Liminality and psychotherapy

Rites of passage and ritual

Exploring the concept of rites of passage, Turner (1988: 25) explains that rituals "separated specific members of a group from everyday life, placed them in a limbo that was not any place they were in before and not yet any place they would be in, then returned them, changed in some way, to mundane life.‟ The term ritual refers to the systematic use of rites or behaviour that may be private or social and which "may involve sacred or secular symbols‟ (Cohen 2002). Achterberg et al. (1994: 3) assert that rituals "give significance to life passages.‟ Ritual and image-making can help individuals navigate through illness (Achterberg et al., 1994). Sometimes, people report having significant dreams during transition phases. This might link to what Mohkamsing-den Boer and Zock (2004) call a “rêve de passage‟ (dream of passage) which, like ritual, may also have a “transitional function‟ in crisis and change situations.

Ritual is an important aspect of psychotherapy (Fisher, 2019; Wilson, 2022) and rituals are "an important aspect of all art therapy groups‟ (Skaife & Huet, 1998: 12). Examples of "rituals of art therapy‟ include "time for making images followed by discussion, often in a circular group; the display of work, shifting focus from one group image to another or holding the group image in view‟ so psychotherapy or art therapy "becomes a ceremony of redefinition‟ (Barber & Campbell, 1999: 30).

Rituals are important in psychotherapy and play a role in transition and continuity (van der Hart 1996). Kirmayer (2003: 249) notes that Frank (1973) includes "prescribed ritual time and place‟ as one of the five universal elements that occur in systems of symbolic healing. The other universal elements outlined by Frank (1973) are: a person who is experiencing difficulty, a person who is defined as a healer who is deemed to be efficacious, "symbolic actions that are intended to transform" the difficulty or illness, and "expectations for recovery". Kirmayer (2003) notes that "These elements make up the ‘assumptive world’ invoked by a specific healing practice. Much of the efficacy of healing interactions can be understood in terms of symbolic and strategic moves within this shared assumptive world (Dow, 1986; Kirmayer, 1993; Levi-Strauss, 1967)." Achterberg et al (1994: xv) propose that "an image or a symbol that effects healing – is most fundamentally evoked through some form of ritual. A healing ritual forms the "container‟ for using the imagination for healing.‟

Liminality

Rites of passage are fundamentally characterised by the liminal phase (Mahdi et al., 1996) which is the most important as it is the core of where transition occurs (Lertzman, 2002). Turner outlined key characteristics of liminality experienced by "threshold people‟ (Turner 1995:95) including: 

• Limbo: "ambiguity‟, "social limbo‟, being "out of time‟ (Turner, 1982: 24), "neither here nor there; … betwixt and between‟ (Turner, 1995: 95); 

• Power / powerless: "submissiveness and silence‟ (Turner, 1995: 103), structural inferiority and outsiderhood (Turner, 1975: 231), reduced status, "passive‟ (Turner, 1995: 95); 

• Playing: "playful experience‟ (Turner, 1988: 124-125), "ludic (or playful) events‟ and use of "multivocal symbols‟ (Turner, 1982: 27); experience of "flow‟ (Turner, 1982: 55-58), potentially transforming, possibility (Turner, 1986:42; 1990: 11-12); 

• Communitas: "intense comradeship‟, "communion‟ (Turner, 1995: 95-96); 

• Embodied experience: experiencing physiological "ordeals‟ (Turner, 1995: 103), "pain and suffering‟ (Turner, 1995: 107), stigma, "effacement‟ (Turner, 1982: 26), "polluting‟ (Turner, 1967: 97), "sexlessness‟ (Turner, 1995: 102), androgyny (Turner, 1967: 98), involving "performance‟ and "expression‟ such as in "acts‟ and "works of art‟ (Turner, 1982: 12-15).

1. Limbo

The first characteristic of liminality to be explored in its relevance to life difficulties and to psychotherapy and art psychotherapy experiences is limbo. Turner (1988: 25) discusses how during rites of passage people can find themselves "in a limbo that was not any place they were in before and not yet any place they would be in.‟ He describes this as a state of "ambiguity‟, "social limbo‟, and being "out of time‟ (Turner, 1982: 24), "neither here nor there; … betwixt and between‟ (Turner, 1995: 95). People do not necessarily move through the three phases of rites of passage but can get held in liminality (Turner, 1974). There can be a phase of acute liminality and there may be an enduring phase of chronic liminality (Little et al., 1998: 1490), such as when a person has a long-term condition. Perhaps chronic liminality can also happen if long-term therapy is needed, or if therapy goes on and on with little sense of an ending.

Limbo in psychotherapy and art psychotherapy could link to how therapy acknowledges the importance of "staying with the uncertainty or not knowing what it “means” or “says” which is central to the therapeutic process‟ (Case and Dalley, 1997: 65). This is about "cultivating the ability to wait‟, which Claxton (1998: 174) regards as similar to Keats' concept of "negative capability‟ (Rollins, 1958: 193). Limbo also relates to the liminal space-time that psychotherapy and art psychotherapy offer.

Liminal space

Turner (1982: 25) notes that in rites of passage the change in social status is often "accompanied by a parallel passage in space… the literal crossing of a threshold which separates two distinct areas.‟ "Threshold‟, "liminal‟ or "ritual space‟ is important in self-discovery and transformation (Bly, 1993: 194-199). Perhaps one way of conceiving liminal space in therapy is to use Foucault's (1986) concept of the "heterotopia‟, a real place set apart from other places, a place that is somehyow 'other' or different. Perhaps some of the spatial locations in therapy experiences might be described as heterotopic and I suggest that heterotopia could be a metaphor for the psychotherapy and art psychotherapy space and indeed the artwork / play spaces within therapy.

Foucault (1986: 24-25) proposes that heterotopias probably occur in every culture although they take varied forms. One category features "crisis heterotopias‟ which are "privileged or sacred or forbidden places‟ for those in crisis, but he suggests these are being replaced in our society by "heterotopias of deviation‟ meant for people regarded as different to the norm. The latter might link to the aspect of stigma potentially associated with liminality (Turner, 1967: 97) and mental health issues, and indeed with seeking psychological help (Pandey & Thomas, 2001). Perhaps, taking a stance that is trauma informed and avoids psychopathologising can help make psychotherapy a constructive heterotopic crisis space, as opposed to "heterotopias of deviation‟, thus reducing perceived stigma.

Foucault (1986: 25) suggests that the heterotopia is "capable of juxtaposing in a single real place several spaces, several sites that are in themselves incompatible‟ and can take the form of "contradictory sites.‟ Perhaps, in psychotherapy, contradictory views can be explored, various symbol meanings within artworks can co-exist. 

Foucault (1986: 24) uses the metaphor of a "mirror‟ for a heterotopia. He suggests that in the mirror "I discover my absence from the place where I am since I see myself over there‟ and "I come back toward myself; I begin again to direct my eyes toward myself and to reconstitute myself there where I am.‟ Simon (1992: 199) asserts that "Art as therapy is a mirror that the patient makes to find his own self reflected.‟ Perhaps psychotherapy and art psychotherapy and the artwork offer heterotopic spaces and mirrors for discovery and reconstitution of the self that could be termed a form of "re-authoring‟ (White & Epston, 1990) or "narrative reconstruction‟ (Williams, 1984). Perhaps the heterotopic mirror function of in psychotherapy can provide a "site of alternate ordering‟ where the person can "begin again to direct my eyes toward myself and to reconstitute myself there where I am.‟ (Foucault, 1986: 24).

