Among Health, Illness and Time: Chronic Disease, Waiting Time, Recovery, Perception of Time and Resting Time

  • Maria Giulia Marini


Nobody ever seems to have enough time: there are only 24 h in a day, and yet, we continue to struggle to squeeze countless things into our already busy schedules. Healthcare professionals are no different, and as everyone else in this ever more efficiency-driven society, they are asked to push their limits constantly further. Time, or rather shortage of time, is a constant mantra. The shorter the visits are, the larger the productivity. So how is it feasible to even consider embracing a new activity like the practice of NM? Where could they possibly find the time to practise the art of listening, the tools for reflective writing, the moving forwards from disease to illness and giving each patient a central role and so right time as proposed by NM? Time is finite.

Keywords of the Natural Semantic Metalanguage

A moment A long time I live the time You live the time Kind of time Do little Feel ‘more’ good (better) 

Nobody ever seems to have enough time: there are only 24 h in a day, and yet, we continue to struggle to squeeze countless things into our already busy schedules. Healthcare professionals are no different, and as everyone else in this ever more efficiency-driven society, they are asked to push their limits constantly further. Time, or rather shortage of time, is a constant mantra. The shorter the visits are, the larger the productivity. So how is it feasible to even consider embracing a new activity like the practice of NM? Where could they possibly find the time to practise the art of listening, the tools for reflective writing, the moving forwards from disease to illness and giving each patient a central role and so right time as proposed by NM? Time is finite.

But again, is time finite? As other great questions of life, we can search the answer to this dilemma through the symbolism of ancient mythology. In Ancient Greece, time was mainly represented by two deities Chronos and Kairos: the former was envisioned as an old man who ate his own offspring (Apollodorus, 180 BC-120 BC, n.d.), symbolising future being relentlessly overtaken by the past. Time eats everything; thus, we are finite, and the time of the doctor’s consultation with the patient is finite. Kairos instead was envisioned as a young winged-ankle god of opportunity. He symbolised an interruption in the flow of time and a window of instant intuition that leads to good judgement and decisions (Liddell et al. 1843). Today, we might consider it the quantum leap, the instantaneous infinitesimal time to reach a higher energetic level. Further, in the setting of NM, Kairos could be seen as the instant intuition grasping the value of patient experience.

As put by John Launer, one of the founding fathers of NM as well as a physician and an educator, good conversations inviting patients to change take just 10 min, provided one knows the appropriate questions to ask and clear the field from their egos and a priori diagnosis (Launer 2007). NM does not require more time but a change in perspective. It may be argued that training in narrative skills requires time, but if we compare the time needed for completing a core curriculum (medical humanities and NM are offered only in few universities in New York, London, Milan, Rome, Paris and few others) with the time needed to re-educate an intern or practitioner who has been overexposed to the biomechanical aspects of medicine, we may see the advantage. Once the skills have been mastered, practicing NM and spending 5 min for writing the parallel chart (the written room of thoughts of doctor-patient encounter) is worthwhile the effort, especially if one considers the patient’s waiting time spent waiting for the doctor. However, not all patients require the same time; some may require 20 min, while others only 5 min; it is very subjective and obviously depends on the circumstance.

To recall the concept of the Greek gods of time, practicing NM may be more a matter of Kairos, i.e. of reaching a different energetic level to establish a successful relationship with patients. It involves a different perception and open to different questions and different answers. Yet, reality ties us to the Chronos sphere, accounting for wastes of time and time-saving: here, we are time keepers with a chronometer. Kairos, the little god with winged ankles, is able to fly, to be light in the sky, and takes our hands so that we can learn to fly over time: if we listen carefully to some doctor-patient encounters, the ‘context’ is filled by tests, investigations, remedies and drugs. How do you feel? is a tricky question that can allow the expression of a qualitative adjective such as ‘bad’, ‘better’ and ‘good’ or the spreading out of the inner realm with fear, anger, pain or joy. The first kind of answer brings back to physicians, in a sort of Pavlovian’s reflex, to change therapy, prescribe new tests and comment blood parameters: Chronos is the winner with the productivity of investigations and therapies. Kairos would like that we, as free children, could express our emotions so that an authentic doctor-patient relationship can start. Kairos shows us another way to practise as counsellors, psychotherapists, nurses and doctors.

Of course, Kairos is not replacing Chronos, but if we do not do anything to block our behavioural stereotype with patients, as defensive medicine, the defensive wall of Chronos will be reinforced, and daring new changes in healthcare context will not be possible. Kairos is an act of bright courage. It is catching messages in the patients’ words, for example, the fact they might be worried for losing their job. In following a Kairos approach, the physician would not continue talking about the disease but would rather ask, ‘What can I do in helping you overcome the fear of losing your job?’

Defensive medicine is paralysing the development of fresh and genuine doctor-patient relationship (Sonal Sekhar and Vyas 2013). It is an old conservative approach, like the old god with the beard eating his offspring: in this case, eating thoughts and feelings of physicians, nurses and patients.

Therefore, when we are questioned about how much time does the practice of NM require, we answer in a quite provocative way ‘no extra time’. It is simply a different way of caring for people, built on positive dynamic patient-carer encounters, which can reduce over testing and overtreatment (the so-called defensive medicine).

Kairos involves ‘active listening’. As evidenced by Langewitz and colleagues in their study on Spontaneous talking time at start of consultation in outpatient clinic: cohort study, patients took an average initial time of only approximately 22 s before being interrupted by the doctor (Langewitz et al. 2002). Therefore, the study assessed a sequential cohort of patients from the outpatient clinic of the Department of Internal Medicine at the University Hospital of Basel to evaluate how much talking time a patient actually needed to express their problem. Doctors were trained for 1 h on basic elements of active listening, such as pausing, using facilitators like ‘hmm-hmm’, nodding or echoing. They were told to simply ask the patient ‘What brought you here?’ and not engage in other types of questions. Moreover, they were advised to interrupt patients talking for more than 5 min to comply with their consultation schedule. Of the 330 patients, 53% were women and 47% men; the mean spontaneous talking time was 92 s (SD ± 105 s; median 59 s), and 78% (258) of patients had finished their initial statement in 2 min. Only seven patients had talked for over 5 min; yet, they had not been interrupted because the doctors felt that the patients were providing important information. No other sociodemographic variable (education, income, civil status, type of employment and sex) significantly influenced spontaneous talking time except for age (rs = 0.41; P < 0.001; 17–29 years, 77 (105) seconds; 30–49 years, 92 (93) seconds; 50–87 years, 108 (114) seconds). In conclusion, the findings showed that most patients (when left to speak uninterrupted by the doctor) only needed 2 min.

