The episode was directed by Kim Manners, who cited it as his favorite third-season episode and praised David Duchovny's performance in this episode, saying "Duchovny drove himself, and he was brilliant in that show." Manners also said of the episode: "I think 'Grotesque' is a frightening show. I think it is a disturbing show, and I think that's why—for me—it's such a good show. We pulled it off making the viewer feel uneasy. I even found it a difficult show to watch. Yeah, it was a pretty dark hour of television and I would like to do more of those." To get inspiration, Manners played the soundtrack to the film "Jacob's Ladder" (1990) on repeat until his wife "finally asked, 'Do we have to listen to that (bleeping) CD again?'" Manners also theorized that this episode may have inspired Carter when he eventually developed the show "Millennium", which premiered on Fox the following television season.