Karen B. Rosenbaum, MD

Reviewed by Karen B. Rosenbaum, MD, and Susan Hatters Friedman, MD

 is a novel by Australian author Liane Moriarty,

, which was made into a 2-season HBO series. 

was recently adapted into an 8-episode Hulu miniseries, which premiered on August 18, 2021. Although there are many important plot changes between the novel and the miniseries, the miniseries is very well cast, making Moriarty’s characters come to life. Both the novel and the miniseries deal with 9 people who want to reinvent themselves through an exclusive (and expensive) 10-day “wellness” retreat led by a mysterious woman named Masha, played seemingly effortlessly by Nicole Kidman.

[Spoiler Alert] Masha’s backstory is that she was a ruthless, successful businesswoman who nearly died (the method is different between the novel and the miniseries) and was rescued by a mild-mannered, eager Yao (played by Manny Jacinto from 

, who was then a practicing EMT. She survived and changed her life, building “Tranquillum House,” an idyllic wellness retreat where the 9 perfect strangers meet. The novel is set in Australia, but the miniseries is set in the fictional town of Cabrillo, California, although it was filmed in New South Wales, Australia.

Psychiatric themes include suicide and experimental psychopharmacology. For example, the Marconi family are 3 of the Tranquillum House guests: They are the parents and twin sister of a deceased boy who each blame themselves and each other after the boy—17-year-old Zachary—died by suicide 3 years prior. In the book, Zachary’s mother, Heather Marconi, reveals that she did not pay attention to the side effects on the insert of a new asthma medication Zachary was taking, 1 of which was suicidal ideation. In the show, she only remembers reading this while under the influence of Masha’s LSD. In the book, the sister of another guest, Ben, dies by drug overdose after losing a long battle with addiction.

The miniseries takes many liberties with the plot of the novel, including changing characters’ professions, which ultimately shifts the tone of the story. For example, another character, Carmel, a mother of 4 whose husband left her for another woman, becomes violent in the show, but not in the novel. These plot and character changes do increase the suspense, but they also make the characters more 1-dimensional. The book feels less mysterious, but in both, the person responsible for the wellbeing of 9 people, Masha, has a dark past and a narcissistic side that drives her to do things that are self-serving and not in the best interest of others. In both the miniseries and the novel, when the guests eventually realize that they are being medicated, Masha calmly tells them, “It’s called ‘microdosing,’ and it’s perfectly safe.”

Microdosing usually implies taking very small amounts of a psychedelic such as LSD or psilocybin-containing mushrooms—not necessarily enough to cause an altered state of consciousness, but enough to experience an elevation in mood. Well-respected establishments such as the Depression Evaluation Service at Columbia University

 are currently researching the use of psychedelic medications, and several studies examine the risks and benefits of low-dose psychedelics. For example, in 2020, Lea et al“examined motivations, dosing practices, and perceived benefits and limitations of microdosing.” They found that reported benefits included “cognitive and creative enhancement, reduced depression and anxiety, enhanced self-insight and mindfulness, improved mood and attitude toward life, improved habits and health behaviors, and improved social interactions and interpersonal connections.” Some of the negative effects included that these drugs are still illegal, involve self-administration, bring only short-term benefits, and may result in more frequent “off” days.

One of the many problems with Masha microdosing her guests through smoothies is that there is no consent. The guests are unaware that this is happening, and some of them have possible contraindications to psychoactive medications such as other medical conditions and family histories of addiction. The microdosing also causes frank hallucinations. The Marconi family, for example, all see the deceased Zachary. There are also unpleasant side effects, as seen in a study by Anderson et al where 18% of people described physiological discomfort and 7% described increased anxiety.

In the 8th and final episode, Masha makes an ironic attempt to show some semblance of therapeutic integrity. When the Marconi family confronts Masha, saying she left out vital information indicating that she had ulterior motives for helping them hallucinate Zachary, Masha replies, “It’s not acceptable for a ‘therapist’ to be talking about her own life.”

Despite some interesting character development in terms of some of the backstories of the guests and of Masha and her staff, there are very few likeable characters. Although they are all human in terms of having flaws, weaknesses, and difficulties, it is difficult to relate to them at times. Wellness retreats are gaining in popularity, and the benefits of yoga, meditation, and other alternative medicines are widely known and accepted in our field. However, the experimental practices at the fictional Tranquillum House are off-putting and potentially harmful, and they may potentiate fears around the mental health and wellness communities. There are also frank references in the miniseries to Western psychiatric facilities not being as safe as Masha’s experimental “wellness” facility. It is important as psychiatrists to know what entertainment our patients are consuming so that we can dispel potential myths around mental health and experimental psychopharmacology.

is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. 

 serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of 

Family Murder: Pathologies of Love and Hate

 (Washington, DC: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and was awarded the 2020 Manfred Guttmacher Award by the American Psychiatric Association.

