words. I kept thinking, however, I still wanted to allude to painting, perhaps through some other means. Eventually, the idea for a painting of a woman with some damage to it kept resurfacing for me. 

2. What was your initial vision for the cover of The Silent Patient?
I initially envisioned torn paper revealing the word “Silent.” I ripped some watercolor paper in a way that unfurled to reveal first the word “Silent” and then a bust of a Greek goddess’s mouth much like Alcestis’s. The Greek tragedy Alcestis is an underlying theme of the book.

3. How did input from the book’s author inform the cover’s aesthetic?
With The Silent Patient, we showed my early designs that featured a series of torn watercolor papers to Alex, the author. He liked the direction, but suggested we move towards canvas instead, as the heroine paints with oils, not watercolor. He was right, of course—and I agreed we should be more authentic to the story. Thankfully, the pivot was not too difficult to make as we were still in initial designs.

I’m a painter by training, so I actually have a lot of past paintings and stretched canvases at my house. It was simply a case of photographing some initial tests, which I did with my iPhone on my deck, and then showing initial designs for another round of feedback.

The raw canvases that I stretched myself many years earlier were worn naturally with time: threads hung frayed at the edges and the staples binding wood and cloth were lightly rusted and placed in a way that only a human hand can master. The details made the difference and everyone was excited about this direction, so we had the same canvases professionally shot. I particularly like how the threads aligned with the details of her blowing hair in the end.

4. How many different cover designs did you create for The Silent Patient?
Many designs were done, even once we were happy with the series of canvas photographs I was working with. At one point, I was exploring about five different themes and each theme had about five covers with different type layouts, fonts and color schemes. So it’s safe to say that at least 50 covers were done. Because of this ongoing process, I like to say, “Design is a verb.”

Some of the themes explored included painting studios, paintings, a rip obstructing a mouth of a woman or a Greek female bust, and many variations of the tear and the torn canvas.

Almost as important as what we explored that went on to influence the final design are the designs that didn’t work. For instance, psychiatric wards and paintings of women with the face blurred as if wiped by a painter were interesting but felt too amateur.

5. How did you land on this as the final design? How do you know when a design is right or finished?
The standard was high for this wonderful suspense thriller that happens to also be Celadon’s first release. 

This particular photo of a woman, which came with my third round of photo research, really caught my eye. It was a little haunting and seemed to really capture the protagonist. With a little Photoshop magic, I was able to ghost her back on the canvas as a secondary or tertiary read. When I thought I had the right placement of the rip over the mouth, I took a pause. I had a few doubts — one being that it was a light cover, which is not always embraced by the sales team for a thriller. Fortunately, our publisher, Jamie Raab, said, “I’m not concerned about a light thriller cover. We’ve had successes with light thriller covers it the past.” And fortunately, everyone from editor to publishers to author to agent agreed.

6. Nowadays, it’s important that a cover looks as good on a digital screen as it does on a printed book. How did that affect your creative process as you worked on The Silent Patient’s cover?
Legibility and visual boldness have been increasingly important as we now view covers on the digital screen and even sell half our books that way. I easily embraced this shift as I had worked with mass-market covers in the past and pride myself in doing work that is both elegant and bold. I remember a time when all literary book covers had the tiniest type. From the perspective of type, the covers before digital sales were easier to design, as they tended to be image-driven.

In contrast, type-driven covers require an expansive knowledge of type. I’ve always considered myself a type geek; I love and have continued to study the craft—it goes so deep. Increasingly, type is having a revival, as millennials have been very interested and savvy about type design. There is so much talent out there in type design and hand lettering, so I also love to commission bespoke work for the right cover. In fact, in the past few years, with my design process, I often start with the type layouts and work with relevant imagery later.

I think a lot of top cover designers do this now. It’s been a natural evolution from a sales team dictating, “Make it bigger!” to designers embracing bold elegant type from the get-go. For The Silent Patient there were several options but in the end I chose a “humanist” font, which has influences from both ancient chiseled type and the calligraphic style. Humanist fonts have an ancient/modern quality, my favorite aesthetic, and are most legible online.