Abstract
Although multiple concepts of time can be found in psychiatric discourses and practices, the notion of time as an absolute category seems to predominate. In particular, the notion of “chronicity” implies the persistence of symptoms over the temporal course of a disease, thereby following a logic that conceptualizes time as an objective and universal measure. I argue that such a notion of time impedes the development of patients and the metrics by which to map change. This article, therefore, aims to present a different concept of time that should enable dealing with "chronic" mental illness in more flexible and creative ways. A case study of an everyday psychiatric routine is presented, followed by an in-depth analysis of its temporal implications. I conceptualize the notion of time as an extended field, being relationally and intersubjectively structured and linked to performed activities. Such a notion of time needs to be seen as a flexible and fluid matrix that possesses the character of an event-oriented and productive space. This conception favors an individualized temporality of change, suggesting concrete therapeutic procedures that can be implemented in clinical practice.
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Notes
There have been many other ways to describe “chronic” mental illness. Early defintions were based primarily on prior or current care at institutions, since most seriously ill patients were long-term residents of psychiatric hospitals (Goldman 1981). With the emergence of community-based treatment philosophies, policymakers required a specific, constant and operational definition to extend benefits and entitlements, evaluate needs and plan effective programs. Classifications, therefore, proliferated in search of a consensus about inclusion and exclusion criteria of the group of the “chronic” mentally ill. Thus, questions arose about the nature and degree of disability, length of illness or treatment, relevant diagnostic categories and relative importance of each (Bachrach, 1988; Talbott, 1978).
Matters of time have been equally neglected in social theory. In particular, the extensive tradition of structuralist approaches caused a neglect of temporal concerns within the anthropological discipline (Adam 1990; Lightfoot 2000; Ohnuki-Tierny 1990). Theorists focused on structures, thereby presenting a world without change—a static framework, which delimited the boundaries of before and after. As such, social sciences separated change from structure, appearing as mutually exclusive theoretical choices. Only with the renaissance of the body did the classical distinction between change and structure start to vanish, representing a site of practices, both integrating a structural foundation and agent powers (Lock and Farquhar 2007).
Many temporal aspects of “chronic” mental illness have been left out in this article. Thus, it does not intend to elaborate on the enormous literature on the subjective experience of time by the “chronic” mentally ill. Schizophrenic suffering has been interpreted as resulting from temporally unrestricted fields of meanings, whereas the “schizophrenic” present is described as being concretely experienced as having no velocity or tempo, rather being temporally discontinuous and fragmented (Jost 2000; Lacan 1966). A meaningless future is shown to be characteristic for depressive disorders, whereas the present is experienced to be torturous due to its slowness, just as the past cannot be closed up (Jost 2000; Rohde-Dachser 1987). OCD patients seem to have the omnipotent delusion to be able to control time by means of their compulsions, based on the desire to enlarge the temporal frame or, at least, to bring it to an end (Jost 2000). Borderline personality disordered tend to live purely in a sort of timeless present without any temporal synthesis and, thus, have to reinvent the wheel over again (Rohde-Dachser 1987). These deviances of experiencing time were demonstrated to utilize enormous amounts of energy, being artificially constructed and permanently contested by their surrounding other concepts of time (Schweitzer 1995:94). Temporal therapeutic interventions were shown to aim at reinstalling temporal relations to bridge the loss of continuity and temporal fragmentations (Jost 2000; Rohde-Dachser 1987).
On the other hand, Frederic Jameson (1991), Walter Benjamin (1968) and Jacques Lacan (1966) all described a sort of collective “chronicity” within modern societies. Jameson outlined a temporal implosion within contemporary civilizations, resulting in a perpetual presence. Thus, the subjective temporal continuity is destroyed, leading to the re-emergence and repetition of modern styles to the point of stagnation (Jameson 1991). Benjamin (1968) described the contemporary sense of a motionless and cyclical time, resulting from the alarming experience of the accelerating tempo of modern societies and opposing destabilization and crisis (248). Lacan’s (1966) and Deleuze’s (1997) notion of schizophrenia implied a loss of temporal order in the form of linear admissions of meanings, which organize a sentence in time, leading to a discourse. All these authors portray repetition, recycling and recontextualization to be a sort of postmodern originality, with, however, obvious “chonic” characteristics.
As stated by Adam (1990), “A-theory … is committed to the idea of change” involving “ideas of motion, passing and flowing” (145). In contrast, natural science seems to prefer a metric concept of time, which strongly influenced the metatheoretical concept of psychological growth. However, absolute time is a metaphysical notion (52). Maybe it results from human beings’ strong desire to be immortal—that time shall endure also after death. Einstein’s theory of relativity has been revolutionary, implying that durations of movements change according to their relational frames and liberating natural science from an absolute notion of time. In fact, the dichotomy of A- versus B-series time reminds us of the intense debates of subjectivists versus objectivists and phenomenologists versus structuralists. At heart, it is a false dichotomy to reality, which ought to be bridged and has been used in this article only to clarify the subject of interest. A good example that has avoided such a dichotomy is the work of Pierre Bourdieu, who presented a critical analysis of both subjectivist and objectivist traditions in philosophy and social sciences. With his praxeological concept of the habitus, he tried to break away from structuralist approaches without falling back into old philosophy of the subject or of consciousness (Bourdieu 1982).
