The Concept of Time in Rehabilitation and Psychosocial Adaptation to Chronic Illness and Disability

Abstract

The first part of this article focused on providing the reader with a general overview of the concept of time with special emphasis on understanding time’s role in the structure of personality theories and their associated therapeutic approaches, as well as linking the discussion to the understanding of time in the context of psychosocial adaptation to chronic illnesses and disabilities (CIDs). In the second part of this article, the author seeks to (a) briefly comment on the association among death, disability, and time; (b) discuss findings from the clinical and empirical literatures regarding time perception/orientation within the context of psychiatric disabilities; (c) review findings on the relationships between time perception/orientation and psychosocial adaptation to CIDs; and (d) highlight those treatment modalities that have been suggested for individuals whose disabilities have resulted in time distortions.

Keywords

time chronic illness disability rehabilitation adaptation

The literature on time, its perception, orientation, meaning, and in general relationship to the human experience is of voluminous magnitude. In Part I of this article, the concept of time was approached from a historical perspective, with emphasis on theoretical and clinical views regarding the nature, structure, and passage of time. Whenever permissible, implications of how time aligns with psychosocial adaptation to chronic illness and disability (CID) were suggested. Part I concluded with a review of how time is conceptualized and integrated within the boundaries of several of the leading personality theories and psychotherapeutic models. When appropriate, referencing pertinent literature from the field of adaptation to CID was attempted.

In Part II of this article, the discussion decidedly swings toward the field of rehabilitation with particular attention to the theoretical underpinnings and empirical findings that directly address psychosocial adaptation to CID. Accordingly, in this part, the discussion focuses on (a) briefly reviewing time and death, as the latter has been linked, albeit most symbolically, through the paths of loss, grief, and threat to life, to the onset of various types of CID; (b) time orientation/ perception within the context of psychiatric disabilities, namely, anxiety, mood disorders, psychotic impairments, and antisocial personality disorders; (c) the relevant empirical literature on the relationships between time orientation/perception and psychosocial adaptation to CID; and (d) those treatment modalities that could be beneficial for individuals whose CID results in time distortions.

Time and Death

Over half a century ago, Heidegger posited that the inevitability of death lays the foundation to how humans perceive and experience time. Time has been described as “the arch enemy of all living” (Doob, 1971, p. 92), the “enemy of man” (Frank, 1939, p. 293), and accordingly, man “remains impotent against the inexorable passage of time” (Arlow, 1986, p. 525). Similarly, the American philosopher Dewey (1940) termed time as the “destroyer,” whereas Seymour (2002) maintained that bodily deterioration and its eventual death are directly related to the flow of time. Time has also been reflected and symbolized in mythical figures such as “Father Time,” “The Grim Ripper,” and so on, and as such has been feared and hated (Arlow, 1986; Ingram, 1979). It is of interest to also note that even the world of physics, the Second Law of Thermodynamics, often referred to as the Law of Entropy, indicates that all closed physical systems, with time, move into a greater state of entropy (or increased amount of disorder). In other words, this process indicates the evolution of initially well-organized, dynamic systems (literally reflecting an active mode of functioning) into disorganized, lifeless systems as time goes on (Davies, 1995; Greene, 2004).

Indeed, for humans and most organic (as well as inorganic) matter, time is firmly associated with decay and death. Time, therefore, is closely linked to the concept of mortality. Whitrow (1972/2003) maintained that humans’ awareness of their own mortality is linked to their existential anxiety of the passage of time and, therefore, is closely aligned with the unpredictability of the future. Hans Reichenbach (1956) also posited that an inescapable conclusion emanating from the irreversible flow of time is that of the gradual approach of death. Accordingly, he suggested, death anxiety transforms itself into the fear of time. Similar sentiments were also expressed by Fraser (1975) who posited that the passage of time is intimately associated with the inevitability but unpredictability of death, thus necessitating mastery of future contingencies. To ward off this omnipresent existential anxiety, or the end of individual time, humans have nourished hopes for immortality and life after death (Sherover, 2003). The future is, then, the harbinger of feelings of anxiety, whereas the past is more likely to offer a safe haven from such fears. The past, however, is not immune from lingering experiences of anxieties as is commonly observed in such conditions as posttraumatic stress disorder (PTSD) and dissociative identity disorder (previously known as multiple personality disorder).

