Commentary on "The Social Relocation of Personal Identity"

What journey must clinical psychiatry make once it has fully accepted and mourned the "death of the subject?" As Hinshelwood frames it, and I think he is right, clinicians will need

new ways of talking about personal identity, new conceptual tools. . . . Words indicating identity such as "my job," or "mine" [will have to be rethought. . . . Personal identity has to be understood as a process, and an interpersonal process at that, rather than as a structure. . . . [Furthermore,] this process does not end with childhood . . . it continues throughout life to be something that we gain, that may be altered, distorted, or to an extent even lost, by interpersonal processes.

(Hinshelwood 1995)

In order to rethink psychiatry, taking seriously the role of the social, clinicians must eventually devote as much attention to the humanities and social sciences as they currently devote to the biological and psychological sciences (Kleinman 1988). It is not so much that the "biopsychosocial" model has run its course, it is more that the model (which was meant as a corrective for the biomedical model) has not yet been adequately applied (Engel 1977). In psychiatry, there has been an unbalanced preoccupation with the biological and the psychological at the expense of the social. Rather than start over with a new paradigm, clinicians should turn the current model on its head. At least until the imbalance is corrected, the "biopsychosocial model" should become the "sociopsychobiological model." By changing the order, clinicians could change their hierarchies and the social could get the more sustained attention it deserves.

Of course, I can suggest changing hierarchies easier than I could convince actual people vested in a particular institutional order (in this case, experts and profiteers at the biological and psychological levels) to step down and let other actual people (experts and profiteers at the social level) have a turn at power. But my commentary is not about politics (one P, by the way, which was left out of the title of this journal); it is about mapping the journey clinical psychiatry must make based on the social relocation of personal identity. The first leg of the journey, where Hinshelwood's article is most helpful, is that clinicians must develop conceptual tools for understanding the mechanisms of interaction between the mind and the social, much as we are now developing tools for understanding the mechanisms of interaction between the mind and the body/brain. Second, clinicians must better understand that human mental functioning is as much socially embedded as it is biologically embodied. As such, clinicians should be as adept at the social level as they are at the biological and the psychological levels. Third, clinicians must better appreciate the role of the social in human suffering. Racism, sexism, classism, and prejudice are not just words—they are stones, and these stones inflict much of the pain that our patients bring to us. Fourth, clinicians must better recognize that we too are dynamic products of social interaction, and this includes not only our personal identities but our knowledge, our theories, our practices, and our norms. And fifth, we must acknowledge that one of the dynamic processes involved in who we are is the power differential in the clinical setting combined with the fact that we too benefit from the clinical encounter (Lakoff 1990). It is not a one way street. Our patients are not the only ones who benefit from our actions, and (with our increasing awareness of the social relocation of knowledge) we can no longer hide behind a veil of science as the neutral arbitrator for all that we do (Kuhn 1970; Rorty 1991). "Who us?" we clinicians seem to say. "We have no interest in electrically shocking our patients. We are just following the 'dictates of science.'" It is not so easy as that, and we have to start putting our own self-interest out on the table (Habermas 1984).

Sound like a long road? It is. But, as we tell our patients, all journeys begin with the first step, and who knows what pleasures there might be along the way. One such pleasure is...