The Long Time: Feeling Bad for a Long Time

‘I’m sick to death of this particular self. I want another’.

Time though has many other facets, and Kairos is only one aspect. The time of patients, for example, the time for bringing back balance to what has become disrupted in their life, is often much longer, or rather is a much ‘slower’ time.

Orlando, Virginia Woolf

In Virginia Woolf’s Orlando (1928), the main character, Orlando, is tormented in the quest for identifying and conquering his/her real ‘essence’. The process is slow and is crossed by periods alternating life experiences, lethargy and metamorphosis, after which the character finally reaches understanding. Orlando was born as a male during the reign of Elizabeth I of England but ends his story as an emancipated woman at the turn of the twentieth century. He passes through two eras, two aeons, to reach his/her metamorphosis: the modern era and the contemporary one. Across the centuries, Lord Orlando takes off his clothes of a rigid male and full of false gender absolutisms in which ‘every man is…’ and ‘every woman is…’ dictated in a life of honours of great values for others, but of no value for himself, to become the ‘other self’ desired by Woolf. Approximately, around 1610, the triggering factor of horror and compassion for a soldier dying next to him in war will make him fall asleep in some oriental non-lieu to be born again later as Lady Orlando. From this moment, in the following centuries, he struggles to affirm the fact of ‘being a woman’ through the right of inclusion in conversation with male poets, such as Swift and Pope, who celebrate her beauty but ridicule her female intelligence or through the right of private property, from which she is excluded because she has no male heirs. The novel ends with the encounter with an adventurer arriving on his horse and ready to leave again for non-specified ideals in the New Continent; here, she ends the love story with the restless cavalier to conquer her freedom, autonomy and independence and thus completing her metamorphosis.

Orlando is the manifesto of the dual nature of Virginia Woolf. The peculiarity of Orlando is that in these two eras (more than 400 years), the protagonist falls into lethargy to heal from life experiences continuously affecting his/her most intimate soul and the people she/he has encountered and who have passed away. Every time Orlando wakes up as a man or woman, he/she decides to radically change his/her life by moving to other countries or changing sex, lover and profession. Thus, the novel is extraordinary: to make deep and not ephemeral changes, there must be two elements, time and sleep.

The first element, time, dilates across centuries until becoming the age, the ‘Aion’—where history, as life phases, divides in centuries: for ancient Greeks, Aion, another of the multifaceted ways to call time, is translated as the succession of historical ages throughout eternity. Aion symbolises cosmos and its seven stellar orders (the Greek representation of the eternal universe expanding towards eternity) (Von Franz 1992).

Sleep, the other ingredient, represents a dreamless rest, an oblivion, a long pause, retreating from worldliness, becoming a cocoon to mature and give life to a new blooming. Using terms of NSM, it would be expressed as ‘not doing’. Scientific and hard-working Western world based on efficacy can barely understand the transformation mystery that happens when one withdraws and creates a void as taught in the oriental approaches to life (Zen, Yoga and mindfulness).

Yet, I write about NM and ask you what Orlando’s story has to do with illness narratives. We can look at patients and their familiar stories, which live with diseases not only in a ‘chronic’ but also in an ‘aeonic’ way, almost eternal in their perception—a succession of eras, phases and cycles. When Virginia Woolf started writing Orlando, she was feeling ‘bad’ (so to use a term of NSL) or, as we would label her today, ‘depressed’. De facto she was an emancipated and free woman facing a very hostile society. The book was her way to understand and solve her discomfort, travelling across a 400-year aeon and reading her life through lethargy (rom Lethes, oblivion, and Argos, inertia) (Liddell et al. 1843), i.e. the inactivity in the resetting of memory. The protagonist is seesawing between happiness and unhappiness for almost the entire book. Yet, through his/her experience of young love, war, poetry, politics, society and again adult love, he/she finds his/her final happiness, open to the new experiences. For the society at that time, Virginia was considered to be ‘not normal’ and ‘sick’, as she was in love with the woman to which the novel is dedicated: this is the occasion for passing again through this suffering of being victim of social constrictions in the ancient world of unequal opportunities to arrive then in the modern world loving her diversity. There are both the real time of writing and the long time necessary for metamorphosis.

Listening to the narratives of ‘sick’ people, we see that they want to be ‘normal’ as Lord Orlando, at least initially, and they search for a key to be accepted by the others: family, friends, workplace and external environment. This happens especially in the case of disabilities. Searching for normality, yet, can be an idiot chimaera, if it becomes a useless obsession stealing time to the discovery of one’s own real essence. As explained by Arthur Frank in The Wounded Storyteller (1995): In order to cherish ourselves in our state of discomfort and the world around us, we must find our own way of living our diversity and turn that ‘frailty’ into a point of strength. We cannot obtain this in the short term. It requires honesty, long time and lethargy between attempts, as taught by the great Virginia.

While above I focused on the need for an instantaneous and quick time, Kairos, to realise and correct pathways of patient care, I wish to stress the importance of living according to a slow and persistent maturation time, consistently with the saying, ‘haste makes waste’. As Carl Gustav Jung wrote, the soul—the undefined that defines our essential nature—is much slower than the rational mind (Jung 1969). Latins, who were a people of pragmatic spirits, conciliated both time dimensions with the paradox festina lente (Suetonius (2nd century BC) n.d.), make haste slowly. We must remember that next to the voracity of infinitesimal time, our nature—above all, the suffering one—needs long times for accepting the illness condition, finding a new way to live with the disease. Decisions that may help us will be taken calmly, as choice we will take with who takes care of us. This is a juggling exercise between velocity and slowness.