Inside the Tranquillum House from Hulu’s Nine Perfect Strangers

. August 25, 2021. Accessed September 5, 2021.

. Columbia University. 2021. Accessed September 13, 2021. 

Psychedelic microdosing: a Subreddit analysis.

5. Anderson T, Petranker R, Christopher A, et al. 

Psychedelic microdosing benefits and challenges: an empirical codebook

Articles

Microdosing at “Tranquillum House,” and its implications for real-world experimental psychopharmacology.

Nine Perfect Strangers

Edited by Susan Hatters Friedman, MD, Committee on Psychiatry and the Law, Group for the Advancement of Psychiatry; Washington, DC: American Psychiatric Association Publishing; 2019.

196 pages • $42.50 (softcover) • $34.00 (e-book)

True crime has become increasingly popular, as evidenced by the well-attended “Death Becomes Us” True Crime convention in New York City in March 2019; numerous podcasts on true crime; and increasing numbers of novels, documentaries, and dramatic series depicting true crime. For example, the podcast Serial (2014) about the murder of Baltimore teenager Hae Min Lee recently became an HBO documentary series (2019). In the popular podcast 

, Karen Kilgariff and Georgia Hardstark tell each other true crime stories each week with comic interludes. Their tagline, “Stay sexy and don’t get murdered.”

Consistent with the true crime trend, in 

, Susan Hatters Friedman, MD, (and other authors on behalf of the Committee on Psychiatry and the Law of the Group for the Advancement of Psychiatry) uses a high-profile true crime vignette at the beginning of each chapter to illustrate its subject matter. In the introduction, Susan Smith, a notorious mother who drowned her two sons in a lake in 1994, is presented, and her story is used again in chapter six as an example of child murder by parents. The high-profile case of Lyle and Erik Menendez, which was recently made into a 

 miniseries (“Law and Order True Crime: The Menendez Murders”), was used to introduce parricide in chapter eight.

In addition to addressing compelling material, the comprehensive book on family murder serves as a guide to all psychiatrists-not only those who practice forensic psychiatry-on how to handle cases in each chapter. This book also would be relevant to general psychiatrists who may encounter patients with a history of violence or violent thoughts against family members, or patients who have been exposed to traumatic familial incidents. Topics covered include intimate partner homicide by men and women, feticide, neonaticide, fatal maltreatment and child abuse resulting in murder, child murder by parents, siblicide, parricide, intimate partner homicide in elderly populations, and familicide.

Each chapter is divided into multiple subsections-including the true crime introduction, background information, epidemiology, motivations, and multiple references-and addresses prevention, risk assessment, aftermath, and legal issues. All chapters offer guidance for the psychiatrist on the mentally ill offender and information on whether mental illness is a common contributor in the type of family murder. The statistics are often surprising. For example, when antisocial personality disorder is dropped, fewer than 5% of mentally ill parents have maltreated their children. The authors explain throughout the book that although a great deal of publicity surrounds the murder of family members, such murders are rare and, therefore, research and data in this area are limited.

I spoke to editor and author, Susan Hatters Friedman, MD, about the motivations for writing the book. She explained, “We sought to bring together comprehensive data about murder within the family, as well as real-life stories of this tragedy. We hope that the book is helpful to those completing evaluations after the fact-but, moreover, helpful to the ultimate goal of prevention.”

An interesting aspect of family murder described in the book is that there are often motivations of “love” as well as “hate,” as indicated in the subtitle, and the motivations are generally complicated. For example, in the story described in chapter nine, an 88-year-old man had shot his 86-year-old wife in a hospital room and planned to shoot himself as well but was apprehended. He explained clearly to authorities his altruistic motive that his wife had been begging to die.

 is an in-depth guidebook that synthesizes the available research. It will be helpful for forensic psychiatrists who are evaluating someone who killed a family member or intimate partner and for general psychiatrists who are seeing patients for whom they are worried about the risk of family violence. The book will also be of interest to attorneys involved with these cases, as well as to the general public interested in true crime, since it is well written and concise. It will broaden the true crime fan’s knowledge about family murder, as the book situates the case vignette within what is known in the literature about that type of murder.

 is a general and forensic psychiatrist in New York City and on faculty at New York Presbyterian-Cornell Weill and New York University Langone Medical Center.

This article was originally published on 6/4/2019 and has since been updated.

The express goal of this guidebook: “to bring together comprehensive data about murder within the family, as well as real-life stories of this tragedy.”

Karen B. Rosenbaum, MD

Articles

Nine Perfect Strangers

Forensic Psychiatrists Explore True Crime and Family Murder