Mental Illness: Shutter Island, Movie Review Example

Summary of the Film

Director Martin Scorsese’s 2010 film, Shutter Island, is a gripping and somewhat Gothic thriller, and one that enjoyed great public and critical reception.  Set in the 1950s, the movie recounts an ostensible investigation being conducted by two United States Marshals, Teddy Daniels and Chuck Aule.  A patient has unaccountably vanished from her secure room at the Asheville Hospital for the Criminally Insane, a facility in Boston Harbor, and the film loses no time in setting up an intensely mysterious atmosphere.  Upon arrival, Daniels and Aule meet with the chief psychiatrist, Dr. Cawley.  He establishes the virtual impossibility of the woman’s escape, along with the additional factor that the conditions of the island are such as to render survival outside of the institution highly unlikely.

The film’s hero, or protagonist, is Daniels.  He is presented as a man in his mid-thirties, evidently capable at his profession, yet apparently troubled; ill on the ferry over to the island, he appears from the start to have immense difficulty in coping with the circumstances of the location and the case.  That is to say, there is an evident degree of unease in his manner which belies that of a trained and experienced U.S. Marshal.  From his opening encounter with the hospital’s guards to his taut, tense interview with Cawley, Daniels is clearly unsettled.   Above all, he manifests from the start an implacably suspicious behavior, even with his ally, Aule.

As the film proceeds, Daniels reveals to his partner that he is, in fact, there to achieve another goal, that of locating Andrew Laeddis, the arsonist responsible for the death of his wife and children several years earlier, and whom he has reason to believe is being held at Asheville.  Something, however, is very wrong, beyond that of the melodramatic mystery at hand.  Daniels is haunted by recurring dreams/visions of both the horrors he witnessed while liberating the death camps at the close of World War II, and of his late wife.  Then, unrealistic scenarios are presented; the missing patient’s chief clinician is “on vacation”, and the woman herself inexplicably returns to the facility after some days of surviving in the hostile, stormy landscape.

Throughout the film’s progression, an increasing urgency marks Daniels’s mistrust. He suspects his partner of some sort of complicity in the entire affair, and he goes off on his own to investigate, confronting and attacking a dangerous patient he believes to be Andrew Laeddis.  Most tellingly, Daniels braves a cliff and uncovers a lair containing whom he believes is the real, missing woman.  She informs him that she is a doctor herself, and has had to escape because of the radical drug experimentation being performed at Asheville, and which she is certain has already been applied to Daniels. As the film ends, it is revealed that Daniels himself killed his wife some years earlier, upon discovering her murder of their children, and that he has been in the grip of ongoing cycles of hallucination.  The entire construct of the “investigation” has been fabricated by the doctors to finally push Daniels into accepting the truth of his own actions, and in a permanent manner.  The alternative is a lobotomy, and the film concludes with Daniels’s seeming voluntary selection of the surgery.

Illness Assessment

As the fictional character of Teddy Daniels is presented in a dimensional manner, it is possible to assess his mental state employing the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) from the American Psychiatric Association.  As is evident, nothing further can be uncovered regarding such a contrived character, as the film itself also adds dramatic components not necessarily in keeping with any true illness. Nonetheless, there is ample material with which to evaluate the individual, once the extraneous effects of the story and the medium are set aside.

The single, most difficult aspect to diagnosing the character is also the most helpful, in a sense; Daniels is something beyond high-functioning, as regards all external behaviors.  He is, as noted, blatantly troubled and persistently driven by extreme suspicion, but he nonetheless exhibits clear thinking, rationality, and reasonable, if occasionally exaggerated, emotional responses.  Given the duality of the film’s storyline, it is not feasible to assess Daniels’s functioning relevant to how he is perceived by others; the entire scenario is contrived. However, it is probable that he would be perceived by ordinary people as an intelligent, driven, disturbed man, yet not one suffering from an illness.

As will be discussed later, degrees of high functioning easily obfuscate diagnosis. It is, plainly, expected that those who are mentally ill manifest specific behaviors indicating such. With Daniels, however, one component appears especially prevalent; his mistrust is so omnipresent as to indicate a persecution complex or a paranoiac state. His partner cannot be relied upon, and everyone he encounters is, he believes, lying to him. Behind this is the larger, paranoiac framework of the government’s attempt to isolate the man who destroyed his family.  Consequently, a cursory examination may safely categorize Daniels as paranoid.

