It only makes sense that Sarah Nelson would follow her curiosity toward health profession questions; that’s the direction her own vocational goals are taking her. In this research she interviewed three professional women working directly in healthcare: a primary care physician, a psychiatrist, and a professor. She crafted identical questions that probed the relationship between liminal themes and medical practice. She provided information on liminality to all of the interviewees in advance. And after conducting the interviews she compiled the responses and drew her conclusions from their responses.

Interestingly, the responses Sarah received reflected one of the great challenges of Western medicine; the highly liminal domain is not easily traversed by those trained in worldviews and methods not easily adapted to the liminal. In other words, though traversing liminal reality requires practitioners adept in liminal leadership, that in no way means that those in the medical professions have been trained or equipped to provide that. In fact, the worldview of the western medical establishment may actually work against it. There are historic and cultural reasons for that and contemporary movements within the healthcare professions have stretched toward a more holistic model that might remedy some of those biases and deficits, but those concerns are outside the scope of this project.

Here is a summary of Sarah’s research in her own words.

Liminality and Healthcare
Sarah Nelson

I initially thought I would be presenting correlations and commonalities between all the different healthcare providers I have been interviewing. I thought I would be pointing at a PowerPoint on the board right now. But just like in an experiment, the results sometimes do not match the hypothesis, so you must change the hypothesis. I found few commonalities between these healthcare providers. Their liminal journeys through healthcare varied—big surprise I know. After interviewing all these amazing women, I realized I had been given something far more valuable than correlations. I was given their stories, their unique life experiences, and their idiosyncratic journeys through liminality. So, I knew the only way to truly honor their stories was to share the underlying message within them the best I could—and the only way to do that is through story.

Though I keep the names of my interviewees confidential, I will tell you that one is a respiratory therapist that now mainly teaches, one is a primary care physician, and one is a psychiatrist in private practice.

We’ll start with the first question I asked them, “Do you believe that physical liminality created by illness manifests itself in a parallel psychic/emotional/spiritual liminality at the same time and why?” The answer was a unanimous yes, of course. All agreed that there is a lot of emotional turmoil and strife that occurs when one is suffering from an ailment. There are the worries and thoughts of doubt that surface during a negative diagnosis. Sometimes there is almost a peace that comes over patients when they find out there is a name for what is happening to them. Internal liminality varies from person to person. Even the most religious of the women I interviewed didn’t believe there was a true Aha! spiritual/religious moment for people like there is in the movies. People don’t have as strong of an external-self and internal-self connection as we would like to believe. Most of the time we think of a person going through a physical illness and having psycho-emotional symptoms, but we don’t always think about the opposite. Often, people will have a mental illness and have physical symptoms as the result. The internal and external liminalities of a person are clearly connected, but most don’t quite see it.

My next question was, “What inner psychic/emotional/spiritual transitions have you witnessed while caring for a patient who is struggling with a disease process?” This question seemed to stump most of the practitioners. According to the respiratory therapist and primary care physician, that wasn’t an aspect of patient care they were around very much. Besides observing obvious emotional transitions, there isn’t much internal patient care that occurs in most traditional medical facility settings. The psychiatrist agreed with this statement and said that patients are referred to her if they need internal care. All the practitioners talked about how back in the 80s until recently medicine was all about fixing the problem. Going to the doctor was a colder experience, but now many medical facilities are wanting providers to consider the emotional/mental side of medicine when caring for a patient. They want providers to practice sympathy, but not necessarily empathy.

My third question was, “In what ways does the liminal state of the patient affect those around them, such as the family or caregivers? How does the patient’s liminal state affect family members and medical providers differently?” It would seem the practitioners answers came from experience being the family member of a patient instead of experience being the provider. The universal answer was that it is much harder being the family member of the patient than the practitioner. At the end of the day the provider can leave work behind and go home to their own families. But even when the family member of the patient goes home, they still carry the liminal burden of their loved one. The difference is that they can go home and not actively be a participant in the patient’s liminality.