A Long Time to Feel Good

The need for rest to recover and to safeguard rest is very vivid in our current society. However, as much as it is necessary, it is risking extinction: the disappearance of the time to rest after an illness means the fading away of convalescence.

Once convalescence was considered to be just as important as cure. It was needed for the body to regenerate and get strong after an illness or a surgical intervention, a trauma or any other factor that had unbalanced the body and the mind. The term ‘convalescence’ comes from the Latin cum—‘with’ and to be worth ‘to be well’ or ‘with the health’, as in regained health.

Nowadays, the term ‘convalescence’ appears obsolete and has almost disappeared from our daily vocabulary, leaving place for sentences like ‘you’ll return as good as before’, ‘as good as new in no time’, ‘we will immediately put you back on your feet’ and ‘we’ll operate on Friday so he/she can be back to work on Monday’. Prescribed rest seems to be something outdated and difficult to achieve. The attitude of quick restoration though is not only manifested by the carers but by the patients as well who view checkups and medical procedures as a bothering waste of time, taken away from the duty of productivity.

In Italy, up until the 1990s, the hospitals were refunded for their services based on the total number of days of hospitalisation rather than on the number of patients or type of surgical intervention. Accordingly, hospital convalescence was a never-ending affair, with an economic gain for the hospital. Whenever a person was to undergo a procedure, admission would be scheduled approximately 1 week before so that the hospital could have enough time to (calmly) perform all the tests they needed on the patient, occupying a hospital bed and preventing its use for some other potential patients (backing up the already ‘eternal’ waiting list) and eventually prolonging discharge for another indefinite quantity of time. Times were endless, and the patient could no longer wait to be back home to his/her daily routine.

With the introduction of diagnosis-related groups in reimbursement procedures from the national healthcare system (as in Europe and the USA), this has changed, speeding processes towards an earlier patient discharge (Baker 2002). Time has been so compressed that the hospital convalescence has almost disappeared whatever the reason for hospitalisation (acute illnesses, planned interventions, accidents and traumas). Today, the world keeps on spinning as if nothing happened; all too often, people expect to go from the ‘off’ or ‘sick’ mode to the ‘on’ or healthy mode in symphony with the smiling hyperefficiency world. Despite the time of resting at home to recover one’s strength, we have come to the point to feel guilty for taking some time off from our chores. This binary status between on and off is extremely evident in advertisements that show a person suffering a severe cold and sitting at their desk in front of their computer; once they have taken the medication, they return to be their own smiling self and are ready for the next business meeting. The advertising lasts for seconds, though does not obviously reflect realist timing.

Yet, convalescence is almost a taboo, hardly pronounceable in this society in which we are living: Hartmut Rosa, a German sociologist, calls it the ‘Society of the acceleration and alienation’ (Rosa 2010).

People can accept you sick or well, i.e. on or off. Women after delivery are discharged from hospital within 24 h, without having the time to recover from the fatigue of pushing the baby out. Patients who underwent orthopaedic surgery sometimes are asked to walk when it is premature, and then they can experience consequences of this hurry which can require further surgery. Quality of recovery is a complex construct whereby definition is heavily influenced by the opinions and biases of the individual patient, clinician or institution. As a result, recovery assessment tools differ in their fundamental definitions of recovery, breadth and assessment timeframe. Accurate assessment of recovery is essential as suboptimal recovery has both economic and prognostic implications. Quality of care is often substituted as a surrogate at the institutional level for quality of recovery, but it is ideologically distinct from patients’ perceived quality of care, recovery and satisfaction. Thus, it is important to respect the uniqueness of individual time of recovery.

Alain de Botton, a Swiss-born British author and co-founder of The School of Life in 2008 says as follows: ‘What’s lacking is patience for convalescence’. People should not only consider recovery from important illnesses but also from work overload or stress of the daily life.

The School of Life offers a curriculum of classes teaching emotional intelligence to deal with day-to-day events of life to the death of a loved one. These classes are taught by leading authors, artists, actors and academics, combining their own experiences with ideas from great thinkers of the past to offer participants intelligent and playful ways to interpret the world and their place within it. Since the time of the publication of the book, The School of Life has attracted 3.3 million of followers around the world.

Thus, Alain de Botton insists on taking time for oneself as a system of care: the danger with stress is based on (Lundberg 2005) ‘The sympathetic adrenomedullary system secreting epinephrine and norepinephrine and the hypothalamic pituitary adrenocortical (HPA) system secreting of cortisol. Their physiologic effects are also a link between the psychosocial environment and various health outcomes. The stress responses have been important for human and animal survival, evolution and for protection of the body. However, in modern society, some of these bodily responses may cause harm rather than protection. Catecholamines have been linked to cardiovascular disorders such as hypertension, myocardial infarction and stroke, cortisol to cardiovascular disease, Type 2 diabetes, reduced immune function and cognitive impairment.

Long-term health and survival requires an adequate balance between catabolic (mobilisation of energy) and anabolic processes (growth, healing). Today, lack of rest, recovery and restitution is a greater health problem than the absolute level of stress’.

In 2016, Durham University conducted the widest survey ever on rest, involving over 18,000 people from 134 different countries in the rest test, an online survey asking people what made them feel good to investigate the public’s resting habits and their attitudes towards relaxation and business (BBC Website n.d.). Over two thirds claimed that they would like more rest; nearly a third said they needed more rest than the average person, while 10% thought they needed less.

The survey found that those who felt they needed more rest scored lower in terms of wellbeing. Similarly, those who responded saying that they thought they get more rest than average or do not feel the need for more rest had wellbeing scores twofold higher than those who wanted more rest, suggesting that one’s own perception of rest level actually matters. Dr. Felicity Callard, principal investigator of the project and social scientist, said, ‘The survey shows that people’s ability to rest, and their levels of well-being, are related. We’re delighted that these findings combat a common, moralizing connection between rest and laziness’.