Yet, the fact that death is an outgrowth of human (and all living things) existence also suggests that death, being the negation of life, is therefore necessary for imbuing life with significance, meaning, and direction (Minkowski, 1970). Furthermore, the insatiable human need for denial of death (Becker, 1973; Greenberg, Solomon, & Pyszczynski, 1997; Rank, 1932/1989) is what facilitates living “in the present” while, at the same time, planning for the future as if death is avoidable (Minkowski, 1970). Adopting a clinical view, Cohn (1957) and Orgel (1965) suggested that the rigid rituals commonly seen in people with obsessive-compulsive disorders are a kind of “time machine” adopted to keep the notion of death in abeyance, thus warding off the finality of life.

CID applications

The role that time plays in the context of death can be traced to the notion that CID has been symbolically equated, at least in the psychodynamic literature, with death and dying of certain body organs and functions (e.g., blindness as the “death of eyesight”; paralysis-linked spinal cord injury (SCI) as the “death of mobility”; Chan, Livneh, Pruett, Wang, & Zheng, 2009; Livneh & Siller, 2004). If, indeed, certain forms of CID are symbolically reflective of death, then it could be argued that the onset of CID further nourishes the universal human fear of death and its symbolic association with normal aging and the passage of time. Although much of the available literature in this field was spawned by research on attitudes toward people with CID, the very nature of psychosocial adaptation to CID suggests that coping with the aftermath of life-threatening medical conditions (e.g., cancer, heart disease) embodies the concept of time and its psychological orientation. For example, the literature on coping with cancer frequently contrasts the impact of two sets of coping strategies. At one extreme, we find fatalism (i.e., stoically accepting diagnosis and seeking no other information about condition or making no plans to confront its implications), as well as helplessness/hopelessness (i.e., engulfing oneself with the diagnosis and adopting a pessimistic attitude about survival). At the opposing pole, we find the strategy of fighting spirit (i.e., being determined to fight illness by obtaining information and adopting optimistic attitude about its eradication). Cancer survivors who have engaged in efforts to combat the stressful impact of their condition, by demonstrating fighting spirit, have shown remarkable resilience in the face of their often bleak diagnosis. They have coped with their diagnosis and its implications by actively focusing on their present regimens and pursuing future plans to minimize its impact on their lives. In contrast, those who have passively accepted their condition as a “death sentence” adopted a hopeless view of their future, lacked the will to actively cope with their condition, and were unable or failed to engage in present-focused efforts, or set future goals to successfully combat their condition. Their view of time appears to be past focused (“I’ve had a good life”) and future truncated (“I avoid finding out more about it”) in its orientation (Greer & Watson, 1987; Watson et al., 1991).

Time and Psychiatric Disorders

A voluminous body of literature exists, that links time perception and/or time orientation with psychiatric disorders. The distortion of time perceptions, be it a contributing mechanism to the onset of psychiatric disorders, a correlate of their manifestation, or a by-product of their nature, is nevertheless an integral part of their symptomatology. This body of literature can conveniently be discussed under four primary headings, namely, (a) time perception and anxiety disorders, (b) time perception and mood disorders (mostly depression), (c) time perception and psychotic disorders (mostly schizophrenia and bipolar disorders), and (d) time perception and personality disorders (mostly antisocial personality disorder; Cottle & Klineberg, 1974; Edlund, 1987; Melges, 1982, 1989; Rappaport, 1990; Zimbardo & Boyd, 2008). It is beyond the scope of this article to fully address the rich literature that was aggregated over the past 60 years. However, the present section seeks to provide the reader with a succinct overview of the major concepts and empirical findings drawn from the available literature.

Time and anxiety disorders

It has been long thought that images and anticipation of future events carry profound influence on how individuals experience the present (Barlow & Durand, 2009; Cottle & Klineberg, 1974; Zimbardo & Boyd, 2008). When life events render the future unpredictable, uncontrollable, and mostly foreboding, increased levels of anxiety ensue, feelings of dread consume present thought processes, and temporal integration is threatened (Cottle & Klineberg, 1974; Maslow, 1962; Melges, 1982, 1989). Threat and anxiety are, therefore, future oriented. Efforts to manage anxiety may, therefore, focus on the more positively embedded past time perception and minimization of future time projection (Krauss & Ruiz, 1967). Empirical findings on the relationships between time perception and anxiety are scarce but appear to lend some support to these clinical observations. Krauss and Ruiz (1967) reported that scores on a measure of anxiety were indeed negatively correlated with future time perception among hospitalized psychiatric patients. Terr (1983), in a sample of 30 children and adults who experienced a psychic trauma and exhibited a wide range of PTSD-related symptoms, found frequent alterations in perception and memory of time duration and a pronounced belief in foreshortened future perspective. Rappaport, Fossler, Bross, and Gilden (1993) reported that in a sample of older individuals, future time orientation (FTO; in the form of seeking meaningful and purposive future life possibilities) correlated negatively with death anxiety, suggesting that in older individuals with lower levels of death anxiety the ability to focus on the future was more intact.