This does not, however, hold up.  For one thing, Daniels’s mistrust is not uniformly applied, as he fully accepts the information presented to him by the hidden woman later revealed as a delusion. That she is not real does not eviscerate the import of his belief, for a true paranoiac would soon doubt even a manufactured informant. “She” feeds his fears and confirms his extreme suspicions, but her essential value as a construct lies, not in enabling persecution beliefs, but in her fictive being itself.  Paranoia typically does not require additional material created by the sufferer, as the psychodynamic causes of narcissism, grandiosity, perfectionism, sadomasochism, and rebellion ordinarily are amply fueled by actual, external elements (Kantor, 2004,  p. 117).

It seems far more likely that Daniels is suffering from delusional disorder.  He very effectively creates a “pseudocommunity” to support the depth and range of his delusions. More precisely, the facilities at Shutter Island provide him with something of an ideal platform upon which to do so. Delusional disorder frequently requires elements of persecution and paranoia, and these can be no better manufactured than in the form of supposed caregivers who are, in fact, plotting against him in this fictive construct (Sadock, Sadock, 2008,  p. 183). Delusional disorder is of itself open to other diagnoses, however, and the character of Daniels indicates that he could be classified as Mixed Type by DSM-IV standards.  That is, he is clearly delusional, but in a variety of ways.  In addition to the strong persecution complex evident, there is as well something of a grandiose view of himself as the “savior” of the situation of the island (Clyman, 2010), which refer back to characteristics of paranoia.  This difficulty notwithstanding, that Daniels does indeed suffer from delusions is the keynote in any DSM-IV analysis.  His delusions are the concrete form his illness takes, throughout the film, and they are astoundingly elaborate and well-constructed.

For example, when he confronts the woman whom he believes to be the missing patient in the cave, he is as well developing physical symptoms of shaking. “She” accounts for this by explaining that the staff and doctors have been administering drugs to him in the coffee, food, and cigarettes he has accepted from them.  The audience later learns that the shaking is not part of his delusion, but a genuine symptom of, in fact, the drug withdrawal Daniels is undergoing as part of the radical exercise in forcing him to confront reality.  This reveals the intricate organization of his delusions; faced with a physical symptom he cannot ignore, his high functioning mind finds a way to strategically employ it within the delusion.

Persecutory-type delusional disorder is marked by intense feelings of paranoia, and the sufferer, true to the larger designation, constructs often complex scenarios which support the persecution.  Not unexpectedly, this condition is often difficult to distinguish from paranoid and/or schizoid personality disorder (Cohen, 2003,  p. 244).  The problem with this diagnosis, unfortunately, is that Daniels does not fully adhere to it in terms of a relentless sense of being persecuted.  That is to say, he exerts himself to end the circumstances; he has, in fact, no other ostensible goal, and this essentially defies the definition.  A true victim of persecutory-type delusional disorder does not, generally, so actively seek to vanquish the persecution.

Ultimately, then, it appears that Daniels suffers from a variation of delusional disorder, and this can be established by the other, most striking fact of his case: the durations of his delusions.

When everything about him is taken into consideration, Brief Psychotic Disorder seems to be the villain.  It is not brought about by medical conditions or the use of drugs, it is a transient psychotic state, and its duration may be a single day or a month (First, Tasman, 2009, p. 253).  As is revealed, Daniels has in the past been able to free himself from his delusions, only to revert back to them, and consequently the disorder applies.

Treatment

A major dilemma inherent in treating victims of any form of delusional disorder lies in the nature of the illness itself.  Many will not consider treatment, not unexpectedly, because the strength and complexity of their delusions are consistently and potently reinforced by them, and they cannot admit to the likelihood of actually being ill.  Moreover, such sufferers rarely manifest behaviors ordinarily associated with psychotic disorders; there is no dysphoria, erratic behavior, or deficits in functioning (Weiner, Craighead, 2010,  p. 469).

Given the complexity inherent within cases of high functioning delusional disorder, even of the brief psychotic type, it would seem that drug treatment would be unavailing.  For one thing, anti-psychotic drugs do not generally work well with patients suffering from delusions; the pathways within the disorder, particularly in high-functioning individuals, do not follow the disruptive patterns of a typical psychotic disorder (Lieberman, Tasman, 2006,  p. 20).  That is to say, the delusions of a high-functioning person like the hero of Shutter Island are, in a sense, non-delusional, because they have the form and structure of actual reality. Any drug effective in combating the process of the delusion creation would then seriously impair the individual’s necessary, cognitive functions.

Ideally, therapy is called for in this instance.  As the character demonstrates, he can at times fully appreciate the scope and nature of his illness.  Moreover, there have been episodes wherein he has maintained a sense of reality for extended periods of time.  That Daniels has reverted back to his delusions by no means indicates that a therapeutic form of address may not be permanently effective.   That this therapy has, in fact, enabled periods of lucidity points to a probability of permanent success.  In this patient’s case, it would be recommended that an intensely interactive, yet non-aggressive, therapy be maintained, and on a rigorously held schedule.