Among the activities that the respondents considered most restful, the top five were as follows: reading (58%), being in the natural environment (53.1%), being on their own (52.1%), listening to music (40.6%) and doing nothing specific (40%) and were mostly done alone. ‘It’s intriguing that the top restful activities are frequently done alone. Perhaps it’s not only the total hours resting or working that we need to consider, but the rhythms of our job, and rest and time spent with and without others’, Callard adds.

Modern Life

The results of this survey come at a time when the urge to be busy defines modern life and the topic of rest is at the forefront of many people’s minds. Rest can seem hard to find, whether in relation to an exhausted body, a racing mind or a hectic city. Rest is a much broader category than sleep and has physical, mental and spiritual components. But much less is known about the potentially restorative benefits of rest partly because it means different things to different people.

The survey asked respondents to state how many hours of rest they had within the last 24 h. The results showed that on average, being younger and having a higher household income was associated with having fewer hours of rest. Those with caring responsibilities or in shift work which included nights also reported fewer hours of rest. Claudia Hammond said, ‘We had no idea how many people would choose to complete the Rest Test. More than 18,000 gave up their precious spare time to tell us what they thought about rest, which shows us what a pressing issue it is. These results show just how crucial it is to our well-being to ensure people do have time to rest. We can begin to try to work out what the optimum amount of rest might be and how we should go about resting’.

When Time Is Back and Forward: Cyclic Time and the Hours

After we learnt the importance of rest, I wish to spend some words on the need to bring back and honour ‘natural time’, the ‘cyclic time of our world’ and its impact of the human being.

Today, if one does not want to be labelled as ‘reductionist’ in care and medicine, medical sociology insists to move the attention from the sick organ or from the disease to the patient, or better, to the person integrated in his/her biological, psychological and social context. This ‘biopsychosocial’ paradigm represents an openness that distances itself from the mechanistic model—well exemplified in the man-machine metaphor, according to which disease breaks the pieces and a good mechanic-physician must repair or scrap—to reintegrate the living being in its social context, being the human (Anthropos), as Aristotle anticipated, a biologically living (bion) and social (politikon) being. It was and still is impossible to split our biological being from local, relational, everyday-life events. To heal in a holistic way—another word today very inflated, where olos means whole—the biopsychosocial model helps us (Havelka et al. 2009).

Still, in the search for a relationship among health, disease and social context, is it enough to talk about relationships, children, weddings, cohabitations, fertility, sexuality and furthermore, school, work, employment, unemployment, productivity or salary? Is it enough for us to divide everyday life in compartments at the cost of oversimplification (cosmic time, cyclic time of nature)? When a condition of fragility, insecurity or illness appears, forcing us to deal with the appraisal of our lives, does this paradigm satisfy us?

To date, quality of life questionnaire includes all these items, including sexuality and spirituality issues. Yet, are these questions able to grasp the information they are enquiring? The closed nature of the questions and their answers (i.e. yes/no; on a scale from 1 to 10, how happy do you feel today?) is embedded in the historical period we are living in: they will mirror that vague reductionist accent that will bring us to an oppositional qualification between good and evil. In short, we do not give voice to the many facets of our life and our biology, our psyche, in more or less productive relationships—in our reflections, inquiries and researches, reducing them to a mere schedule of home-work-school-hospital or another place. On the one hand, we are embedded in our current historical time (2018), and on the other hand, we are also embedded in a cosmic one. Yet, we miss a cosmology and our contact with natural time and nature itself, or better, we miss our cosmic time—where ‘cosmic’ means harmonious, beautiful, cyclical and biological one.

So far, we have analysed the linear time (Chronos), the time-opportunity (Kairos) and the eternal time (Aion) with the rest; but, we have still not considered the cyclic time of hours (Orai) of nature: the seasons, pacing the cyclical rhythm of nature and the ‘eternal return’ (Duk 2003). The Hours are the last piece of the puzzle that make up the four dimensions of time: that one that flows without return, the Chronos; the eternal one and the instant one, the Aion and the Kairos; and the longest time and the one of the eternal return (hours).

Time is cyclical not only for ancient Greeks but also for oriental philosophies: Japanese poems, the haiku, are based on the seasonal rhythm. Rhythm itself, in its etymology, indicates the flowing: Panta rei, ‘everything flows’, as Heraclitus stated (sixth century BC). Everything flows, just like hours. Nature has its precise laws: planet Earth is in aphelion, far from the Sun in summer, and in perihelion, near the Sun in winter, and—except some little realignments of the terrestrial axis or a catastrophic meteorite that destroyed dinosaurs—we have many statistical probabilities that the Sun will rise tomorrow (Hume 1711, 1712, 1713, 1714, 1715, 1716, 1717, 1718, 1719, 1720, 1721, 1722, 1723, 1724, 1725, 1726, 1727, 1728, 1729, 1730, 1731, 1732, 1733, 1734, 1735, 1736, 1737, 1738, 1739, 1740, 1741, 1742, 1743, 1744, 1745, 1746, 1747, 1748, 1749, 1750, 1751, 1752, 1753, 1754, 1755, 1756, 1757, 1758, 1759, 1760, 1761, 1762, 1763, 1764, 1765, 1766, 1767, 1768, 1769, 1770, 1771, 1772, 1773, 1774, 1775, 1776) so we can serenely sleep. The humankind has been ruled so much by these Earth rotation and revolution movements since its appearance on this planet that this biological time is encrypted in our DNA (Liu et al. 1992).

Since childhood, we realise that the Sun rises day after day and time goes by with the alternation of seasons. We wait for spring through the memory of our childhood, the metabolism of our cells, or maybe because of our collective subconscious (Jung 2002).

In this cosmic time, we beat linear time, Chronos, the despot whom inexorably proceeds during years: we may be 30, 50 or 70 years old, yet springtime comes back for our planet and for our bodies and for plants and animals. This is a wonderful miracle. Here, in this cyclical time, the flowing rhythm triumphs, and we become immanently living in nature: Jung was right when he wondered the reasons of birth of discomfort in civilisation. He situated it precisely in the loss of contact with seasons, agriculture, the summer harvest, the autumn seeding, the winter long wait and the spring renaissance. Primo vere: Latins called this season the first version, the first twisting. In ancient Greek mythology, it was the first and last of the hours: Thallo, the blooming spring; Auxo, the summer luxuriance; and Carpo, the autumn harvest of fruits (Hyginus n.d.). The cold of winter was symbolised by a man, Cheimon, that means beside winter, bitter cold, snow: he was not a goddess, but—in a certain sense—the fall from goddess. The hours were the young sisters of the three Moirai, women producing the warp of the rope of the linear time: they formed the strings, and they cut them at the end of life. They were daughters of Zeus and Themis, the universal order. If the Moirai determine and rule the chronological time of individuals (birth, growth and death), the hours bring the cosmic time, and the cyclical laws always involve a new renaissance. It is the same tree newly growing, teaching us that the cyclical time is sovereign in the plant realm as for animals in their different mating seasons.

More ancient civilisations had actually established eight seasons linked to the astronomical movements of our planet defined by two solstices, two equinoxes and seasonal interludes as well as the variations of time we may define climate—from klima, i.e. the inclination of the terrestrial axis, which were all linked to human mood. In fact, our behaviour is intrinsically linked to the cycles of nature (Saeed and Bruce 1998) and adapts to the seasons just like animals and plants do through a dormant or hibernation phase. Yet, the signs of these adaptations are often taken in their extreme manifestations and classified as symptoms of medical disorders, such as seasonal affective disorder (Oginska and Oginska-Bruchal 2014). In fact, the definition of winter disorder reads as ‘depression, lack of energies, sleepiness, weight gain, desire of carbohydrates’ (Narrative Medicine Website n.d.) and is prevalent in late autumn and winter. Despite the fact that the definition basically overlaps physiological behaviour of the majority of us in winter, the tendency in Western efficiency-driven societies is to treat these symptoms with antidepressant drugs. The biopsychosocial model does not permit hibernation. The ‘sabbatical’ winter period for listening to our body preparing for another spring season is not an option.

In the Persian culture, people were aware of winter gloominess. To overcome it, there was the ritual of carpet weaving and looming: by creating carpets portraying beautiful spring that had a therapeutic effect. During the cold winter weather when landscapes and mindscapes are shattered by ice and snow, women used to create carpets imagining the beauty of the spring depicting the tree of life, full of flowers, leaves, fruits, nests, birds, the top standing out the blue sky and the roots embedded in a brown soil covered by fresh grass (Citati 2006).

Speaking of spring and Orai, it is also worth recalling the masterpiece of the renowned painter Botticelli, portraying Venus covered by a veil of flowers brought by the spring Orai. The painting is an ode to life, in which the dullness of autumn and winter leave place to a coloured rainbow and where life is emphasised through the prosperity of the female figures, who are all of the childbearing age.

Another interesting symbol is represented by the story of Persephone, the beautiful girl who lives with her mother in the 6 months, the harvest goddess Demeter; together, they generate spring and summer, while she lives with her husband in the other 6 months, Hades, the god-king of the underworld. There are autumns and winters without harvests (Nilsson 1941). Again nature is feminine in blossom, and its disappearance turns the world cold. No empathy, no boundaries at the light of the Sun, but just profound boundaries in the underworld.

Could we, in this long waiting time, learn to be wise and patient also from the alternation of clear and grey sky? Learn to be patient? Could we allow ourselves to mourn as Demeter does in the 6 months she is left alone without her daughter, who is ‘living with the dead people’? Is it beneficial to shed tears? Yes, in one out of two individuals: tears belong to the languages of care. In an international study on crying (Vingerhoets and Bylsma 2007), participants across 37 countries were asked about their most recent crying episode: most reported feeling better mentally after crying compared with how they felt before crying (51.4%), 38.3% reported feeling the same and 9.7% felt worse. In terms of physical improvement, 27% felt physically better after crying, 56.4% reported feeling the same and 15.6% felt worse.

To overcome difficulties of the disease and other traumas we encounter in life, the cyclic flowing of seasons and the hours teach us the art of patience, together with art of crying and smiling afterwards, cherishing hope.

Narrating illness means having the possibility to rejoin the cosmic time, the more ancestral, and giving again this cycle of dignity and the necessary space: not for a matter of justice but because rejoining our roots brings us to a blooming awareness. Maybe it distances us from materiality and totems, but it puts us in contact with a Zen spirituality. Japanese not only stroll under blooming cherry trees, but they contemplate petals falling in the wind. In the film of Kitano, Hana Bi (Kitano 1997)—flowers of fire—the policeman’s wife living with cancer at end stage asks her husband to bring her there to see cherry trees blooming, assist to a pink renaissance and to the estrangement before the awareness of death. The cosmic order is a natural law: alienation means being not able to feel the universe and the body embedded in the world.

If we want to enlarge the horizon from the biopsychosocial model, let us begin to give it again the cosmic and natural sense poorly allowed by our Western civilisation, being more and more standardised in places and continuous and identical in seasons. Narrative belongs to our human nature, and language is an instinct: in the chapter dedicated to place and wellbeing, we will see how much natural setting of care is wished by people. When I am referring to nature, I am referring to trees, water, sea, mountains, countryside, animals, flowers, colours, light, sky and ground. Nobody of our interviewed people who were asked ‘what is your ideal setting of care?’ mentioned concrete, as we will see in Chap.  7. The overuse of concrete in our world and society is a killer of our relationship with nature.

The sense of beauty I am feeling while writing these considerations is surprisingly found in an odd convergence of a Nobel Prize in Medicine given in last 2017: the discovery of the circadian rhythm in relationship to the Earth’s revolution and rotation movements.