Liminal time

Turner (1995: 96) asserts that liminal experience is a "moment in and out of time.‟ Foucault (1986:26) suggests that heterotopias are linked to "slices in time‟ and the "heterotopia begins to function at full capacity when men arrive at a sort of absolute break with their traditional time.‟ Turner (1982: 55-59) suggests that in liminality there can be an experience of "flow‟ or timeless absorption in the moment. Csikszentmihalyi (2002) explores the concept of flow. There can be experiences of various types of time, e.g. chronos - chronological quantitative time, kairos - qualitative time, and aion - eternal or sacred time. Segall (2015) summarises: "Aion is time as experienced by the archetypes themselves (rather than, as with Kaironic time, when the archetypes spill out of eternity to participate in our more mundane experience)." Segall (2016) states "Only Chronic time seems to happen to us, while Kairotic time waits for our creative response. Aionic time dissolves any difference between what happens to us and what we make happen." The word Aion (αιών) was originally used by Homer to mean entirety analogous to a lifetime, then by Plato to mean divine time, and by Aristotle to mean the eternal time of the cosmos as viewed as a whole from 'outside' (Keizer, 2000). Aristotle, in Physics, 219b (IV.xi), asserts that chronos features three elements: it features movement or change in time, it can be measured, it has a serial order as in before and after (Smith, 1969, pp.2-3); "chronos time is a grid upon which events can be plotted..." (p.3).

Kairos is "the right or opportune moment‟ and "reigns where creative purposes are to be achieved‟ (Aldridge 2000: 3). See the section on Kairos on this website. Smith (1969, p.1) summarises that "kairos - points to a qualitative character of time, to the special position an event or action occupies in a series, to a season when something appropriately happens that can not happen at 'any* time, but only at 'that time', to a time that marks an opportunity which may not recur." Bartunek and Necochea (2000) note that White (1987: 13) clarifies that the term kairos originates in archery and weaving. In archery it relates to an "opening‟ or "opportunity‟, specifically "a long tunnellike aperture through which the archer's arrow has to pass.‟ Interestingly, Turner (1982: 41) asserts that liminality can have positive and active qualities especially when the transition or threshold is "protracted and becomes a “tunnel”, when the “liminal” becomes the “cunicular”.‟ In weaving, kairos relates to “the critical time” when the weaver must draw the yarn through a gap that momentarily opens in the warp of the cloth being woven‟ (White 1987:13). Overall White summarises that it means "a passing instant when an opening appears‟ which must be moved through to achieve success. Kairos encompasses ideas of crisis and opportunity. Perhaps psychotherapy can enable experiences of flow and kairos by creating an opening or opportunity for "ritual and aesthetic performances‟ in which Schechner (2003: 58) suggests the limen is "expanded into a wide space both actually and conceptually‟ and "becomes the site of the action.‟

Hartocollis (1983) and Sabbadini (1989) propose that varieties of time and timelessness experience feature in psychoanalysis. Similarly Schubert (2001) comments that analysis has to handle an apparent contradiction in that it creates and uses both a timeless perspective, as in regression and rhythmic recurrence of sessions, and a linear time perspective, in its time-limited nature and development towards set goals. He suggests this parallels the timeless nature of the unconscious versus the linear time of conscious reality.

In relation to time and space, Foucault (1986: 26) asserts that heterotopias have "a system of opening and closing that both isolates them and makes them penetrable.‟ They are "not freely accessible‟ but either entry is "compulsory… or else the individual has to submit to rites and purifications. To get in one must have permission.‟ Perhaps this parallels healthcare systems and psychotherapy which both have ritual-like procedures of assessment, entry and time boundaries. Toombs (1990) cautions that in temporal experience of illness there can be a disparity between the patient's experience of "flux of subjective time‟ and the healthcare practitioner's approach based on objective time. Kairos and chronos. As a psychotherapist and art psychotherapist I need to be aware that clients can use therapy to escape from "our fear of losses, separations, endings‟ and to "escape from it into timelessness‟ or an „addiction to the experience of timelessness‟ (Molnos, 1995: 19-20). Dreifuss-Kattan (1994: 125-128) suggests that artworks become "transitional objects between… past time and present time‟, allowing for "a temporary defense against timelessness in its traumatic, fragmenting aspect‟, and helping patients face endings and mortality and experience the duality of "end‟ and "endlessness.‟ This links to Yalom's work on the existential givens, such as death, and our defences against them and implications for psychotherapy.

Bakhtin (2000: 84) uses the term "chronotope’, meaning "time space‟, to refer to "the intrinsic connectedness of temporal and spatial relationships that are artistically expressed in literature.‟ Perhaps Bakhtin's (2000) concept of the "chronotope‟ could be applied to the artwork in art psychotherapy that embodies clients' expression of "time space‟. He proposes that in "the literary artistic chronotope, spatial and temporal indicators are fused into one carefully thought-out, concrete whole. Time, as it were, thickens, takes on flesh, becomes artistically visible; likewise space becomes charged and responsive to the movements of time, plot and history‟ (Bakhtin, 2000: 84).

2. Power / powerlessness

A second characteristic of liminality to be explored in its relevance to clients' experiences and psychotherapy / art psychotherapy is power / powerlessness. Turner (1975: 231) suggests that liminality is associated with structural inferiority and outsiderhood, submission to "authority‟ (Turner, 1995: 103), being "passive‟ (Turner, 1995: 95), "submissiveness and silence‟ (Turner, 1995: 103) and also with "ritual powers‟ (Turner 1995:100). Difficult life experiences and trauma can evoke feelings of helplessness or powerlessness. A trauma informed pluralistic approach in psychotherapy / art psychotherapy aims to empower people and promote a sense of agency.

The issue of power in healthcare is complex (Canter, 2001) and the relationship is fiduciary, based on trust. In pluralistic practice, collaboration is important and empowerment of the client is vital, promoting client strengths, choice, agency, and voice. This is consistent with the trauma informed care principles of empowerment, choice, collaboration. It is also an important part of co-production. Perhaps patients' degree of trust in the fiduciary relationship with a doctor and/or psychotherapist can depend on whether they perceive the practitioner's power as constructive or not. or how information is used. For instance, as "legitimate‟, "expert‟ and "referent‟ or not, or as "reward" or "coercive" forms of power (French & Raven, 1959). Turner (1982: 26) describes how liminal persons undergo a "leveling‟ process which can feature symbols of effacement. Promoting client choice is important in psychotherapy and also with regard to art materials and therapy decisions in general and this is facilitated through the therapy contract and regular contract reviews. Psychotherapy and art therapy can aim to promote empowerment. Yet losing control to art materials or play processes during spontaneous creative work might also help a person come to terms with lack of control, or it may trigger difficult reactions. 

The next section on playing also discusses the relationship between various types of play and power or powerlessness.

3. Playing 

A third characteristic of liminality to be explored in its relevance to cancer experiences and psychotherapy or art therapy is playing. Liminality is associated with "varieties of playful experience‟ (Turner, 1988: 124-125). Indeed, Wilson (1980) reconfigures the classic three phase rites of passage model and parallels separation with "preparation‟, liminality with "play‟ and incorporation with "a game‟ where people develop new thoughts and behaviours. Turner discusses the relevance to rites of passage of Callois' (1962) theory of play. A surrealist and anthropologist, Callois outlined types of play ranging from play bound by conventions (ludus) to spontaneous improvisation (paidia). Turner (1988: 125) notes that paidia stems from the Greek word for "child‟ (Caillois, 1962: 27) and it is defined as "free improvisation‟ (Caillois, 1962: 13) and "spontaneous manifestations of the play instinct‟ (Caillois, 1962: ). Ludus involves a "tendency to bind it with arbitrary, imperative, and purposely tedious conventions‟ (Caillois 1962:13) and "calculation and contrivance‟ (Caillois, 1962: 31).

Therapy has been conceived of as a form of playing, in fact Winnicott (1996:57) makes "a plea to every therapist to allow for the patient's capacity to play.‟ The presence of the psychotherapist or art therapist is important because "It would seem that play lacks something when it is reduced to a mere solitary exercise‟ (Caillois, 1962: 39) and such players "need an attentive and sympathetic audience‟ (Caillois, 1962: 40). Therapy can seem to give a person permission to play.

