Nine Perfect Strangers

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

BOOK REVIEW

Nine Perfect Strangers

by Liane Moriarty; Flatiron Books, 2020

576 pages; $7.98 (paperback)

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

Nine Perfect Strangers is a novel by Australian author Liane Moriarty,1 who is also known for her novel, Big Little Lies, which was made into a 2-season HBO series. Nine Perfect Strangers 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 The Good Place), 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.2

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.”1

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 University3 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.4 More research is needed.

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.5

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.

Dr Rosenbaum 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. Dr Friedman 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.

References

1. Moriarty L. Nine Perfect Strangers. Flatiron Books; 2018.

2. Andriotis ME. Inside the Tranquillum House from Hulu’s Nine Perfect Strangers. August 25, 2021. Accessed September 5, 2021.

3. Depression evaluation service. Columbia University. 2021. Accessed September 13, 2021.

4. Lea T, Amada N, Jungaberie H. Psychedelic microdosing: a Subreddit analysis. J Psychoactive Drugs. 2020:51(2);101-112.

5. Anderson T, Petranker R, Christopher A, et al. Psychedelic microdosing benefits and challenges: an empirical codebook. Harm Reduct J. July 10, 2019.