Time and mood disorders

Symptoms of depression commonly include (a) hopelessness and helplessness; (b) grief, mourning, and preoccupation with loss and failure; and (c) psychomotor retardation, which is also typically experienced as a significant slowing of subjective time (Barlow & Durand, 2009; Edlund, 1987; Friedman, 1990; Melges, 1982, 1989; Wyrick & Wyrick, 1977; Zimbardo & Boyd, 2008). Feelings of hopelessness point to a truncated or blocked future (occasionally referred to as foreshortened or constricted FTO; Gjesme, 1983; Melges, 1982). They also indicate disregard of future plans and goals (Orbach, 1975). Feelings of grief and loss suggest a disproportional focus on the past and its no longer available rewards. Brenner (1974), Arlow (1989), and Rappaport (1990) further argued that, in contrast to those who experience anxiety (i.e., the feeling that something bad is about to happen), people diagnosed with depression tend to focus on the past (i.e., something bad has already happened) while consideration of a positive past, and especially future, appears to be no longer a viable option to them. In a similar vein, their estimation of the passage of time is often faulty, such that time is experienced to be passing too slowly. It is as if in depression, the flow of time has slowed appreciably, even ceased its perceived forward movement completely or is even assuming a backward flow! (Rappaport, 1990). Empirical findings of these notions (Blewett, 1992; Dilling & Rabin, 1967; Gil & Droit-Volet, 2009; Melges & Fougerousse, 1966; Tysk, 1984; Wohlford, 1966) indicate that the perception of the flow of time among people diagnosed with depressive disorders is, indeed, slowed down and may be, further, directly correlated with retarded psychomotor activity and altered level of physiological arousal.

Time and psychotic disorders

Psychotic disorders are commonly exemplified by bipolar disorders and the various types of schizophrenic disorders. In the former group of people with bipolar disorders, clinical reports (Edlund, 1987; Melges, 1982; Mezey & Knight, 1965; Tysk, 1984; Zimbardo & Boyd, 2008) have indicated an opposite trend, during the manic phase, to that observed in people with unipolar depression, such that subjective time estimates appear to reflect the experience of rapid flow of time (e.g., racing thoughts) and an overexpansion of FTO (i.e., the individual’s span of awareness into the future). The latter group is marked by impaired reality testing, disorganized thinking and behavior, and inappropriate affect. Melges (1982, 1989), as well as other researchers (e.g., Edlund, 1987; Friedman, 1990) of time perception among people with severe psychiatric disabilities, argued that time distortion in these populations may be at the root of the symptoms encountered among people with these impairments. Entrenched in the symptoms that are associated with psychotic disorders is the collapse of the past (e.g., recollection of prior events) and the future (e.g., expectations of events) into the present. Present perceptions, therefore, appear to be timeless, and they are all experienced as equally real (Melges, 1982, 1989). Moreover, perceptions of inner events (recollections and expectations) are often confused with outer events (ongoing perceptions triggered by environmental-based stimuli and events; Melges). Time and space, as such, lose their defining dimensionality and are experienced in a disintegrated, fragmented, and dysfunctional manner.

These distortions or disorganization of psychological (i.e., subjective) time typically encompass distortions of rate (duration), estimation, sequencing (ordering) of time, and temporal perspective. They are all manifestations of disorganized thinking (Lehman, 1967; Melges, 1982, 1989; Melges & Freeman, 1977; Zimbardo & Boyd, 2008). Indeed, the so-called cognitive “primary processes,” those operating forces within the unconsciousness, that we all encounter during dream sequences and that are characterized by chaotic, diffuse, and disorganized mental images (unlike the more mature cognitive “secondary processes” of well-organized, reality-oriented thinking) strongly mimic the experience of timelessness noted in acute psychoses and during infancy (Doob, 1971; Freud, 1933/1965; Masler, 1973; Melges, 1982). Empirical findings (Braley & Freed, 1971; Densen, 1977; Dilling & Rabin, 1967; Johnson & Petzel, 1971; Melges, 1982; Tysk, 1983; Wahl & Sieg, 1980) indicated that for a large number of people diagnosed with schizophrenia, (a) time was claimed to “stand still”; (b) clock and calendar time were inaccurately estimated (often overestimated); (c) FTO, as compared with that of nonimpaired individuals, was of shorter duration, more incoherent, and mostly disorganized; and (d) experiences of timelessness and personal time fragmentation were evident. These manifestations of temporal disintegration have been observed in psychotic episodes such as failing to properly index the past, accurately perceive the present, and logically anticipate the future (Edlund, 1987; Melges, 1982). More recent research findings suggest that time perception distortions may be linked to more generalized lack of temporal coordination in the brain and to pronounced neuropsychological dysfunction (Carroll, Boggs, O’Donnell, Shekhar, & Hetrick, 2008; Carroll, O’Donnell, Shekhar, & Hetrick, 2009; K. H. Lee et al., 2009).

