In lieu of an abstract, here is a brief excerpt of the content:Rules and CommunityJeffrey Bedrick, MDThe paper, “The Dilemma of Compliance: Roles and Rules in Schizophrenia, Censorship, and Life,” by Riley Paterson raises a number of interesting issues. I am only able to address a few of these issues here, and I do so in the hope of broadening our consideration of some of the basic concerns.Paterson focuses his attention on the potentially repressive side of rules, even while acknowledging (...) the broader role of rules in human life. Thus, towards the end of his paper he writes “While I regard all experience as rule- and role-bound, the aforementioned groups”—those who “experience schizophrenia, persecution, or are otherwise marginalized and vulnerable”—“experience rules and roles with particular violence.” He admirably warns us to be sure that in our work with people we are not traumatizing or re-traumatizing them.But rules play a broader role in human life. Paterson discusses censorship and the role that rules can play in repressing the expression of ideas. But rules also allow the use of language and govern communication in general. Writers living under censorship resorted, Paterson notes, to a system of exoteric and esoteric writing and communication. But those esoteric texts, if they were not to remain purely private and unknowable to those who read the texts, had to follow certain rules and conventions to signal the reader that the exoteric text was not all there was, and that there was another, esoteric, meaning to be found within the text. Writing under conditions of censorship remained a communal, intersubjective, endeavor.With schizophrenia, the seeming central topic of the paper, the situation becomes even more complex. We shall see that Paterson’s analyses point us in two different directions.Paterson writes:In schizophrenia we see an exaggerated instance of the dilemma raised above: There is a gap that exists between the publicly available roles, and the person we feel ourselves to be. We are required to conform with the demands of these roles to preserve what we feel most natural in ourselves. People with schizophrenia often must conceal, at times, their experiences of hallucinations and delusions in order to preserve some ability for social interaction. In my clinical work, however, people with schizophrenia have often reported it has felt freeing to learn when and with whom they can share those thoughts and experiences. Freeing, not because they need to hide part of themselves but because doing so opens up possibilities of social interaction and community.Further, Paterson writes of the difficulties people with schizophrenia may have with ‘weintentionality.’ Referencing Salice and Henriksen (2021) [End Page 381] he concludes that “the self-disorders of schizophrenia preserve a capacity for joint intentionality (rule following) but severely inhibit an experience of group belonging and identity (weintentionality).” Indeed he notes, again following Salice and Henriksen (2021), “that some individuals experiencing more mild forms of schizophrenia spectrum disorders found great comfort and safety in rule following.” The problem for people with schizophrenia thus seems less with applying specific rules, which might in some cases be meant to regulate or repress behavior, than in establishing we-intentionality. Many phenomenologists have explored the concept of intersubjectivity and have noted, as have many psychoanalysts and therapists, that there is no pure, interior subject but that our very selfhood is formed in interaction and relation to others. (See, for one example, the work of Alfred Schutz (1967) for a phenomenological investigation of intersubjectivity and the social.) To borrow Paterson’s gardening metaphor, there are no sole, beautiful flowers. They must be cared for to grow, or be part of a natural ecosystem that allows them to flourish.Cognitive and negative symptoms are widely accepted as posing more of a burden to schizophrenia than the more flamboyant hallucinations and delusions. These seem to me to be due less to a difficulty conforming or complying to social rules that may be felt to be restrictive or repressive and more due to the difficulties with intersubjectivity and we-intentionality. The people I have worked with who were most limited by their schizophrenia in my judgment have been people with severe thought disorders who demonstrated severe loosening of associations and word salad. I say... (shrink)

I have great sympathy for what seem to be two main goals in Michelle Ciurria’s (2014) “Moral Responsibility and Mental Health: Applying the Standard of the Reasonable Person,” although I am not sure the reasonable person standard achieves either of the goals. These central goals seem to be to preserve an objective standard of moral responsibility and to do so in a way that “does not depersonalize the target individual” (Ciurria 2014, 7). In this commentary, I focus on my doubts (...) about the adequacy of the reasonable person standard, at least as presented in Ciurria’s paper, to meet either of these goals. It might be that had she chosen the example of the psychopath rather than Tourette syndrome to work through in a .. (shrink)