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Can Serial Killers Be Cured?

Hulu's gripping series "The Patient" poses the question.

Key points

  • Some psychologists have argued that the urge to kill is a learned response that can be unlearned through therapy.
  • A 2003 case study documented a man with strong homicidal urges who successfully eliminated them after eight months in a psychiatric hospital.
  • Disorders like schizophrenia and bipolar disorder put men at a higher risk for homicide, so treating the disorders is one way to reduce the risk.
A scene from "The Patient"
Source: FX

One thing that sets Hulu’s excellent and gripping series, The Patient, apart from the many serial-killer dramas that preceded it is how understated it is.

Almost the entire 10-episode series, which just concluded, takes place in a single basement room and consists mostly of conversations between its two main characters, Sam Fortner (Domhnall Gleeson), a serial killer who desperately wants to stop killing, and Alan Strauss (Steve Carrell), the therapist Sam has kidnapped and chained to the floor to help him.

Every conversation between the two men drips with tension as Sam opens up about his persistent urges to kill, and Alan earnestly tries to talk Sam down, partly out of a genuine desire to help and partly because he understands that it’s his only chance to save his own life.

The series raises several thorny questions, like whether effective therapy is possible under coercive conditions and whether it’s possible for someone to learn empathy. But the central question of the series is whether Alan will succeed in curbing Sam’s homicidal impulses. At multiple points, the show encourages you to ask whether Sam can really change at all.

The Patient is fiction, but what does research say about this question? Maybe not surprisingly, there aren’t a lot of studies on treating serial killers because they’re so rare. But there are some reasons to think that the popular perception of serial killers as callous, unreachable monsters is not so accurate.

Killing as a Learned and Unlearnable, Response

For example, psychologist Robert Hale argued that, for some killers, the urge to kill could be a harmful learned response to feeling, just as, for many other people, anxiety is a maladaptive learned response to being in benign situations. If so, the same methods and strategies that therapists use to treat people with anxiety or phobias to unlearn those responses might be applied to people with homicidal feelings.

The Patient’s creators may have had this idea in mind when writing the show. In an interview, co-creator Joel Fields said of Sam’s motivations that the fact that “he feels victimized is the reason that he’s entitled to everything he does.”

Hale’s argument was theoretical, but a case study published in 2003 by psychiatrists Andrew Reisner, Mark McGee, and Stephen Noffsinger detailed the treatment of a 27-year-old man called Mr. X in the paper, who was admitted to a psychiatric hospital with recurring fantasies about killing people.

He was initially treated with mood stabilizers and antidepressants, as well as an antipsychotic due to some delusions he was having–like a belief that he was nonhuman. The case study reported that the drugs helped with his emotional regulation and made him more open to cognitive therapy, through which he learned to better manage his thoughts and feelings.

Over the course of eight months, he came to recognize that he really liked people and wanted meaningful relationships but feared rejection. He learned more constructive ways to handle social rejections when they happened. His strong desire to kill people gradually went away, and in a follow-up four months after being discharged, he remained in good mental health.

Treating Mental Illness to Prevent Homicidal Behavior

Some of Mr. X’s treatments fit with the conclusions of a 2015 review of over a decade of published studies on predictors of homicidal behavior in men. The study, conducted by a team of researchers led by Leo Sher, was not specifically focused on serial killers but on homicidal behavior in general.

The team found that homicidal tendencies were commonly predicated by well-known psychological disorders, particularly schizophrenia, and bipolar disorder, especially when combined with substance abuse. For example, the researchers wrote, “whereas schizophrenia presents a two-fold risk for murder, schizophrenia with co-occurring substance use presents an eight-fold risk in comparison to the general population.”

In other words, the best treatment for killers may be treating the underlying conditions driving them to kill. With Mr. X, getting his bipolar-like mood swings under control was a key step in helping him to start thinking clearly about what he wanted and why.

This research is obviously limited, and it’s debatable how well these conclusions will generalize to most actual serial killers. The authors of the Mr. X case study noted that many serial killers are psychopaths, and psychopaths are believed to be largely immune to therapy.

But cases like Mr. X and series like The Patient offer a positive message for the rest of us. Showing us that change is (sometimes) possible in the most extreme and ugly corners of humanity should give us hope that we can change, too, if we want to.

To find a therapist near you, visit the Psychology Today Therapy Directory.

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