The Natural and Eco-friendly Nobel for Medicine

The following excerpt is from the press release of the Nobel Academy, October 2017 (Nobel prize n.d.):

Life on Earth is adapted to the rotation of our planet. For many years we have known that living organisms, including humans, have an internal, biological clock that helps them anticipate and adapt to the regular rhythm of the day. But how does this clock actually work? Jeffrey C. Hall, Michael Rosbash and Michael W. Young were able to peek inside our biological clock and elucidate its inner workings. Their discoveries explain how plants, animals and humans adapt their biological rhythm so that it is synchronized with the Earth’s revolutions.

The Nobel Prize in Medicine has been assigned to Jeffrey C. Hall, Micheal Rosbash and Michael W. Young (who have been working together at Brandeis University in Waltham, Massachusetts, and at the Rockefeller University) for their research on the circadian night-day rhythm and physiological functions of living beings. The Nobel Prize has shown that a gene, which is named period (Liu et al. 1992), controls the regular biological daily rhythm and codifies for a protein PER that accumulates inside cells during the night and is depleted during the day. Later, they find other protein-based elements of this system, revealing the mechanism that manages the self-sufficient clock inside the cell. The complexity of our biological clock is managed by two other genes, the timeless (TIM) and the double time (DBT) genes (Price et al. 1998) that modulate the 24-h regulation of the day-night rhythm. The study of the ‘circadian’ rhythms proved how fundamental synchronisation is important for our wellbeing.

In my opinion, this is one of the most caring Nobel about human, animal and vegetal physiology of Earth, maybe more, of the entire cosmos. If we read the first sentences of the Nobel Academy press release (Nobel prize n.d.), we find the words ‘rotation of our planet’: so, we, as living being, are integrated into the rotation movement, i.e. Earth’s axis of ‘our’ planet that rotates on itself. They could write just ‘of the planet’: they add that possessive adjective, ‘our’, making all the races living on this planet responsible and sharing this soil. At the end of the first paragraph is written biological rhythm so that it is synchronized with the Earth’s revolutions. There is that ‘sibylline’—‘the Earth’s revolutions’. The revolution movement of the Earth is that one carried out in a solar year, 365 days, when the Earth by continuing the rotation on itself, pacing the circadian rhythm, realises its orbit around the Sun, creating the cycle of the seasons. Therefore, the topic of light and dark assumes a different dimension that touch the rhythm of the seasonal nature, where there are long days with more light and shorter nights, and vice versa. There is the aurora borealis and the long Austral night, and vice versa. I do not believe that the words of a press release are chosen without a reason, but the moving from the rotation to the revolution movements (How many? Of which years? Ages? Past, Present and Future?) opens to broaden breath horizons and gives a ‘stellar’ dynamism. That little mosquito flying around the fruit used to isolate the period gene, that Drosophila melanogaster we all studied at the high school, here is elevated in a stellar ecosystem.

This Nobel Prize reminds us that our microcosmos is inside a macrocosmos that exists through an interdependence between light, darkness, life and stars’ movement. It reminds us the sense of responsibility and of belonging to our planet. Isn’t this enough? It reminds us that we are human beings in a big clock: if we change the rules of nature too much, like reducing the hours of sleep to be more ‘performative and productive’, this involves a reduced harmonisation with the ‘celestial movement’ and could damage our sense of ‘human being’. Richard Wiseman is analysing the sleep since decades and has written (Wiseman 2014):

Two-thirds of us are sleep-deprived. And this isn’t just an inconvenience, making us foggy and caffeine-dependent. Lack of sleep brings with it a host of problems—an increased risk of heart attacks, cancer, diabetes and an increased risk of weight gain. You might well wonder just why so many of us are so bad at sleeping? And since the humble snooze can protect our physical and emotional health, can make us feel energetic and confident and creative, why the majority of us consistently don’t get enough sleep?

Wiseman writes that before the invention of the electric lights, people used to sleep for 10 h, an appropriate time to feel rested and to face better the next day. Nowadays, we can take pills of melatonin to overtake the jet lag, which stimulates the production of PER proteins that we will need for the next day, but only for a specific period, to protect our organism. However, beyond the occasional trips, the LED light in our bedrooms and in our bathrooms at night and the city lights damage our melatonin’s production. For PER, I could add further that the period protein PER stands for performative (English term is also nowadays a trend in the people’s productive efficacy evaluation).

Different studies have suggested that exposure to light at night (LAN) induces sleep disturbances, impairs melatonin section and disrupts the circadian physiology and behaviour (Boivin 2000; McClung 2013). Depression is frequently accompanied by these conditions. A greater depression risk, observed in night-shift workers, is significantly correlated to LAN exposure and circadian misalignment between internal biological and environmental rhythms (Bara and Arber 2009). Recent studies have demonstrated that in humans, 5-lux LAN exposure in home settings is significantly associated with depression symptoms (Fonken et al. 2012).

Professor Kenji Obayashi and his team in Nara Medical University, School of Medicine, Japan, enrolled 863 participants during 2010–2014 to test the association of LAN exposure with the incidence of depressive symptoms in an elderly general population. They observed that bedroom LAN exposure in home settings, including low average light intensity, is significantly associated with depression risk (Obayashi et al. 2018). The researchers visited participants’ homes predominantly on weekdays, instructed the participants to maintain a standardised sleep diary and measured bedroom light intensity objectively using a portable light meter placed facing the ceiling at the head of the participant’s bed. Thereafter, they assessed the depressive symptoms. Out of the 863 participants, who did not have depressive symptoms at the baseline, the LAN group exhibited a significantly higher depression risk compared with the ‘dark’ group (hazard ratio = 1.89, almost double). Maintaining darkness in the bedroom at night might be a novel and viable option to prevent depression.

This is another evidence about the importance of respecting the natural circadian rhythm and indicates how dangerous it is to neglect what is happening in nature for being more productive: the risk of becoming depressed.

Even with exceptions such as artists who create by night with the moonlight or women that breastfeed helped by oxytocin, dreams, as stated by Wiseman, are useful to recapture the logic path interrupted during the day and open widely the doors of creativity and possible awareness’ solutions and expansions towards situations that seem hard to solve during the daylight. I believe that everyone had solution ideas in the middle of the night, then turning on the other side of the bed, restart to sleep, softly cradled by the sweet rotation of our planet.

