Review of “I Know This Much Is True” TV series (Derek Cianfrance, USA, 2020)

“Man Can Do What He Wills But He Cannot Will What He Wills”
On the Freedom of the Will, Arthur Schopenauer, 1839.

By Dr. Franco Ferrarini, gastroenterologist and film reviewer.

This short HBO series centres on the life of two twin brothers, Thomas, and Dominick Birdsey (both played by Mark Ruffalo), the former affected by Paranoid Schizophrenia (PS), a condition which plays a pivotal role in the plot. The core of the story is Dominick’s persistent attempts to help Thomas after seeing him being bullied as a kid by their stepfather Ray (John Procaccino) who did not understand the kid’s behavioral abnormalities and social withdrawal triggered by his mental condition.1 The situation of the Birdsey brothers reaches a nadir when Thomas cuts off his own right hand as a sacrifice for the wrongdoings of the Unites States during the First Gulf War. He refuses the surgeons’ advice to attach his hand. Following that traumatic experience, Thomas is sentenced to involuntary commitment in a judicial mental asylum. His mental situation worsens in the asylum soon reaching a catastrophic crisis.

‘I know this much is true’ HBO series, official YouTube trailer

PS is the commonest form of Schizophrenia characterized by dominance of positive symptoms (hallucinations and/or delusions) over negative and cognitive symptoms such as blunting of affect, impaired volition, disorganised speech, thought and/or attention.  The pathophysiology of PS implies alterations in neurotransmitters such as dopamine, serotonin, glutamate. However, its etiology is not yet well understood; genetic factors play a role, but environmental and psychological factors, notably also play a role. These underlying factors are evident in Thomas’s childhood trauma and first and second-generation immigrant background (see below).2

This series addresses several important issues such as the role played by families and society in supporting or neglecting patients with psychiatric conditions. As seen in Thomas’s case, bullying at home, being brutally treated in a judicial mental asylum where he is deprived of his brother’s help, and being denied the opportunity of socializing, all exacerbate his mental illness. Beside medications (e.g. antipsychotics) the treatment of PS is based on psychosocial support and both cognitive behavioural therapy and family interventions, all recommended approaches in the UK NICE guidelines.3

From a psychological viewpoint, one should also consider the complicated relationship and interdependency between the twin brothers: Dominick feels great responsibility for Thomas while Thomas is in desperate need of his brother’s help often saying, “you are me”. Thomas’ reminder to Dominick to support him is crucial for their combined well-being as neglecting one’s twin is like neglecting oneself.

In analyzing the background to Dominick’s protective attitude towards Thomas, the viewer is introduced to an earlier school event when Dominick wrongly accused a school mate, of native American descent, of a theft she did not commit. Dominick accused her because he simply did not like her. The girl was subsequently expelled from school, escaped home, and was never seen again. It is tempting to speculate that having acted unjustly against a member of an ethnic minority group, Dominick feels obliged to redeem his guilty conscious by helping his desperate twin.

Dominick’s sense of obligation introduces another relevant plot device which is ‘the freedom of will’. In this regard, the director uses a long flashback to introduce us to the Birdsey brothers’ grandfather, Domenico (Marcello Fonte), who emigrated from Italy to the United States.  Domenico got rid of his brother in a similar unjust way as Dominick did with his school mate, implying the existence of a possible connection between our actions and those of our ancestors thus adding a transcendent feature to the “nature versus nurture” debate in relation to the underlying motivations of our decisions. We may believe that we can make decisions of our own free will, but our decision-making process can be heavily influenced by variables that we cannot control. Ancient Greeks were well aware that under the influence of these variables we may be forced to make only one decision in a given situation, in fact in their pantheon sat Ananke, the goddess of necessity and constraint, not surprisingly mother of the three Parcae who inflexibly decided the duration of each human being’s life.4 The Greeks thus concluded that humans are inescapably bound to live and die according to the dictate of the Gods which cannot be modified.

Besides the multitude of mental health issues it raises, “I know this much is true” is worth watching because of both Cianfrance’s directorial skill and Mark Ruffalo’s astounding acting brilliance in the twin roles, for which he won the 2020 Primetime Emmy Award for Outstanding Lead Actor in a Limited Series or Movie.



1. Howes OD, Murray RM Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014; 383(9929):1677–87.

2. Owen MJ et al, Schizophrenia. Lancet 2016; 388(10039):86-97.

3. Accessed November 30 2020.

4. Kerényi K, The Religion of the Greeks and Romans, Greenwood Press, 1973.

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