Time and antisocial personality disorders

Over half a century ago, Cleckley (1959) maintained that individuals diagnosed as sociopaths and those designated as criminals often fail in, and may even be incapable of, their efforts to pursue long-term goals in an organized, well-orchestrated manner. Cleckley, therefore, speculated that for these individuals, a disruption in the processing of present needs and wishes occurs, which then interferes with the capacity to envision future consequences. According to several theorists and clinicians (e.g., Melges, 1982; Smith, 1985; Wilson & Herrnstein, 1985), sociopathic behavior is characterized by foreshortened FTO or constricted “time horizon.” The present-oriented, impulsive efforts of those diagnosed as sociopaths (nowadays typically categorized under the most severely impaired individuals with antisocial personality disorder; American Psychiatric Association, 2000) to obtain immediate gratification are linked to their inability to anticipate future events along with their consequences (potential risks and rewards; Melges, 1982). Empirical findings lent some support to these notions. Results from an early study by Stein, Sarbin, and Kulik (1968) showed that high school youths with a record of delinquent behaviors scored significantly different than a matched sample of nondelinquent youths on a measure of future events, indicating less prosocial and less realistically extended future time perspective. Hartocollis (1972), for example, reported that on projective tests (e.g., Rorschach test, thematic apperception test [TAT]), patients diagnosed with antisocial personality disorders displayed limited awareness of time, most notably of the future and the past. Black and Gregson (1973) also observed a shorter time perspective in a sample of prisoners when compared with a nonprisoner sample. Getsinger (1975) reported that males diagnosed with sociopathic disorder produced a greater number of errors in time estimation, demonstrated poorer temporal delay, and failed to integrate among past, present, and future, as compared with individuals termed self-actualizers, based on their high scores on a measure of ego resiliency. Trommsdorff and Lamm (1980) observed that, among male adolescent delinquents, FTO was less differentiated, less extended, more pessimistic, and more internally derived than that of nondelinquents. Lilienfeld, Hess, and Rowland (1996), albeit in a sample of undergraduate students, found that measure of psychopathic personality/antisocial behavior was negatively correlated with self-report measures of FTO, thus lending further support to prior observations that antisocial tendencies may indeed be associated with the inability to successfully process perceptions of the future.

Time, Coping, and Psychosocial Adaptation to CID

The concept of temporal adaptation has received only a scant treatment in the fields of health, psychology, and rehabilitation. In its broadest sense, it may be conveniently regarded as occupying a continuum whose anchoring poles describe successful temporal functioning versus poor temporal functioning (Cottle & Klineberg, 1974; Kielhofner, 1977). The former pole refers to the capacity for a conscious, meaningful, flexible, and balanced integration of past experiences and future expectations into present activities. The successful integration of past, present, and future temporal aspects is considered paramount to the continuity of life activities and is informed, among other factors, by situational necessities and available personal resources (Zimbardo & Boyd, 1999, 2008). In contrast, the latter pole reflects poor ability to integrate these temporal aspects and results in unsuccessful efforts to organize life activities. It has also been extensively implicated in the development and maintenance of various psychiatric disorders (reviewed earlier in this article).

Successful temporal adaptation is further imbued with such fundamental concepts as change (vs. immutability), evolution (vs. stagnation), and dynamics (vs. inertness). Indeed, its essence derives from the notion that adaptation is a continuous process that requires various internal (e.g., emotional, cognitive) and external (i.e., environmental) life adjustments over time and is not a single instant, static concept (Vaillant, 1977; White, 1974). The capacity for temporal adaptation also suggests successful coping behaviors with stressful life events and is associated with positive self-esteem (Zeidner & Saklofske, 1996). Although there have been many approaches to viewing and classifying coping (e.g., Carver, Scheier, & Weintraub, 1989; Lazarus & Folkman, 1984; Tobin, