Transitions
I first read about ‘rites de passage’ back in the 1960s. I was a student, enrolled in a social anthropology course, and Arnold van Gennep’s book Les Rites de Passage was listed. It had appeared in an English translation back in 1960. A key text, it described the process through which a person or a group goes through a change in social status. Van Gennep explained that rites of passage have three phases: separation, liminality, and incorporation.
In the first phase, people are withdrawn from their current status and prepared for the move from one social status to another. “The first phase (of separation) comprises symbolic behaviour signifying the detachment of the individual or group … from an earlier fixed to point in the social structure.” There is often a detachment or ‘cutting away’ from the former self in this phase, which is signified in symbolic actions and rituals. One of the examples Van Gennep uses is the cutting of the hair for a person who has just joined the army. He or she is ‘cutting away’ the former self: the civilian.
The transition (liminal) phase is the period between stages, during which one has left one place or state but has not yet entered or joined the next. “The attributes of liminality or of liminal personae (“threshold people”) are necessarily ambiguous.” I’m not sure why this example came to me, but this is a bridegroom on a stag night or bride at a ‘hen do’. This is a sanctioned time when misbehaviour is permitted – even encouraged.
In the third phase (reaggregation or incorporation) the passage is “consummated [by] the ritual subject”. Having completed the rite and assumed their ‘new’ identity, the individual re-enters society with anew status. Re-incorporation is characterized by elaborate rituals and ceremonies, like debutant balls and college graduation, and by outward symbols of new ties: thus “in rites of incorporation there is widespread use of the ‘sacred bond, the ‘sacred cord’, the knot, and of analogous forms such as the belt, the ring, the bracelet and the crown.”
Anthropologists like to observe these rites de passage in societies, as they are often insightful: they demonstrate the markers of social status, and the symbolism is a guide to other rituals in behaviour, both on special occasions and in more mundane activities. This perspective received considerable impetus with the development of the sociological theory of symbolic interaction, peoples’ use of shared language and rituals to create and reinforce symbols and meaning. It’s a frame of reference that helps us better understand how individuals interact with one another through symbolic worlds, worlds that shape individual behaviour. For theorists symbolic interactionism was a framework that helped understand how society is preserved and created through repeated interactions between individuals. It is the shared understanding and interpretations of meaning that shape many of the significant interactions we see between individuals. Individuals act on the premise of a shared understanding of meaning within their social context. People live in both natural and symbolic environments.
I wasn’t a sociologist, but I was interested in this perspective. However, that interest grew significantly once I met Anselm Strauss . Anselm was a short, slightly overweight and quietly spoken man, a professor of sociology at the University of California Medical Center in San Francisco. I think the best word to describe him was gentle. He loved music, played the piano at home, and had a fascination with kinetic sculptures. From when I first met him at the end of the 1960s, I realised he was the teacher I aspired to be, never lecturing but always asking questions, and by that means revealing understanding and insight. He set a standard for how to be a university professor that remained my goal for the years I worked in academic institutions, a standard I longed to meet, but one which was always just beyond my grasp. If you think about it, that’s always the best thing to aim for, something that is almost there, encouraging to strive to be better.
Perhaps there is no better way to explain what he was like than to quote from the introduction from an Anselm Strauss’ festschrift, written by Roberta Lessor in 2000 (in a supplement to Sociological Perspectives):
Anselm Strauss was the most unpretentious academic I have ever known. In his nearly sixty years of working and publishing, Strauss advanced symbolic interactionist theory and method remarkably, yet he was soft-spoken and unassuming. His dress and demeanor mirrored his personality. He preferred open-collared shirts and his trademark pullover sweaters to coats and ties, and he was even known to carry drafts of whatever he happened to be working on in a plastic bag—much lighter and easier on the back than a briefcase. He lived most of his life with chronic illness and worked the small necessities of self-care into his daily routine. Totally the sociologist, he used his experiences both in and out of the hospital as data, observations of “medical work” from which he could draw insights. This was a life lesson I took from Anselm: observe what life hands you as data for a sociological analysis. It makes life more interesting, you may improve your analytic skills, and it may even help your situation. Sometimes Anselm needed to take a short rest, and if he were working with students in a seminar, he would give a characteristic, almost dismissive, small wave of his hand and say, “just go on, I’ll be right back.” That might mean his reclining on the bench beside the fireplace in the Third Avenue Victorian (which housed the sociology program) while we went on with our seminar for twenty minutes. Or it might mean his closing his eyes as he sat in his chair, to return to the conversation in a few minutes with a smile and his full attention.
I had first met Anselm on one his early visits to the UK. Initially I saw him as some variety of kind uncle, enquiring about what I was doing. As he would draw me out, wondering about why I had mentioned something, querying what I meant by the words I used, initially I didn’t ‘get it’. It took some time before I realised how extraordinarily effective he was as a teacher. Indeed, he was never a ‘teacher’, but rather a friend on a journey, who appeared to know something about the territory, and would every so often point out a possibly worthwhile detour, or a reason to stope, reflect and reconsider. At my first acquaintance, I didn’t realise he was a wonderful guide: I suspect I imagined that, back in the US, he gave lectures like everyone else did. It took a visit to see him in beloved San Francisco for me to understand how he was helping me learn.
He also wrote several insightful books. Time for Dying is one of these (it was preceded by Awareness of Dying). As he explained in the preface, he and co-author Barney Glaser (a researcher in the department) saw the book as directed to two audiences. ‘Because we wish to contribute toward making the management of dying – by health professionals, families and patients – more rational and compassionate, we have written this book, first of all for those who must work with and give care to the dying.” The second audience was social scientists, a contribution to exploring the “temporal aspects of work”, a group that included those with interests in many areas, some far from interested in health care and hospitals.
Time for Dying was published in 1968. My copy is hand dated 1971. Reading it more than fifty years later was a shock: not because it wasn’t the book I had thought it to be, but because its underlying approach has become so firmly embedded in the way I have worked. Anselm Strauss described his approach as ‘grounded theory’ in a book published a year earlier (The Discovery of Grounded Theory, also written by Strauss and Glaser). They made it clear they had had several goals in mind when writing about their approach to developing theory. They wanted to:
- to legitimise qualitative research;
- to criticise the functionalist school in sociology;
- to demonstrate the possibility of building theories from the data, instead of choosing to rely on ‘ethnographic’ description (what a man from Mars would see).
My copy of Time for Dying still has the original paper wrapper cover – which shows eight people, all in medical whites, standing together and clearly discussing a case. At the bottom of the cover we read the book is “a detailed analysis of the reciprocal effects of patients, staff, and institutional structure in the management of terminal patients in institutions”. The Introduction makes it clear that the book was written ‘first of all’ for people who have work with and give care to individuals who are dying. It notes that in 1963 53% of all death in the US were in hospitals and nursing homes. I suspect the figures are higher today: a 2019 Australian study found 51% of deaths were in a hospital/medical service area, and 29.5% in residential aged care facilities (although this is a wider category than nursing homes. This is, of course, an indicator of how far death is managed ‘out of sight’, with a little under 15% taking place at home. As the Introduction made clear (and must be even more the case today), “outsiders to the family have been delegated responsibility for taking care of dying during their last days or hours”.
Time for Dying focusses on the ‘temporal features of terminal care’. It is an important perspective, as we often are encouraged to think about the psychological or ethical aspects of behaviour towards a dying individual. However, they want to remind us that this is also about ‘work’, both routine, around meals, drug administration and the like, and the less predictable, including tests, interventions and responses. It is a complex work management process, especially as many patients approaching death may be heavily drugged, temporarily comatose or even unconscious, and typically having little conversational interaction with the staff. Inevitably, while many staff may be involved when there are critical incidents occurring, for much of the time attention is limited and relies on impersonal monitors as much as on staff observation.
As Glaser and Strauss point out in their Preface, “the training of physicians and nurses equips them principally for the technical aspects of dealing with illness. Medical students learn not to kill patients through error, and to save lives through diagnosis and treatment. But their teachers put little of no emphasis on how to talk with dying patients; how – whether – to disclose an impending death; or even how to approach the subject with wives, husbands, children and parents of the dying”.
In 1971, I arrived at the University of Edinburgh, where one of my interests was looking at ways in which the social and behavioural sciences could be introduced into the medical school curriculum. The two books on dying had made an impact on me, although not just in relation to the dying: as I saw it, medical students needed a better appreciation of sociology and psychology to be able to fulfill their roles effectively. I continued to look at ways to enhance student understanding of these issues for the next ten years, in Scotland and then in Australia.
Fifty years later, an appreciation of the social sciences is now a standard part of the medical school curriculum, and nurses and doctors are much better prepared to deal with the families and friends of patients. Inevitably, some will be more able to deal with social and psychological issues than others. Individual differences will always be evident.
When my wife was dying some years ago, the contrast between her two principal doctors was vivid. Her medical oncologist was open and helpful as he explained progress, and later the lack of progress to me and my children. He explained his strategies, and his enthusiasm for measures, his warmth, and his devotion was evident. So was his distraught appearance as it became clear that the measures he was trying were failing. His colleague, the surgical oncologist, was clear, direct, and basically impersonal. It was only after an unexpectedly long surgery, that the other side of his character emerged: he was tired, frustrated, and – although he couldn’t bring himself to say it – defeated. He knew the prognosis was bad, but he couldn’t find the words to explain. He left that to his colleague. To be clear, I don’t mean to imply any criticism: both dealt with what they knew and communicated well, but their approaches were a reflection of personalities that were intrinsic.
That time illustrated an important lesson about transitions. Van Gennep was an astute observer of rites de passage. However, describing social process and symbols is an account that is essentially de-personalised. It is concerned with identifying the underlying ways in which we manage changes in social status. It influences the way the ‘work’ is executed. However, at the level of specific transitions, variation is enormous. In that sense, ‘real’ status passage in a task that involves many participants, each one of whom contributes to shape the process. Perhaps I can best explain that by example.
Marriage is a very important kind of status change. While occasionally the bride and groom might feel it is all about them, they are one, albeit important, part of a complex process of negotiation. In addition to the couple, others who take part, and often have important parts to play as well as very real interest in the outcome, can include parents, other family members, friends, colleagues, officers (whether priests or delegated officials), not to mention musicians, choirs, caterers, waiting staff, and so on. In some cases, the cast can be hundreds!
I have managed to get married three times. On the first occasion, it was essentially a ‘family’ business, with several family members on both sides. The next time, it was a tiny group, little more than my wife and I, a few members of her family, one child, and a few others. The third time around, it was largely an event for friends. Each time around, it was a time of transition: a brief interlude before becoming a married couple. However, the symbolism, the process, and the participation of others varied enormously. To return to Anselm Strauss, he would observe that this is a matter of ‘work’. People have roles and tasks, for a short-term project. There is a clear outcome, and certain rules that shape the way the work is undertaken. But each marriage was undertaken in its particular way.
Strauss and Glaser on dying describe this feature of status passage brilliantly. The two books, and especially Time for Dying, capture both the characteristics of the underlying process, while carefully noting variations and unpredictable alternatives. However, as is also true of some other major rites de passage, success is determined by all the participants in the process feeling ‘it was done right’, respecting the unique elements of the event, while also knowing that the appropriate social proprieties were respect. We are all involved in social transitions, and we want to feel good about how they were accomplished.