For those who read the Odyssey (Homer n.d.), one of the trials of Odysseus was the land of the holy cows of Helios, the Sun god. They were sacred, untouchable and inedible. The number of these cows was less known: seven herds composed by 50 cows and 350 holy animals were dedicated to the Sun. Among the expressed theories, one of the most likely is that this number was a symbol of the calendar’s days (in the past, around 350). Therefore, to kill one or more days was a sacrilegious action, changing the natural rhythm of rotation and revolution of the Earth towards the Sun. This is wonderful. It reminds us that we are not alone, that also plants sleep at night and that for anyone of us a sunrise grows to announce the dawn and day that will come, along with the sunset and the evening before night. It reminds us that humanisation means taking back the time of 9–10 h of sleep to be sharper and more aware during the day and switching off cell phones, TV and LED lights to prevent chronic diseases and unhappiness. It reminds us that accommodation systems exist—like the timeless gene that works also in the dark, in a situation of light deprivation, just for limited time. However, the emergency that for months the light could disappear on our planet was faced in our biological evolution.

Furthermore, it reminds us a cosmological system, which owns an extraordinary power of care. It has its own language, which has to be decrypted. Once decrypted, the benefit of pacing with the natural rhythm of light and dark as well as cold and hot will put the biological clock of the cells of our bodies in connection with the holistic system of nature.

The Narrative of Time: I Feel My Time, You Feel Your Time, I Say My Time Is… and You Say Your Time Is…

Time perception is one of the themes which philosophers and scientists have put into questioning and, more universally, all individuals, possibly, because it belongs to universal archetypes: what is behind the sensation that time flies or never goes by? Is time course different between youth and old age? What if we are sick or healthy? Moreover, are these hypotheses or prejudices originating from a lack of objective knowledge about time phenomenon true?

Among the usual clichés, or maybe through the convergence of a number of researches, we assume that ‘the perception of time for young and adult people follows almost opposite tracks, where for elder people time seems to pass faster’ (Gemignani 2015). Neurosciences can help us to explain this phenomenon: different awareness of time can be linked to a different capability to memorise events, more enhanced in young people, thanks to the presence of chemical mediators implicated in the processes of cerebral plasticity.

Time, Young and Elder People

For adults, time flows faster than for teenagers. This phenomenon is defined as ‘telescope effect’, which is the tendency to position the events inside the memory through a chronological order so that recent events result more distant in time and more remote events result nearer. Young people fix the object that is close to the telescope far away, while elder people closely investigate most distant things, getting lost in infinite details. Memory is a parallel process to how time is perceived: ‘short-term memory’ is very active in young people, and ‘long-term memory’ is that one persisting in elder people’s thought, occupying space for new time.

The temporal perception appears influenced by the body and brain’s biochemical conditions. In particular, dopamine is one of the main neurotransmitters involved, which contributes to that sensation by which time goes by faster. The same effect is given by substances such as cocaine, which enhances the dopamine effect. On the contrary, this effect is inhibited by neuroleptics, which are drugs used to treat diseases such as schizophrenia making time feel longer. In addition, several cerebral zones are called to account these chemical mediators: in summary, according to this theory, time perception is intrinsic in our neuronal system and ages gradually, favouring the sense of tempus fugit (Virgil (29 BC) n.d.), time flies. Other researches in psychology have confirmed this telescopic effect of perception of time, showing that only a small percentage (10%) of elder individuals escape from the temporal acceleration trap (Wittmann and Lenhoff 2005).

However, there are other kinds of time, even able to interfere with this finding: we have to train enough to concentrate on the Kairos, the ‘here and now’, the ‘carpe diem’ and the eternal and the cosmic time. However, other external incentives can deny this time perception, which bring us back to believe other possible declinations of ‘time factor’.

Let us simply think about school children who get bored at school and feel that lessons are endless and tedious and the hands on the clock seem to be still in a fixed position? Yet, the same children will see time fly with some teachers. The fact that time goes faster during holidays is almost rhetoric. Hence, we can add that the perception of time is also influenced by being with other people, places and activities: there are people for whom holidays never pass; it is an empty space to be filled with the unknown, and it is better to seek refuge in an ordinary working routine, revealing the necessity to not know the mystery of unpredictable time. Maybe, having too much time to ourselves for thinking brings shock and fear and puts us in front of the extraordinary difficulty of letting ourselves free to experience the unknown, the unruled, out from strict rules not only of life but also of mindset.

Going back to science to find evidence on several ways of ageing and that an elderly age chased by a faster and faster time is not so unavoidable against which perhaps we can find some possible forms of human intervention.

In a study conducted by the French university Blaise Pascal and the English university in Keel, results contradict the fact that the older we are, the faster time flies. Young and elder individuals were given a questionnaire on time perception, and they received eight phone calls a day for five consecutive days (Droit-Volet and Wearden 2015). Such calls forced participants to stop for each call and to talk ‘here and now’ about their emotions, activities and feelings on time. Although the study findings did not show any perceived difference in the speed of time between young and elder people, it is likely a bias from the ‘experimental’ design keeping elders under pressure, in everyday life, without fearing the forward flight—in contemporaneity—and giving a particular sense of attention in a possible fragile moment, such as ageing. This research may be the key of active ageing: avoiding elders’ discrimination and giving them an important role in their microcosm. This study may be a trailblazer for older age compared to the attention we give to elders, once more respected for their experience, in their world, apparently less dynamic; it gave value to their stories and so their capability to remember old story detail, the long-term memory.

Today, in this ‘fast and furious’ world, it is hardly permitted to look back, and elders are seen as active or inactive, heavy and useless. To ‘activate’ them, it is important to make them call eight times for days to acknowledge their being. Is it possible to balance between the request of being up with current time and the respect due for their single passed experiences? This is anyhow a key between a good time perception and concrete and realistic achievable behaviours.