Thus, the final move into assisted living was only prepared by integrating events and experiences of her whole life. Actualized decisions that related to her past led to the decision to move. For example, the patient started to talk for the first time about her recurrent traumatizations in the past after her third visit to the assisted living facility. After an enormous relapse of psychotic symptoms for about 10 days, she finally decided to move. Thus, change occurred only after her engaging within the extended now with processes that occurred within the past—contrasting with a theory of change, which stresses the importance of the “here and now” in relation to occurrences in the direct “before” and “after.”
In many parts, my argument seems to correspond to Heidegger’s (1993) notion of time, as outlined in Sein und Zeit. In particular, the idea that being and can only be experienced by a temporality supports the ideas outlined in this article. Heidegger equally rejects the idea that human beings exist within a temporal structure, arguing instead that they are this structure themselves. However, he seems to prefer a transitory notion of the present, outlining two temporal phenomena of human beings. First, he presents death as the dominant structure of the Dasein, stressing the importance of constant passage of time and decease. Second, focus is directed on the future, in which we are “thrown forward,” such as we are always “ahead of ourselves.” Thus, his Dasein, in effect, is characterized by two temporalities—one of permanent becoming and one of progredient dying—both rendering the presence to something ephemeral and temporary. My argument, in contrast follows a metaphysic that acknowledges that persons are not the ones who either will certainly die or permanently become, but those who primarily live (Hick 2000).
In this sense, both Giddens and Nietzsche stressed the importance of repetitive phenomena as means to create and explain progress. Moreover, in some societies, phenomena of repetition are more valued than notions of change or progress (Evans-Pritchard 1940a, b; Leach 1961; Lefley 1990). To name one, Evans-Pritchard investigated how the Nuer divided time according to the actant’s direction of attention, rather than according to objective markers of environmental change. Their concept of time was primarily based on social activities. Certain activities were associated with certain times, such that the Nuer could not speak of time as something actual, which can be saved and wasted. They, further, did not have the feeling of fighting against time or having to coordinate activities with an abstract passage of time, because the point of reference was the activities themselves (von Peter 2009b).
This raises the question, How is it possible to proceed from the time of the decontextualized patient to the embedded, concrete time of the anthropological subject? The answer is quite simple: ones has to focus on the daily rhythms of the body, including eating, sleeping, excreting, breathing and walking. In this sense Merlau-Ponty and other phenomenologists turn philosophical attention away from the ideal realm of cognition, instead bringing the magic back into the mundane. Further, postmodern authors, such as Serres and Latour (1995), Deleuze (1997) and De Certeau (1984), investigate moments of speed, sequencing, embodied timing, prioritizing, rhythmicity, spacing, appropriate tempo and duration as aspects of everyday life and might serve as models for investigating temporal concerns within clinical encounters.
Questions of time are questions of power (Jost 2000). Especially, biomedicine is distinguished from other healing systems due to, asymmetric and contradictory temporalities of its practitioners and patients (Frankenberg 1992). Thus, the physician distances herself in time from the patient and treats the patient as allochronic—in another time. Equally, patients are removed from their normal temporalities to a space where different temporal concepts can be imposed on them (Frankenberg 1992). Thus, to interrupt somebody, to make somebody wait or to hurry, to prestructure a future means to impose power on this person. In this sense, when treating patients, important questions should be: Where does the institutional time have to be leading structure, and where should the time of the patient decide? Who has the power to determine the time? Is the patient allowed to act in accordance with his or her own temporal pattern? If yes or no: When, why and how? To avoid power asymmetries, a mutual adaption of temporalities—a sort of “temporal dance” (Jost 2000), instead of a fight for temporal power—is strongly recommended: especially since the mentally ill inherently have difficulties getting used to the temporal patterns of our usual society. The basis for the temporal coordination, thus, has to be mutual respect and patience, instead of a mere orientation at an objective temporal frame.
However, as stated by Herzog (1988), the contemporary discussion about short-term therapies is also stimulated by patients, who do not wish to devote time to their own therapy. They, as well as funding bodies, like governments and insurance companies, seem to follow a described current zeitgeist that favors speed and fragmentation, instead of valuing duration and slowness. This tendency is described to be strongly related to the commodification of time. Time can be “spent,” “invested,” “bought” or “saved” (Frankenberg 1992). Such a commodification can be discovered in all sorts of cultural phenomena: for example, Middle Age and Rennaissance theater plays took longer than today, exemplified by pieces such as Hamlet and Macbeth. Further, symphonies by Mahler or Schostakovitch are considered nowadays to be too long (Herzog 1988). I think that such a argument, which seems to be popular in current theory and everyday life, is false to the complexity of contemporary temporal phenomena. In particular, the fields of arts, literature and (para)religious institutions take into account the human desire for slowness and reflexion.
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von Peter, S. The Temporality of “Chronic” Mental Illness. Cult Med Psychiatry 34, 13–28 (2010). https://doi.org/10.1007/s11013-009-9159-x
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DOI: https://doi.org/10.1007/s11013-009-9159-x