(Note: This review contains plot spoilers).

There are leaks in the ceiling. A storm is brewing. Inside, passageways are dark and twisted, and outside carefully groomed grounds are juxtaposed with ominous cliffs, crashing waves, and inaccessible caves (not to mention rats by the dozen). The setting of Martin Scorsese’s most recent film, Shutter Island, seems to be a hodge-podge of hastily drawn psychoanalytic symbols. Location? The mind of a madman.

Based on a Dennis Lehane novel of the same name, Shutter Island takes place in and around Ashecliffe  Hospital, an institution for the criminally insane located on a New England island. The film opens on a ferry transporting the protagonist, federal marshal Teddy Daniels (played by Leonardo DiCaprio), and his new partner Chuck Aule (Mark Ruffalo) to the island to investigate the mysterious disappearance of a patient who has somehow escaped from a locked cell. Once the missing patient anticlimactically reappears halfway through the film, however, the viewer becomes aware that she is a mere plot device, serving to bring Daniels to the island for the real investigation, which seems to involve secret, experimental surgeries forced on patients in an old lighthouse near Ashecliffe.

The thematic content of Shutter Island draws from a fraught period in the history of psychiatry, incorporating both the transorbital lobotomies made popular across the U.S. by neurologist Walter Freeman as well as the psychotropic drugs that were responsible for the surgery’s decline as the pharmaceutical treatments quickly gained popularity in the 1950s. The transorbital lobotomy (which involves an ice pick-like instrument inserted through the orbit of the eye and into the brain to sever nerve fibers) was performed, at times against a patient’s will (but sometimes with the consent of family), on thousands of people in the U.S., “treating” everything from depression, alcoholism, and unruly personalities to schizophrenia and other diagnosed mental illnesses. The movie depicts the complicated views on lobotomy in the 50s, when some practitioners were horrified at the zombielike patients the procedure produced. Ultimately, the pro-surgery doctors at Ashecliffe have the final say in the “treatment” of the protagonist. The film presents the procedure as a necessary evil in order to protect the staff and patients from Daniels, the asylum’s most violent criminal, whom neuroleptics have not sufficiently subdued.

In Dr. Cawley (Ben Kingsley), Ashecliffe’s primary physician, we are given a third type of psychiatric treatment in the form of psychotherapy. Self-described as a more humane practitioner, Cawley believes in the respect, dignity, and human rights of his patients. The inclusion of these dueling theories increases the stakes for Daniels’ actions as he runs through an elaborate investigation that is stymied by doctors and patients alike. He is eventually told that his partner, Chuck, has been his psychiatrist for the past two years and that everything he thinks is real on Shutter Island is actually an elaborate role-playing exercise constructed to bring him back to sanity and an awareness of his former crimes. The interpretation of his experiences ultimately becomes the focal point of the movie: is he mad or isn’t he? Is the plotline of the missing woman, investigation, and experimental procedures a paranoid delusion, or is he merely being made to believe he is insane to cover up the conspiracy? Although this hackneyed twist has drawn the derision of many reviewers, the film contains nuanced reflections on mental illness that go beyond the old “it was all a dream/it was me/it was a delusional fantasy” revelation. For example, we are confronted in several cases with the idea that once a person has been diagnosed with insanity (or even merely been assumed to be insane), it is nearly impossible for him or her to escape the associations and deprivation of political and personal power that come with such a conclusion. In the film, this of course leads us to further question how we can ever know whether Daniels (a supposedly crazy person who says he isn’t crazy) is or is not insane, but it also provokes consideration of similar diagnoses in contemporary culture—once mentally ill, always mentally ill? The right of interpretation–who determines what is or isn’t sane?–is questioned as well in the character of a woman who killed her husband after he abused her and no one would help. While considered insane by society, she found the action to be completely reasonable in the absence of other options.

Despite the inclusion of multiple forms of psychiatric intervention and constant emphasis of the subtleties of determining the boundaries of the normal, the film also contributes to harmful stereotypes that still circulate in today’s society, leading to the stigmatization and isolation of those with mental illness. The movie both plays on and contributes to the fear of insanity. Some will be quick to write off the portrayal of mental illness as merely an accurate representation of the asylums of a bygone era, but the force of such manifestations should not be discounted in a world where the stigma associated with mental illness is still going strong.  While, of course, some of the horrible experiences of patients in mental hospitals during the twentieth century are well documented, the almost exclusive portrayal of mental illness in movies as something to be feared or reviled propagates modern-day stereotypes that are painfully similar to the historical situations that may have initially inspired them. Although people with mental illness are, as a whole, no more or less violent than the rest of society, the constant portrayal of the insane patient who murders without cause still permeates popular assumptions about disorders of the mind and brain. Shutter Island presents us with anxieties over patients escaping, mauled faces, descriptions of murders the patients committed, and of course the most dangerous patient, our protagonist, a trained soldier who can only be controlled by the “brain death” of the lobotomy. Scorsese does not depart greatly from the pulpy source material, so one could blame Lehane for the cardstock representation of insanity, but Scorsese’s most obvious alteration is just as clichéd and harmful. At the end of the film, just before being carted away to be lobotomized, Daniels delivers this hardboiled line: “Is it better to live as a monster or die as a good man?” That Scorsese has even the patient himself validate the decision to lobotomize speaks to an anxious desire to settle the matter. Of course, the crazed escapee on a murdering rampage makes much better box office fodder than would a more humane representation of the spectrum of mental deviations and psychiatric care, but even so it would be nice to see more films centering on more accurate depictions of mental illness today.

Sarah Birge