The issue of time perception appears complex: from one side, neurosciences tell us we have an internal biological clock that goes far beyond the day and night rhythm of the PER protein, but it is a lifelong biological clock thanks to which we feel a faster time, as we are adding years to life. On the other side, it tells us we can fool our biological clock if we have a rich and stimulating everyday life and if we are a focus point for someone, at least for researchers, while instead time is a function of emotionality and participation we feel.

What About Patients’ Perception of Time?

The word ‘patient’ has an ancient etymology, derived from pathos (‘suffering’, ‘passion’), an ardent feeling. The patient is who suffers: while the Latin verb patior indicates only suffering, ancient Greeks objectified strong passion. Latins got rid of the several hints of pathos, keeping just a consequence: this ‘suffering’ was putting the person in the condition of discrimination, as ‘male-aptus’, not able, so ‘disable’, from here, the root of the word ‘disease’. The Latins gave very scarce consideration to strong emotions and passions and were very much oriented to outcomes and pragmatisms.

Anyhow, nowadays, the sick person is called ‘patient’ that means ‘suffering’. However, we can add to this meaning the feeling of time in a particular declination, that of patience. Patience is an interior quality and attitude of whom accepts pain, difficulties, adversities, troubles, controversies and death and serenely and calmly, controlling emotions and persevering in actions. It requires calm, resolution and application. The patient who pathologically (which by the way also derives from pathos) ‘feels’ has to deal with a time, which tends to be never-ending: the time of being ill. However, from patients’ narratives, we remark a faster and bearable time than that one they lived when the diagnosis was unknown, as if knowing the truth on his/her own health is already a ‘an accelerator of time’, which drives patients to not waste no further. Time before the diagnosis is the time of uncertainty, such as waiting for the result of a test—a waiting time that objectively can last from a few hours, perceived as infinite, to some weeks. In narratives, we read ‘the waiting was unbearable, finally I knew, then…’ (the waiting for the result of a biopsy) and ‘I spent 2 weeks passed searching for a distraction’ (the waiting for the result of an amniocentesis).

Carers must not underestimate this waiting time, which increases until it becomes a colloidal magma which drives patients to be mentally exhausted: they should not minimise the waiting time of their cured ones. Often physicians and medical operators underestimate the issue of time, saying sentences such as What’s the issue, it’s only for 2 days and do not understand the anxiety given by those 48 h of waiting. Maybe it would be more opportune to say, in an empathic way, These 2 days will be long, I can imagine, if you need, call me. It would be fantastic. I write this in the hope that some professional will read this little tip of not abandoning the patient alone in such a difficult situation. However, also the adult patient should activate her/himself in distraction: finding something nice, cultivating an own hobby and something pleasant to distract their mind. Here the carer might help by asking the person: What do you love to do? Which are your hobbies? So, it is important to be a stimulator of doing something nice instead of ruminating on the obsessive thought about the outcome of a clinical test. The coping skills make a great difference about time perception: in an unpublished research of a group of psychologists working with patients with disability, contrary to what they thought before the study that time was never-ending, and never flowing, patients answered that they became familiar with the bothering time. They accepted the time to be themselves bothered as a coping ability. Furthermore, in their disability, some of these patients found benefits from imagination, and in this fantastic realm, there is another rhythm, a different pace of time. In this way, they feel good. They do not get bothered.

However, if a trauma occurred, and poor coping strategies are in place, in some patients living with multiple sclerosis, for instance, there is the personal regret for not having enjoyed enough life before. Therefore, the challenge, despite the trauma of the disease, is finding joy in this new, transformed dimension. Instead of staying in a conscious, still, boring patience, maybe other and funnier forms of entertainment can help us, such as music, which seems to accelerate time, independently from its emotional value.

In the study Time flies with music, whatever is its emotional nature (Droit-Volet et al. 2010), researchers investigated if music influences time perception in a different way from a neutral stimulus and whether emotional values of musical stimulus (i.e. sad music versus happy music) modulate this effect. Music presented in a major note (happy) or minor key (sad) induces the listening person to say that the duration of a melody is shorter than that of a non-melodic stimulus of control, confirming that ‘time flies’ when we listen to music. The singular thing that adds a little more complexity to time is that it is not always so true that time flies while listening to good music we love: if music is ours and is that capable to distract us really, we can arrive also to a paradoxical effect, i.e. time seems to stop (Kellaris and Altsech 1992) towards a peaceful quiet as if time itself were empty of significance because it is the music itself stripping the perception of frivolous things and therefore of tempus fugit.

It is like we found the barycentre, the extreme stability in the middle of a vortex. In the eye of the storm, space and time converge in immobility and quietness.

Exhausted I sought a country inn, but found wisteria in bloom”. Matsuo Basho, seventeenth century.

Practice Time

  • What do you think about the many facets of time? Do you believe that our living experience is something more than a matter of getting older but is also an opportunity to do, to ask and to catch the right thing at the right time? Do you think that you can apply these concepts during a visit with patients or team working?

  • If you want, try to ‘catch the moment’, living the Kairos experience.

  • What do you think about the long time? What about your time to get a real metamorphosis, if something changed your life? What do you think about convalescence and about rest? Please, write down the things which help you rest. Would you like to try to ask to your patients what they love to do for resting? What about convalescence after a disease?

  • What do you think about waiting time? Try to think in your personal and professional life to time of unbearable length, what did you do? Could you do something else to feel less the burden of time?

  • About the cyclic time, what are your feelings? Do you think that we could respect more our ‘animal nature’ and be more in tune with the Earth, Sun and moreover cosmic movements? If you think you should be more respectful of our cosmic time, what would you suggest to your closest people, friends, colleagues and patients?

  • If a metaphoric spring might be joyful, a metaphoric winter might shed tears. How do you consider the convalescent time and the mourning time?

  • What could you tell to ease patients’ difficulty in mastering waiting time? Could you change something in the waiting room at your practice, introducing some activities, new people, new roles and volunteers?

  • Have you ever thought about the relationship between time, music and wellbeing?


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Maria Giulia Marini
    • 1
  1. 1.Department of Healthcare InnovationFondazione ISTUDMilanItaly

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