Shutter Island is a thriller full of familiar B-movie tropes: hard-boiled chain-smoking dicks, former Nazis, hip-swaying femme fatales, storms and mausoleums, fear of the A-bomb.  The central conceit of "madness" is tied up with the film itself: how you believe the film treats B-movies affects your final understanding of "madness".  Is paranoia a trope, a thought disorder or reality - and how do we know the difference?  Are roles really roles when people don't believe they're playing roles?  Is the B-movie noir itself a cultural re-enactment of the trauma of World War II - just as it is played out on Shutter Island?  (I suspect that similar questions have been asked about this film from a slightly different perspective: is it an art house film pretending to be a fifties B movie, or a cheap thriller pretending to the status of art house film?

Answering any of these questions would require first answering another question - "Is this something more than a trashy, manipulative, nasty film making easy use of the Holocaust, war-damaged veterans, murdered children and the mad?" - in the affirmative.) Although this film is not shy of being critical of psychiatry, it is strikingly sympathetic to the project of trying to heal disturbed psyches through careful attention to trauma.  Even the more controversial aspects of (relatively) modern psychiatry are given a hearing that is less prejudicial than usual; for example, the question of psychosurgery is raised in the context of intractable, devastating psychosis, rather than as a threat against a mischievous bon vivant (one might think of One Flew Over the Cuckoo's Nest). The moral preference, however, is clearly for psychotherapy over other forms of intervention, with a wistful and sad refusal to defend psychotherapy by showing that it actually works.