My next question was, “What is the experience of the health care provider when the patient’s liminal state is permanent? If there is no exit from the liminal condition to a renewed state of being, but rather to death or the maintenance of a chronic condition, how does that change the perspective of the provider?” Here is where the provider’s answers began to differ dramatically. For some of the practitioners, whether a patient’s liminal state was permanent or not didn’t directly affect them. Their job was to continue to serve this patient the best they could no matter the circumstance. For others, when a patient’s status went from healthy/potential disease to permanent illness like cancer, diabetes, etc., they take the diagnosis hard. If the provider has known the patient for years, there is an inevitable attachment that occurs—shared liminality within the space of a clinic/hospital. This attachment means the provider grows truly joyful when the patient’s health improves, and it also means that the provider is crushed when the patient’s health declines. The provider will take personal responsibility and wonder if there was something, they could have done to prevent this from occurring. It is harder to separate themselves from a patient liminality-wise the longer they have known the patient.

My fifth question was, “What role may communitas take in the recovery of the patient and how may providers maximize its power – for patients, families and those in parallel situations?” What I found out is that there isn’t a very strong communitas between patients typically. Family being present as a form of communitas for the patient is a powerful tool to improve the health of the patient. Often, providers see two patients going through similar liminal experiences, but due to HIPPA they can’t introduce them to each other (even if it would be beneficial). So, sometimes they will refer these two patients to the same support group in hopes they’ll meet. The practitioners also generally agreed it is very beneficially for patients with certain illnesses that are more permanent to go to support groups. The providers say that they frequently refer patients to smoking support groups, AA, and various other support groups for different mental illnesses. Seeing other people dealing with the same strife and still going strong every day can be a powerful tool for patients to believe it is possible for them to do the same.

My next question was, “How has the experience of liminality in healthcare—in your work life—personally affected you? If you have had a personal experience outside of your work life, how did it affect you? Were the effects different from each other, and if so, why?” The answers to these questions were especially interesting. Medical professionals have literally been taught to avoid connection and thus liminality with patients. It is very interesting how similar that is to how soldiers are taught to ignore and avoid liminality. One provider described it as a wall between her and her patients. They all claimed that this wall is the only way to survive within the medical field. There is an actual term for being overly involved in the liminality of your patients—care/compassion fatigue. All of the negative symptoms that come with liminality (depression, anxiety, draining of emotional resources) that the patient experiences are also being experienced by the caregiver. Almost all the practitioners agreed that their first years in the medical field were the worst and most draining. They were overly enthusiastic and overly caring toward their patients. They all ended up being severely disappointed and drained because they realized they wanted their patients to get better more than their patients did. They realized they couldn’t be so involved in their patient’s liminal experience, and they had to let their patients choose the pace of their own healthcare journey. As medical professionals we all have one very similar trait in common—we are over achievers that want to get in there and fix it. Sometimes you can’t have that fix it mentality with people. Sometimes you need to have a “maintain” or “that’s ok” attitude like one of the doctors told me. One doctor told me that she asks her patients what their health goals are at the start of the visit. She doesn’t ask what their problems on, but what they want to work on—what their goals are. This way she knows what to address instead of getting too focused on things she deems more important that the patient doesn’t care about. Medical professionals can’t be a main liminal support for the patient—we would be losing practitioners every year if they were.

My final question was, “How has liminal experiences in your personal life affected your ability to be a liminal guide for patients and providers?” Most practitioners agreed that learning to handle your own liminal times with grace will directly affect your ability to handle other’s liminalities with grace. One of the doctors told me that she directly relies on her personal experiences to help her relate to the patient, show the patient she understands, and give the patient as sense of communitas. While medical professionals cannot actively engage with patient’s liminal experiences for the sake of their health, they can give a sense of communitas, and they think about their own experiences to try think about how they wish they would have been cared for in that time in their life. Your own experiences give you the wisdom and authority to be a helping hand through their muddled cloud of liminality. Most of my providers I interviewed agreed that healthcare is one of the most (if not the most) liminal of career fields. Most agreed they have grown more as a person in this field and have crossed many more thresholds than they speculate they could in any other field. The problem is that medical professionals have huge hearts capable of so much care and liminal growth, but the conditions that many health professionals face at work keep them from reaching that potential. The long hours, often being short-staffed, and constantly being high stressors makes being a true liminal guide and giving all the care they want nearly impossible.

From all the amazing stories from these women, I have learned that healthcare is both an extremely liminal field and an extremely anti-liminal field. Providers must battle the fine line of being a liminal guide, fighting off care-exhaustion, and battling poor work conditions in order to be the best provider they can possibly be. Maybe next time you go to the doctor, your psychiatrist, or to the clinic you should thank your healthcare providers for the liminal battles they fight to care for you.