Permission is both internal and external, thus relating to Rogers (1996:353-359) summary of "inner‟ and "external‟ conditions fostering creativity. I endeavoured to provide the external conditions: firstly "psychological safety‟ established by regarding both client and artwork as of unconditional worth, being non-judgemental and empathic; secondly "psychological freedom… of symbolic expression.‟ These could foster inner conditions in the client: firstly "openness to experience‟ and a "tolerance of ambiguity‟; secondly an "internal locus of evaluation‟; thirdly "the ability to toy with elements and concepts‟, i.e. "the ability to play spontaneously with ideas, colors, shapes, relationships…‟ 

Types of play and their relationship to power or powerlessness

My professional and personal experience indicated that cancer experiences feature diverse types of play and each seemed to be in a relationship with power or powerlessness. These included play associated with Caillois' (1962) types of play: (i) role-play (Mimicry), (ii) chance or fate (Alea), (iii) competition (Agôn), (iv) vertigo (Ilinx).

(i) Mimicry / role-play

This type involves play that is like or "wearing a mask, or playing a part‟ (Caillois, 1962: 20). This could relate to various forms of disguising such as masking emotions to protect others and denial which may be adaptive as a normal reaction allowing adjustment or may be maladaptive if problematic. It can relate to theories such as Winnicott's concept of the True Self and False Self, Rogers' concept of the organismic self and the self-concept. This type of play might link to concepts of the promoted self, identification, the adapted self, learned behaviour, etc.

(ii) Alea / chance or fate 

This type of play relates to chance or fate. The player is "entirely passive… All he need do is await, in hope and trembling, the cast of the die… alea is a negation of the will, a surrender to destiny‟ (Caillois, 1962:17-18). Superstitious thinking could be evoked which could be conceived as negative or positive. Caillois (1962: 46-47) suggests that a "corruption‟ of alea can involve "superstition‟ and talismans. However, Schaverien (1992, 1994) suggests that in art therapy the artwork can have a positive function as a "talisman‟. McNiff (1998:69) also comments that physical objects made in art therapy become "props, talismans‟. Ritual art-making can have associations with power, play and the auspicious. Ritual threshold art symbols called kolams (Kavuri, 1998; Nagarajan, 1997), muggu or, when coloured, rangoli (Kilambi, 1985; Reddy, 1998), are made by Hindu women in the "liminal space of the threshold‟ of houses (Kavuri, 1998). A "kolam‟ has associations with play and warding off bad luck and is created in a "ritual  performance‟ at a "contingent moment‟ or threshold time, such as morning, and kolams associated with the woman's sense of "agency‟ (Kavuri, 1998).

(iii) Agôn / competition

This play is "competitive‟, "like a combat‟ (Caillois, 1962: 14). Some metaphors relating to illness experience link to fighting the illness, win or lose. Physical or mental illness can be perceived by some clients as an enemy within. The situation can seem sometimes like an either/or, or a competition between wellness or illness, life or death.

In studying Ndembu rites of passage, Turner (1967: 59-92) found that many rituals featured the symbolic colours red, black and white, with white being linked to life, purity and health, black to impurity and death, and red to blood and power. Bly (1993:200) suggests that Europeans have similar meanings for these colours. According to Berlin and Kay (1969), these three colours are the first to be named in many languages. Red can represent ambiguity as in "betwixt and between‟ situations and "conceptual boundary crossings‟ (Jacobson-Widding, 2001: 2247). Owoc (2002), citing Taçon (1999: 122), asserts that "colour plays an important role in the recording of change, in that new identities are "given substance‟ and „particular events are highlighted or defined through the deliberate use of colour and coloured materials.‟ She adds that colour is often "intimately involved‟ in the "communication of change, time, and identity‟.

It is important to point out that Turner (1982: 27) emphasises that liminality involves the use of "multivocal symbols‟, i.e. "symbol-vehicles –sensorily perceptible forms‟, such as "trees, images, paintings… that are each susceptible not of a single meaning but of many meanings.‟ This parallels Jung's (1981: para.199) concept of the "shimmering symbol‟, whose meaning in art therapy is not fixed, but living (McNiff, 1992: 105). Symbols carry a sense of "and–and–and‟, this being "the essence of art as therapy and the therapist must beware of defining symbols as fixed signs‟ (Simon, 1997: 116). Modell (1997) suggests that metaphorical expression enables a fluid experience along two spectra of fixed to open as well as personal to collective meanings. Thus I believe art therapy can promote a both/and perspective rather than an either/or perspective.

(iv) Ilinx / vertigo

Such play is "based on the pursuit of vertigo and… an attempt to momentarily destroy the stability of perception and inflict a kind of voluptuous panic upon an otherwise lucid mind‟ and is etymologically linked to whirlpool (Caillois, 1962: 23-24). It can be an embodied experience - feeling one is reeling, dizzy, falling... This can relate to anxiety related experiences, panic attacks, confusion, inability to think, etc. The existential experience of one's own mortality is perhaps relevant here. 

Symbolic objects

Turner (1982: 32) suggests that ritual objects can be played with but liminal play is not "leisure‟, rather it is "in earnest‟, associated with "work‟ and involves "performing symbolic actions and manipulating symbolic objects‟ or ritual objects to bring about change. Art therapy is not just a diversion or pastime (Schaverien, 1992: 2). McNiff (1998: 69) argues that the physical objects made in art therapy "have especially potent powers for stimulating ritual, performance, and creative movement. They become props, talismans, and ritual objects.‟ Artwork can act as a "transitional object‟ (Winnicott, 1996: 1) in therapy and act as a defence against anxiety, particularly at times of transition (Arthern & Madill, 1999: 1). Young (1994) asserts that Winnicott (1996) believed that the transitional object "is the rite of passage for entering the realms of symbolism and culture.‟  Arthern and Madill (2002: 384) suggest that clients can use transitional objects within "ritualised sequences of behaviour.‟ They propose a five phase spiral theory of how transitional objects enable clients to move through a holding process (Arthern and Madill, 2002: 379) in which the:
1) client cannot hold a positive sense of self;
2) therapist holds for the client;
3) transitional object holds;
4) client holds the transitional object and can evoke the therapist‟s holding capacity;
5) client holds without a transitional object.

Artwork can function as a "container‟ (Bion, 1959: 308-315), a "talisman‟ (Schaverien, 1992) and be the focus of transference. Schaverien (1994: 82) argues that art therapy is different from psychotherapy in that the artwork can become a "scapegoat‟ and then "disposal‟ can occur through its destruction or leaving with the art therapist. She adds that the act is "empowered through ritual, and so becomes an “enactment”…‟ Moon (2001: 39) describes this as "a positive enactment of ritual transference and disposal.‟ Thus artwork, as transitional object, container and scapegoat, has a potential to enable a person both to develop their capacity to hold both positive and difficult aspects and also dispose of particular aspects.

Flow

Writing of play, Turner (1982: 55-59) suggests there is a relationship between the liminal and Csikszentmihalyi's (2002; Csikszentmihalyi and Csikszentmihalyi, 1988) concept of "flow‟, a holistic sensation experienced when one is totally involved in an activity. Csikszentmihalyi (2002: 49-70) describes characteristics of flow: a merging of action and awareness; a loss of self-consciousness yet paradoxically a resulting stronger sense of self; a centring of attention; a loss of ego as kinaesthetic awareness is heightened, a transformation of time experience; a challenge yet achievability as there is a developing "capacity to manipulate symbolic information‟ (Csikszentmihalyi, 2002: 50); and autotelic experience i.e. worth doing for its own sake (Csikszentmihalyi, 2002: 67). He also suggests that £the possibility, rather than the actuality, of control‟ (Csikszentmihalyi, 2002: 60) is experienced and this contributes to feeling empowered through playing.

This links to the "reverie‟ art-making offers (Milner 1977:163; Simon 1992:88), to Maslow's (1971: 63) "absorption‟ component of "peak experience‟, to Winnicott's (1996) concept of the "relaxed state‟ which generates "creative playing‟, and possibly links to meditative experience such as "jhana‟ or "total immersion‟ in an object the mind is centred on (Gunaratana, 1988). 

4. Communitas

A fourth characteristic of liminality to be explored briefly in its relevance to presenting issues and people's experience of psychotherapy or art therapy is communitas. Turner (1982: 58) notes that whilst "flow‟ is experienced within an individual, "communitas‟ is experienced between individuals. A form of social "anti-structure,‟ it is a "liberation of human capacities of cognition, affect, volition, creativity, etc., from the normative constraints incumbent upon occupying a sequence of social statuses‟ (Turner, 1982: 44). In this form of shared experience, social interaction, communion or connection "fellow liminars‟ treat each other as equals irrespective of previous status differences (Turner, 1967: 7).

Montgomery (2002:34-35) comments that groups with specific goals like "coming to terms with a diagnosis of cancer‟ have a "homogeneous population with a shared and clearly stated aim.‟ Promoting social support and connectedness is an important trauma informed care principle. Montgomery (2002:38) cites research suggesting that "group cohesion‟ is linked to efficacy of group therapy (Tschuschke and Dies 1994). Sharing, witnessing and active participation can help individuals build a bridge from "alienation‟ towards social experience (Winnicott 1996). Art therapy group-studio chemistry can be based on "the process of individual people performing the intimate and isolating rituals of painting within a communal environment‟ (McNiff, 1995: 182). McNiff adds: "It is this process of making art together and then bearing witness to the arrivals in a sacred way that establishes the healing imagination of the environment.‟

As noted by Barber and Campbell (1999:30), art therapy rituals can be paralleled with Myerhoff's (1982: 105) concept of "definitional ceremonies‟, in which White (2000) notes that "socially marginal people, disdained, ignored groups‟ can engage in "collective self definitions‟ as can individuals with "spoiled identities‟ (Goffman, 1963). White (2000) summarises that in the "tellings and retellings‟ of definitional ceremonies people's lives are "re-membered‟ thus enabling people to revise "the membership of their association of life‟, contributing to the "production of multi-voiced identities.‟ In art therapy groups, the therapist, group and artworks perhaps provide a "reflecting team‟ or "outsider-witness group‟ (White 2000) in which such definitional ceremonies occur. However, perhaps ritual is a better term than ceremony. Turner (1982: 80-81) explains that "Ceremony indicates, ritual transforms, and transformation occurs most radically in the ritual “pupation” of liminal seclusion – at least in life-crisis rituals.‟ He adds that "Living ritual‟ can be "likened to artwork‟. Perhaps in psychotherapy or art therapy what might be called re-definitional rituals can occur. Care is needed when creating art therapy groups to ensure the group make up is appropriate and to try to avoid cross-traumatisation.

In relation to the four categories already discussed above, I have suggested that Turner's model of liminality illuminates both the psychotherapy or art therapy experience and presenting issue experience. It is possible that liminality and its characteristics are valuable lenses through which to explore the lived experience of diverse experience, particularly life-threatening illnesses and other liminal experiences. Turner's model suggests that at times of transition and anxiety people are stimulated to engage in ritual and symbolic expressions and performances associated with rites of passage. The model throws light on some factors that prompt humans to make art at transitional times potentially for individual and evolutionary functions. 

Perhaps psychotherapy or art therapy can provide an opening for symbolic and metaphorical expression of liminal experience. Amidst limbo it can offer therapeutic liminal or heterotopic space and therapeutic time and timelessness experience and foster capabilities for staying with uncertainty. Amidst diminished power it can offer empowerment and constructive lack of control. Amidst hiding, chance-driven, competitive and frightening forms of play it offers improvisational play with symbolic objects and colours, thus stimulating flow experience and promoting empowerment and a both/and rather than an either/or perspective. Amidst alienation it can provide opportunities for creative communion and comradeship. In general it offers a potential for re-definitional rituals.  This is facilitated by an attentive therapist and "reflecting team‟ that includes the artworks and, in groups, group members. The use of multivocal symbols allows previously suppressed voices to be expressed and join the dominant voices, thus enabling a process of "social inclusion‟ (McLeod 1999) to previously unshared material. Such experience could also develop a person's capacity for crossing thresholds and thus deal with the "oscillating trajectory‟ between acute and sustained liminality (Little et al., 1998: 1493), Perhaps psychotherapy or art therapy accommodates, and can potentially promote better tolerance of, the unique, ambiguous and shifting meanings inherent when confronting difficult experiences.

5. Embodied experience

Turner (1982: 12-14) notes that Dilthey (1976) links "experience‟ with the phenomenological concept of "Erlebnis‟ which relates to our "lived experience‟ engaging in "embodied action‟ (Burch 1990). This is congruent with the embodiment paradigm (Merleau-Ponty, 1962) and "corporeal turn‟ (Sheets-Johnstone, 1990; Ruthrof, 1998) which emphasises that the "body is also, and primarily, the self. We are all embodied‟ (Synnott, 2001: 1). Thus it is important to acknowledge the significance of the body in experiences that bring people to therapy and in the therapy itself, such as in art therapy (Simon, 1992; Lark, 2001).

Turner (1982: 12-15) believes that experience "presses out‟ to an „expression‟ that completes it and which takes the form of "ideas‟, "acts‟ and "works of art‟. Expression involves "performance‟ and generation of "myths, symbols, rituals, philosophical systems, and works of art‟ (Turner, 1982: 52; 1995: 128). This is congruent with art therapy in which experiences are expressed particularly through symbols, rituals and potential embodiment into artwork.

In liminality, the "self‟ can be "split up the middle‟ and becomes both "subject and object, something that one both is and that one sees and, furthermore, acts upon as though it were another‟ (Turner, 1988: 25). Perhaps psychotherapy or art therapy can help address such a splitting. The mind-body interrelationship that is difficult to experience can be "glimpsed in artwork‟ as the physicality and symbolic aspects of art enable "wordless layers of experience to be rendered in concrete form‟ (Wood, 1998: 34-35).

Embodied liminality

Turner (1995: 107) proposes that liminality is an "embodied‟ state and this features various dimensions that might be summarised as relating to realities and/or perceptions of:
1. Physicality: experience of "pain and suffering‟; "physiological processes‟ such as "death and birth‟ (Turner, 1995: 107); „ordeals… often of a grossly physiological character‟ (Turner, 1995: 103); engagement of "All the senses‟ (Turner, 1982: 81).
2. Structural inferiority and power: experience of "humiliations, often of a grossly physiological character‟ (Turner, 1995: 103); "effacement‟ (Turner 1982:26); stigma and perceptions of being "polluting‟ (Turner, 1967: 97); outsiderhood (Turner 1975:231); "marginality and structural inferiority‟ (Turner, 1995: 128). Yet, perhaps in compensation for structural inferiority, liminars can experience „ritual powers‟ (Turner 1995:100); "a special kind of freedom, a “sacred power”‟; "close connection with the non-social or asocial powers of life and death‟; and regard "cosmological systems‟ as important (Turner, 1982: 26-27).
3. Sexual embodiment: "sexlessness‟; „sexual continence‟ or „discontinuance of sexual relations‟; "the absence of marked sexual polarity‟ (Turner, 1995: 102-104).
4. Expression: "performance‟ and "expression‟ such as in "ideas‟, "acts‟ and "works of art‟ (Turner, 1982: 12-15); generation of "myths, symbols, rituals, philosophical systems, and works of art‟ (Turner, 1982: 52, 1995: 128).

The rest of this section will explore these dimensions of embodied liminality by means of discussing how the last - expression, as relevant to psychotherapy or art therapy, relates to each of the first three – physicality, structural inferiority and power, sexual embodiment, in the context of experiences brought to therapy and experiences in therapy.

Physicality

The first dimension of liminal embodied experience that I will explore is physicality. This includes various aspects such as experience of “pain and suffering‟, “ordeals‟ and engagement of “all the senses‟ (Turner, 1982, 1995).

‘Pain and suffering’

Pain reflects our embodied nature since it is an experience of an embodied mind (Kleinman 1994: 8). “Total pain‟ presents as “a complex of physical, emotional, social, and spiritual elements‟ (Saunders, 1996) and exploring this concept, Clark (1999: 727-728) cites Morris (1991: 3) who argues that pain “emerges only at the intersection of bodies, minds and cultures.‟ This perhaps indicates the liminal or interstitial nature of pain. Change in embodied experience, such as suffering, loss of trust, or control over one’s body, is a key distressing aspect of the illness experience (Morse et al., 1995). Art therapy enables symbolic expression of pain (Miller, 1996: 133) and it has been claimed that it can help its management (Thomas, 1995; UMCCC, 2004).

‘Ordeals’

Difficult life experiences can feel like going through an ordeal.

Multi-sensory experience

In liminality, Turner (1982: 81) notes that all senses can be involved, including “kinaesthetic‟ experience, and he links this with the social drama aspect of ritual. All senses can be affected in difficult life experiences. The multi-sensory nature of art-making lends itself to expression of these aspects of such life experiences.

Art-making is a “visceral experience‟ that can reveal “kinesthetic messages‟ (Rogers, 1993: 69) and offer “kinesthetic release‟ (Hill, 2002). Haptics and touch senses are important in art-making, with “hands‟ playing a prime role, and these “skin senses‟ or “somaesthesia‟ link with the kinaesthetic senses of body position and movement (Prytherch and McLundie, 2002). Lowenfeld suggested that there are two art orientations: visual, looking at art from the outside as an observer; and haptic, experiencing more in sensory and kinaesthetic terms and feeling involved in art (Lowenfeld & Brittain, 1987).

Structural inferiority and power

The second dimension of liminal embodied experience that I will explore is structural inferiority and power. This includes various aspects such as body/self image and stigma, embodied boundary, cultural inscribed embodiment, and ritual power (Turner, 1967, 1982, 1995).

Turner (1995: 128) emphasizes that such experiences of “Liminality, marginality, and structural inferiority are conditions in which are frequently generated myths, symbols, rituals, philosophical systems, and works of art‟ which are expressions that can be “reclassifications of reality‟ and our “relationship to society, nature, and culture‟. Perhaps in this way psychotherapy or art therapy can offer a constructive liminal or heterotopic (Foucault, 1986) or chronotopic “time space‟ (Bakhtin, 2000: 84) where negative self-concepts and cultural stereotypes can be re-classified.

Body/self image, stigma

Body image is influenced by cultural factors including gender, age, ethnicity, age, social class, the media (Grogan, 1999) and health conditions (Cash and Pruzinsky, 2004). Synnott (2001: 1-2) asserts that our bodies, body parts and senses are “loaded with cultural symbolism‟ and are “socially constructed‟ and adds that self-change is more evident when “the body-change is sudden and unexpected‟. Some illnesses and medical treatment effects can negatively affect one’s body/self image (Burt, 1995) and self-esteem (Bottomley, 1997), generating feelings of powerlessness and isolation (Colyer, 1996) and loss of bodily ownership and control (Turner, 1996).

Some difficult life experiences can evoke a sense of shame, or a person can be shamed. Some people can feel, or be made to feel, that they are being punished for something they have done - bodies are inherently involved in discipline and punishment (Foucault 1991).Etymologically the word “pain‟ derives from Latin and Greek words meaning punishment and payment (Merriam-Webster, 2004). Goffman (1963) stressed the importance of the visibility element of stigma, and therefore its bodily dimension. Winnicott (1996: 36) suggests we can be patterned and “cut into shapes conceived by other people‟ and can develop a “compliant false self‟ and in contrast the “true self‟ has the “potential for the creative use of objects‟ (p.102). Perhaps in fostering this potential, psychotherapy or art therapy cultivates constructive relationship between the true self and appropriate presentations of self needed in different contexts.

This links to the concept of the “false body‟ (Orbach, 1994) and body ego (Boadella, 1989) which Freud (1923: 26, n.1) suggests can be regarded as “a mental projection of the surface of the body.‟ Rowan (2000) suggests there are three approaches to the body in psychotherapy: body and mind separate; body and mind integrated; bodymind as part of soul. Psychotherapy or art therapy seems to feature the second and/or third approaches and thus perhaps helps foster constructive relationship between the true body and appropriate presentations of body needed in different contexts.

Paradoxically, Myerhoff et al. (1987) suggests that because liminars are out of place, they are also “mysterious and powerful‟ and liminal beings or states can be “sources of renewal, innovation, and creativity.‟ Art therapy can help people move into a more active role and manage body image changes relating to hair, weight and disfigurement (Wood, 1998: 29-30) and emotional trauma, interpersonal problems and spiritual dilemmas (Malchiodi, 1999). Therapeutic groups can modify self-perceptions and internalised other perceptions and lessen extreme feelings thus balancing and integrating positive and negative self-aspects (Foulkes and Anthony, 1984: 150) and decreasing dependence on stereotyped behaviour (Thompson and Kahn, 1972: 116).

Embodied boundaries

The outer boundaries of our bodies are thresholds between the world and us, particularly the skin (Prost, 2004). Glover (1998) discusses how the body has been viewed as a “container‟ and, by virtue of artwork’s “corporeality‟ and capacity to “metaphorise the body‟, it too may be regarded as a container (Stokes, 1978: 328; Wollheim, 1987; Connell, 1998: 44). Thus a key feature of bodily experience is “containment and boundedness‟ (Johnson, 1987: 21) and “containment / constraint‟ (Sinha and Jensen de López, 2000). Anzieu (1989: 17) asserts even our skin is “both permeable and impermeable‟.

In cancer healthcare, Lawton (1998: 127) suggests that cancer patients particularly can be conceptualized as having an “unbounded body‟ when their symptoms cause “the surfaces of the patient’s body to rupture and break down‟ allowing bodily substances normally “contained‟ within the body to be uncontrollably “leaked and emitted to the outside‟. When this is not the case, patients could be deemed to have a “bounded body‟. Having “complete‟ skin is perceived as important (Rudge, 1998). Lawton (1998: 132) proposes that hospices can be places for the “sequestration of the unbounded body‟ and she links this to Douglas’ (1966) theories of “dirt‟, “pollution‟ and disorder of usual classifications. Such threshold crossings are deemed inappropriate, especially when evoking disgust. Lawton (1998: 134, 141) argues there is a “current Western intolerance of bodily disintegration and bodily emissions‟ and a “quest for firm bodily margins‟ (Bordo, 1993: 191), yet some forms of bodily substance sharing are deemed appropriate as in consensual sexual activity. With cancer patients, unboundedness deemed inappropriate can escalate whilst unboundedness deemed appropriate can decrease due to the lack of sexual relations evident in liminality (Turner, 1995: 104).

This is congruent with Turner’s (1995: 109) view that liminars can be regarded as dangerous and he links this with Douglas’ (1966) view that what falls outside usual classifications is regarded as “polluting‟. It links to Kristeva’s (1982: 4) view of the “abject‟ as that which relates to bodily  emanations, is ambiguous and “disturbs identity, system and order... does not respect borders, positions, rules‟. Awareness of embodied liminality means acknowledging the permeable threshold of the body and addressing the otherwise sometimes unspeakable realities of bodily disintegration as part of human existence and no more shameful than other culturally acceptable bodily emanations. It is important to acknowledge how “discourses of shame and dependence‟ affect the handling of “unspeakable‟ bodily needs (Street & Kissane 2001: 169). Bodies have fluid boundaries and ignoring the “volatile, messy, leaky‟ nature of bodies consigns them to the abject (Longhurst, 2001: 23), thus it is important to extend social inclusion to the liminal threshold crossing aspect of bodies.

Foucault’s (1986) concept of “heterotopias of deviation‟, a less constructive variant of liminality meant for people regarded as different to the norm, discussed earlier. Indeed Lawton (1998: 131) draws on Van Gennep (1960: 18) and suggests hospices could be “fringe”/”liminal” spaces within which these “nonpersons”, wavering “between two worlds”, remain buffered.‟ Bodily containment seems related to our sense of identity and self-containment. Anzieu (1989: 98-108) proposes the concept of the “skin ego‟ and suggests that its functions for the psyche parallel those of the skin’s physical functions for the body. Psychotherapy or art therapy may provide a heterotopia of crisis rather than deviation (Foucault, 1986). It is paradoxically a non-invasive treatment (Malchiodi, 1999), yet allows symbolic unboundedness and boundedness through symbolic self-expression and projective and introjective processes. Esrock (2002) proposes that when viewing art we can lose our bodily boundaries and experience an “imaginary fusion‟ of inner somatosensory sensations which through “somatosensory reinterpretation‟ are perceived as qualities of the artwork. In this way the “conventional boundary between self and object‟ is crossed. Esrock links this with psychoanalytic theory of projection and introjection. Milner (1977: 165) also suggests artists can experience a “con-fusion of “me” and “notme”.‟

Inscribed body

Interestingly, terms like sharp, prick, stab, stitch, tattoo and stigma are etymologically linked (Pickett et al., 2000). Body scars can indicate “an individual’s membership of a social group‟ as can tattoos (Anzieu, 1989, 105) and can be the mark of a survivor or warrior (Springer, 1996). There are correspondences between skin, paper and bark and the tree can be an image of our condition (Cohen & Mills, 1999). Turner’s (1982: 44) description of liminality as “an instant of pure potentiality when everything, as it were, trembles in the balance.‟

Cultural embodiment

Turner (1995: 103) suggests that those in liminality are a “tabula rasa, a blank slate‟ which can be “inscribed‟ and “whose form is impressed upon them by society‟. We are not just an embodied self because inherently we are in intersubjective relationships (Cohn, 1997: 25) with other embodied selves (Burch, 1990). Art therapists must address interpersonal body experience (Diamond, 2001), cultural influences on embodiment (Sinha and Jensen de López, 2000; Chapple & Ziebland, 2002) and that we are “culturally embodied‟ (Varela et al., 1993: 150). Hogan (1996) asserts that the artwork is not just a product of an individual, but rather it is embedded in, and influenced by, larger meaning systems. Such intersubjective embodiment experience may be grounded in psychoneurobiology. Recent research indicates that body and emotional experiences are linked to consciousness (Damasio, 2000). Schore (1999, 2003) proposes an “inter-brain‟, “brain-brain interactive perspective‟ which suggests that unconsciously we engage in “adaptive self-regulating processes of the brain-mindbody‟ both within our self (“autoregulation‟) and with others (“interactive regulation‟). Schore (1999) links this to unconscious “affectively-charged transference-countertransference interactions between patient and therapist.‟

Geertz (1973: 89) defined culture as a “historically transmitted pattern of meanings embodied in symbolic form by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life.‟ Culture may be viewed as having layers, like an onion, or like an iceberg with some being visible and others invisible, some conscious and some unconscious (Dahl 2003). This systemic perspective is developed by Hofstede (1991), Trompenaars and Hampden-Turner (1997) and Spencer-Oatey (2000). I have drawn on all these models in figure 4.3 to speculate how intersubjective and cultural influences exist in reciprocal relationships between individual and society. Our motivational roots, values and basic assumptions are the foundation which drive our beliefs, then our behaving and expressing (art-making) and tangible products (art). Hawkins (1997: 426, figs.2-3) uses the metaphor of water lilies for the cultural tangible products arising from the systemic layers. The cultural influences on us can be portrayed by the body as suggested by Bourdieu’s (1977) concept of “habitus‟ or “hexis‟. This refers to the partly unconscious habitual beliefs and dispositions towards action of the “socially informed body‟, manifested or “em-bodied‟ in a “permanent disposition, a durable way of standing, speaking, walking, and thereby feeling and thinking‟ (Bourdieu, 1977: 93, 124). Perhaps artwork, or lack of it, may mirror a client’s habitus as it mirrors their body.

It is possible that some aspects of habitus/hexis are not necessarily permanent and perhaps psychotherapy or art therapy is one approach that can enable a person to modify habitus, for instance from thinking and behaving in an “I'm not creative‟ way to an “I am creative‟ way. This might be a movement from a culturally-imposed constraining false self-body to a more constructive relationship with the true self-body. Importantly this must respect the client’s cultural diversity (Hiscox & Calisch, 1998; Campbell et al., 2003), and must not be the therapist’s own assumed-as-”right‟ cultural model imposed onto the client. Art therapists must have awareness of cultural influences and not let their own cultural views adversely affect professional practice (HPC, 2003a, 2003b), thus ensuring multicultural competency (Lister, 1999).

Sexual embodiment

The third dimension of liminal embodied experience that I will explore is sexual embodiment. This includes various aspects such as impact on sexuality and sexual relations (Turner, 1982, 1995). Part of our cultural embodiment is that we are a gendered body (Chapple & Ziebland, 2002). Body change can impact on the construction of feminine gender identity (Bordo, 1989, Grosz, 1994) Psychotherapists and art therapists need to have awareness of gender and its cultural influences and the effects evident in art and verbal expression (Hogan, 1996, 1997, 2002).

Hair

In some illness experiences such as cancer and its treatments, a person's hair can be affected.  Leach (1967) explored hair as a prominent feature of rites of passage, suggesting it has cross-cultural libidinal (life-force) meaning. Hair can have “magical‟ import as “a public symbol‟ with “explicitly sexual significance‟ (Leach, 1967: 103, 89). The male beard can be a component in masculine gender identity, communicating manliness (Pellegrini, 1973). Hair loss is directly visible to others and can be a “symbolic precursor to the loss of self‟ (Freedman, 1994: 336). Art therapy can help patients come to terms with changes in body image such as hair loss and identity (Wood, 1998: 29-30). Sometimes actual body parts such as hair can be used within art.

Liminal expression in embodied art

In the context of healthcare and psychotherapy experiences, art therapy and Turner’s model, I have explored three dimensions of liminal embodied experience by means of discussing how a fourth – expression, relates to each. The dimension of expression in psychotherapy or art therapy will now be explored further. Rituals associated with rites of passage and liminality are “performed‟ (Myerhoff et al., 1987; Turner 1982, 1988; Schechner, 2003) and have “a performed-for-an-audience aspect‟ (Turner, 1988: 76). Therefore they are intrinsically associated with body expression. Turner (1982: 12-15) asserts that lived-through experience (Erlebnis) is “pressed out‟ into expression that completes it and such expressions can be of three classes. These are: “ideas‟; “acts‟, many of which can be viewed as “expressing and fulfilling unconscious purposes and goals‟; and “works of art‟, in which the “unconscious formative component‟ is even more important. Turner (1982: 15) regards such works of art as “trustworthy messages from our species‟ depths, humanized life disclosing itself, so to speak.‟

Elsewhere, he asserts “artists tend to be liminal and marginal people, “edgemen,”…‟ and liminality frequently generates multivocal symbols, rituals and “works of art‟ (Turner, 1995: 128-129). Art therapy is a key approach that can facilitate and witness such expressions. The embodied nature of art expression is important. Jung (1996: 173;para.291) indicates that symbols are embodied: “The symbols of the self arise in the depths of the body and they express its materiality every bit as much as the structure of the perceiving consciousness. The symbol is thus a living body, corpus et anima…‟ Stokes (1978: 328) argues “There is a sense in which all art is of the body.‟ As suggested earlier, artwork might be a form of “chronotope‟ (Bakhtin, 2000: 84) or embodied “time space‟ in which “Time, as it were, thickens, takes on flesh, becomes artistically visible…‟

It has been suggested that transitional objects and their containing capacity function by a process of “embodiment‟ where the “continued existence of the therapist and the therapeutic relationship is given tangible form‟ (Arthern & Madill, 1999, 2002: 384). Schaverien (1994: 79) asserts that an image can become “embodied‟, i.e. when it holds powerful feelings that have been involved and expressed in its making (Skaife, 1995: 4). An embodied image “conveys a feeling state for which no other mode of expression can be substituted‟ (Schaverien, 2000: 59). A client reported that his art seemed to express something beyond words and “fundamental‟, almost more basic than even emotion.

Revelatory expression

Art therapy can be valuable in expressing that which has not been previously known or voiced. “Silence‟ is a characteristic of liminality (Turner, 1995: 103). Ritual can access “knowledge of what would otherwise not be known at all‟ (Douglas, 1966: 64) and it engages embodied knowledge not easily accessed by ordinary consciousness (Csordas, 1994). The concept of “threshold body‟ acknowledges felt knowledge of the body (Darroch-Lozowski, 1999). An inability to communicate is a feature of some experiences people bring to psychotherapy or art therapy - sometimes “language “collapses” in the face of the recollection of the incommunicable‟ (Little et al., 1998: 1486-1488). Some aspects seem unspeakable, whilst some seem unhearable. This might include issues relating to sexuality, body unboundedness and fear of death.

Macquarrie (1973: 268) cites Jaspers (1931: 716) who suggests that “the basic meaning of art is its revealing function‟ and Macquarrie adds “It reveals being by giving form to what we perceive.‟ Artwork can give form to the “unspeakable‟ (Case & Dalley, 1997: 97; Connell, 1998: 75), enabling “the unsayable to be said‟ and allowing acceptable ways to express “anger, acceptance, or fear of death‟ (Miller, 1996: 132-133). Lynch (1997: 128) suggests art is valuable when dealing with the “silence of the limits‟, those areas of human experience where verbal language and thus verbal therapy are inadequate. Art can reveal personality aspects inaccessible through verbal therapy (Coleman and Farris-Dufrene, 1996: 11). I believe art is also valuable in allowing expression relating to what Lynch calls “the silence of oppression‟ and this might relate to aspects of stigma, shame and the unhearable. Sometimes it is less threatening to approach a difficult issue in the art where it can be initially spoken of in the third person perhaps before being owned (Wadeson, 1980: 10).

Various written comments by clients participating in a piece of research I undertook related to the capacity of art therapy to reveal and express:

·  “It has been a way of expressing things that are unspeakable also emotions that you are sometimes not even aware of until they come out of your art.‟

·  (To) “…unearth hidden emotions and be able to express them in a safe environment.‟

·  “It stimulated thoughts and ideas which came to me outside the sessions, helped me to tap into my creative, intuitive side.‟

·  “The art allowed me to express feelings that were hard to put into words. Sometimes there are no words and art is an unspoken expression.‟

Perhaps psychotherapy or art therapy can help a person to reduce any perceived shame and thus find a voice. As well as being linked to unspeakable and unhearable this also seems linked to the issue of gaze and dealing with any difficulties of being visible or unseeable. We can look at or away from portrayals of suffering (Radley, 2002). This could link to shame and to feeling “exposed‟ and “self-conscious‟ (Erikson, 1977: 227) and “being looked at‟ (Lewis, 1987: 18).

Nathanson’s (1992, 1995/2004) “compass of shame‟ model suggests four defences against shame and perhaps some people can experience some from others or within self. The four points might also relate to defences used by others and society in response to issues such as mental health issues or other presenting issues. Such shaming responses can potentially inflict “symbolic violence‟ which is the imposition of values and meanings onto, or into, an individual or group so that they experience them as legitimate (Bourdieu, 1977). In this way, a stigmatised view of mental health issues and their effects can be an oppressive social construction that can disadvantage, and can also potentially project such defence responses into those affected by such issues.

Art therapy is valuable in providing a metaphorical area where frightening aspects of the human condition can be faced and managed (Arnheim, 1992: 170). Psychotherapy or art therapy also has an important role to play because the principles underpinning its practice accommodate a holistic and social model of health and also integrate a postmodern embodied paradigm (Corker & Shakespeare, 2002; Shakespeare & Watson, 2002).

Therapeutic / creative process and rites of passage

Experiencing life difficulties or mental health problems can provoke a crisis, resulting in an increase of regression and defence mechanisms (splitting, projective identification, projection, denial, repression). People can regress to the object relational “Paranoid-Schizoid‟ position that tends towards a polarised either/or, black-and-white perspective (Jarvis, 2004: 111) – this is a normal response. Here, paranoid refers to how some people can fear internal and external dangers (Riskó, 2001) and death. Schizoid refers to how some life issues and related feelings can be perceived as unbearable inner “bad‟ objects (Balint 1956; Dreifuss-Kattan, 1994: 125) that people attempt to get rid of through splitting and projective identification (Riskó et al., 1996, 1998). The projection is not owned, but is equated with its container, for instance a client stating that the “it/he/she‟ in the art is terrified. Ehrenzweig (1968) compares the Paranoid-Schizoid position to the first phase of the creative process, “Projection‟, in which fragmented unconscious material is projected onto/into the art. Perhaps we might also make a comparison with the rites of passage state of “Separation’ (Van Gennep, 1960; Turner, 1982, 1995) in which there can be a separation from society of that which is deemed ambiguous or problematic.

The transition to a new position involves containment. Projective identification (Klein, 1946, 1975, 1988) serves to “evacuate and “communicate‟ (Bion, 1959) intolerable “undigested‟ aspects (Bion 1984: 6-7). The psychotherapist or art therapist, the heterotopic (Foucault, 1986) “time space‟ (Bakhtin, 2000: 84), and artwork function as “containers‟ for these projections. Body-related claywork lends itself to such projective identification processes (Henley, 2002: 75). Art therapy rituals (Skaife & Huet, 1998: 12) such as contracting, opening, circular sharing, artwork reviews and closing also play a part in containment, thus art therapy involves re-definitional rituals. Healthcare professionals must be appropriately trained for if containment is inadequate there can be a re-introjection of unmodified projections by which a perosn can “experience not the fear of dying made bearable, but a nameless dread‟ (Bion, 1993: 116). When containment is adequate, projections can be “modified‟ or “digested‟, thus becoming “tolerable‟, capable of re-introjection (Bovensiepen, 2002: 245) and thinkable, thus “food for thought‟ (Glover, 1998). Ehrenzweig regards the creative phase of “Integration‟ as vital in this transition as it allows multiple possibilities to be held and both chaos and a “hidden order‟ to be experienced. This “deeper order‟ features a sense of more fluid boundaries between self and the world (Milner, 1977). Perhaps we might also make a comparison with the rites of passage state of “Liminality‟ that features limbo, ambiguity, embodied experience, chaos, playing with multivocal symbols, expression and transition.

The person can move to the “depressive position‟ that tends to be a both/and perspective where ambivalent feelings can be tolerated. Creativity and symbolisation are fundamental in the movement to this position (Glover, 1998). The projection can now be owned and the container viewed as merely representing it (Klein, 1975), for instance the client says the terrified figure in the art represents his/her own terror. Ehrenzweig (1968) compares the depressive position to the “reintrojection‟ phase in the art process in which the art’s hidden substructure is re-integrated back into the artist’s ego. Perhaps we might also make a comparison with the rites of passage state of “(Re)incorporation‟ or re-aggregation back into society and becoming relatively stable. In this way art therapy, like psychotherapy, can be conceptualised as a process of “assimilation of problematic experiences‟ in which one moves through the continuum of avoidance to insight and integration (Stiles, 1999: 1021; Stiles, 2002).

Constructive liminality in psychotherapy and healthcare involves oscillations between these positions. Like liminality for clients, movement through these positions is not simply linear. Creativity involves an inherent “ego rhythm‟ (Ehrenzweig, 1968: 79, 295) or an on-going oscillation between the Paranoid- Schizoid and Depressive positions (Bion, 1984), thus developing a person’s capacity for Keats‟ “Negative Capability‟ (Rollins, 1958: 193) and an ability to tolerate uncertainty (Glover, 1998). Perhaps for clients, experience of this in art therapy or psychotherapy can strengthen the capacity to deal with the “oscillating trajectory‟ between acute and sustained liminality (Little et al., 1998: 1493) and the “shifting perspectives‟ dynamic of illness experiences (Paterson, 2001; Thorne et al., 2002: 449).

Cultural defence mechanisms

“We have, in our culture, an unspoken agreement not to speak about our own death. ... Without such a language we cannot integrate it. Integration requires metaphor and ritual. When as a group we are confronted with an image of dread, the group mind clangs shut. .... It is through the symbolic, the metaphors and rituals, that a group is able to integrate its fate collectively and individually.‟ (Klement, 1994).

Projective identification involves “evoking in someone else aspects of the self which one cannot bear‟ (Segal, 1995: 36) and perhaps this does not just apply to a client’s potential splitting and projection of feelings into the art and the therapist. Perhaps society too can split off intolerable fears of illness, the “unbounded body‟ and, fundamentally, death. This could happen physically through sequestration into hospices (Lawton, 1998). We could speculate that such defence mechanisms could also operate intersubjectively.

In this way, society could regard illness, unboundedness and death as unbearable realities and therefore split and project them, for instance into the person experiencing illness. Such dynamics could be a distortion of an adversarial type of play (agôn), such as when vulnerability and unboundedness are regarded as a weakness, deviance and/or terrifying. They are thus disowned and projected into others who are then perceived as vulnerable and weak. Then, through the mechanism of projective identification, such feelings of terror and stigma could be evoked in some people, thus inducing role-play (mimicry) (Caillois, 1962) whereby people identify with stigmatisation. Such dynamics could also operate if healthcare professionals are not able to own the realities of their own unboundedness and death. This could be driven by the panic type of play (ilinx) (Caillois, 1962) grounded in fears of weakness and mortality.

Pfeiffer (2002) suggests that the dominant Western ontology and epistemology tends towards dichotomies and stereotypes and these basic assumptions need to be critically evaluated in society and in research. An embodied liminality perspective that acknowledges illness and mortality as part of the human condition could be less likely to project denied vulnerability onto others (Shakespeare 1994; Shakespeare & Watson, 2002). Turner (1988: 24-25) asserts that constructive liminality and the plastic arts promote the “reflexive voice‟ and enable people to question basic assumptions and “relations, actions, symbols, meanings, codes, roles, statuses, social structures, ethical and legal rules, and other sociocultural components which make up their public “selves‟.‟ (See figure 4.3). This could promote re-storying, social inclusion and re-incorporation of the realities of our mortal embodied condition.

In the above, I have explored a fifth characteristic of liminality – embodied experience – and its relevance to life difficulties, healthcare experiences and psychotherapy or art therapy. I focused on three dimensions of liminal embodied experience - physicality, structural inferiority / power, and sexual embodiment - by means of discussing how a fourth, expression, relates to each of the first three.

Conclusion

Turner (1982: 75-76) asserts that “liminal reflexivity‟ is necessary if “crisis is to be rendered meaningful‟ and he suggests that “ritual procedures generate narratives‟ promoting the “integration‟. Narrative approaches, such as therapeutic “emplotment‟ (Mattingly, 1994), have been viewed as a form of expressive embodiment of experience (Brockmeier & Carbaugh, 2001: 1). They can integrate illness into the life story and integrate people in their social world (Cheshire & Ziebland 2004). Story-making can be beneficial during life-threatening illness (Bolen, 1998: 95, 109; Murphy 1999: 24-42) and finding new voices can ease “people’s passages through times of transition‟ (Hedtke, 2002: 286). Such narratives, “told through a wounded body‟, give “voice to the body, so that the changed body can become once again familiar in these stories‟ (Frank, 1997: 2). Viewing a person as a “community of voices‟ (Honos-Webb & Stiles, 1998), therapy can offer an opening to encourage previously unheard voice(s) to join the dominant voices, thus enabling a process of “social inclusion‟ (McLeod, 1999). An individual can become inclusive to previously projected material that can also be witnessed by an art therapist or psychotherapist. Art therapy also accommodates various forms of expression and does not privilege verbal voice. Art therapy rituals and symbols have particular value in metaphorising the body thus enabling expression of emotions and bodily states including conscious and unconscious aspects otherwise deemed unspeakable, unhearable, unseeable and unthinkable. Perhaps this is helpful in redressing the structural inferiority of liminal situations.

Art therapy offers multi-sensory and verbal opportunities for symbolic re-portraying. In this way the re-construction of new narratives (Williams, 1984; White & Epston, 1990; McLeod and Balamoutsou, 2000) can “help patients to construct a meaningful narrative of disease‟ (Zollman & Vickers, 1999). In some life-threatening illness experiences, “sustained liminality‟ can be a “prolonged dialectic between body and self, in which a narrative is constructed to give meaning to the challenging and changing biographical, physical and existential phenomena in which illness and aging evolve in the locus of the body‟ (Little et al., 1998: 1493).

Art therapy offers an approach that addresses some of the criticisms of purely verbal narrative approaches in medical contexts (Lambert, 2004). For instance, as noted earlier, art-making in art therapy can evoke and express a variety of time experiences, rather than just a linear approach to time; it values non-verbal expression and embodiment, rather than privileging the articulate and assuming language has primacy; it accommodates multiple shifting experiences, feeling there is no meaning and waiting for meaning, rather than implying that one meaning or truth has to be found.

Working with “multivocal symbols‟ (Turner, 1982: 27) in art therapy promotes and enables individuals to experience the oscillating nature of the creative process and ego positions in a containing environment. This perhaps strengthens the client’s capacity to deal with the multiple narratives evident in an illness or difficult life experience – i.e. the “oscillating trajectory‟ between acute and sustained liminality (Little et al., 1998: 1493) and the “shifting perspectives‟ dynamic of some illness experiences (Paterson, 2001; Thorne et al., 2002: 449)

Perhaps in art therapy or psychotherapy in healthcare, through constructive liminality and containment, developmental oscillation between the Paranoid-Schizoid (separation) and Depressive (reincorporation) positions can be achieved at the individual level. Thus splitting of self and body can be ameliorated and split projections of intolerable “bad‟ objects can be contained, thus modified and made capable of re-introjection. A constraining habitus/hexis can be modified, fostering a more constructive relationship between the true body-self and appropriate presentations of self-body needed in different contexts.

However, constructive liminality and containment also needs to foster developmental oscillation at the cultural level to enable societal projections to be re-incorporated. This could foster reflexive reconstruction of narratives of the “unbounded body‟, stigma, shame, dichotomies of health and illness, and stereotyping. This could be less likely to view illness, unboundedness and death as intolerable, deviant or failures. Perhaps, at individual and collective levels, art therapy or psychotherapy can play a valuable part in promoting a both/and perspective that is more able to deal with ambiguity, ambivalence, unboundedness, uncertainty and multivocal experience.

References

Available on request.

Fisher, M. (2019) Ritual in therapy. Thresholds, April.

Keizer, Heleen M. (2000) 'ETERNITY REVISITED: A Study of the Greek Word αιών. Philosophia Reformata, 65: 53-71

Segall, M. (2015) Minding Time: Chronos, Kairos, and Aion in an Archetypal Cosmos. Footnotes2Plato

Segall, M. (2016) Minding Time in an Archetypal Cosmos. Archai: The Journal of Archetypal Cosmology. https://footnotes2plato.com/wp-content/uploads/2019/03/mindingtimeinanarchetypalcosmos.pdf

Smith, John E. (1969) Time, Times, and the 'right time'; "Chronos" and "Kairos". The Monist, Vol. 53, No. 1, Philosophy of History (January, 1969), pp. 1-13.

Turner, V. (1969) The ritual process. New Brunswick: Transaction Publishers 

Waller, D. and Sibbett, C.H. (Eds) (2008) Art Therapy and Cancer Care. Seoul, South Korea: HakJiSa Publisher / OUP.

Wilson, R.T. (2022) Psychotherapy As Ritual. Journal of Liberal Arts and Humanities, Vol.3, No.1, January, pp. 19-23.