Legal and Ethical Issues as Presented in the Film

Taking the film, Shutter Island, at face value, what enables it to succeed as an engrossing movie is also very much what hampers it as any realistic presentation on the treatment of mental disease.  The movie – conveniently – is set in the 1950s, so a substantial amount of leeway is given for procedures and ideologies both out of date and glaringly unethical, if not illegal.  The surgical procedure of the frontal lobotomy, for instance, is the dark  deus ex machina of the story; it is made clear that, unless demonstrable progress is evident, there is no other recourse. Legalities aside, this is a strikingly extreme measure to take when a patient, even of that era, is not particularly violent, or only expresses violence within the framework of the experimental “treatment”.

There are other issues.  It is strongly suggested that the staff of Asheville, while clearly concerned with Daniels’s well-being, requires more in the way of cooperation from him, rather than recovery.  At the film’s conclusion, it is implied that an outward show of compliance – that  is to say, an acknowledged acceptance of reality – would completely placate the doctors. That Daniels elects to defy this expectation, which choice appears to be suspect in motive by his doctor, ensures the lobotomy.  It is ethically outrageous that any doctor doubting the intent of the patient in such a case would carry on with the radical surgery, which is itself inherently dangerous and less than ethical.

Mental Illness: Media Presentation vs. Actual Care

For some time, mental illness has been a grossly exploited theme in media presentation.  For all its melodrama, Shutter Island is actually a somewhat realistic account of one variety of it, certainly in comparison to the majority of other treatments of the subject in entertainment.  Largely due to the popularity of the 1957 film, The Three Faces of Eve, for example, people believed for decades that Dissociative Identity Disorder and schizophrenia were the same thing.  Even later films based upon the disorder, such as 1976’s Sybil, sensationalized the illness for dramatic effect.

Beyond entertainment venues, it seems that little is known about mental illness through media venues chiefly because of the intrinsically complicated, and often non-apparent, ways in which much of it is manifested.  It is true that modern communication access has rendered certain forms of mental illness components of ordinary conversation; “bi-polar” and “manic-depressive” are commonly and frequently employed when, in fact, anything resembling a change in mood is evident.  Nonetheless, the reality remains that a subject as complex, and as still greatly misunderstood, as mental illness does not easily lend itself to acceptably realistic media presentation.

Then, there is the issue of functioning, alluded to earlier.  A wide variety of severe mental illnesses exist within sufferers who perform ordinary living skills and behaviors perfectly well. Appearance disguises reality in these cases, and a sense of disbelief  is typically generated regarding actual illness because, ultimately, mental illness is a frightening thing to consider.  It creates fear because, simply, it is somewhat unfathomable to the well person, who cannot in any meaningful way identify with someone whose mind is suffering from disease or disorder.

Fortunately, if somewhat ironically, that society has come to accept the extraordinary levels of complexity and variety within mental illness serves to greatly support the field.  That is to say, it seems that, the more blatant the acknowledgment that much regarding mental illness remains unknown, the more respectful society is towards it.  Combination therapies and new drugs are constantly being tested and devised, to treat an increasing range of mental disorders; there are disappointments, but there are as well reasons for optimism.  What is most essential, however, is that the relatively recent and genuine regard for mental illness itself be maintained.  If the days of perceiving the mentally ill as possessed by demons are gone, and the conviction that cutting out segments of the brain is a wholesome way to proceed are now seen as barbaric, excellent.  Nonetheless, it must be remembered always, in terms of actual care for the mentally ill, that an innate regard for what the human brain is capable of must translate to an equal respect for what may go wrong within it.

References

Clyman, J.  (2010.)  “Shutter Island: Separating Fact from Fantasy.” Psychology Today. Retrieved from http://www.psychologytoday.com/blog/reel-therapy/201002/shutter-island-separating-fact-fiction

Cohen, B. J. (2003.)  Theory and Practice of Psychiatry.  New York, NY: Oxford University Press.

First, M. B., and Tasman, A.  (2009.)  Clinical Guide to the Diagnosis and Treatment of Mental Disorders.  Hoboken, NJ: John Wiley and Sons, Inc.

Kantor, M. (2004.)  Understanding Paranoia: A Guide for Professionals, Families, and Sufferers. Westport, CT: Greenwood Publishing Group.

Lieberman, J. A., and Tasman, A. (2006.)  Handbook of Psychiatric Drugs. Chichester, UK: John Wiley and Sons, Inc.

Sadock, B. J., and Sadock, V. A. (2008.)  Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins.

Weiner, I. B., and Craighead, W. E. (2010.)  The Corsini Encyclopedia of Psychology.  Hoboken, NJ: John Wiley and Sons, Inc.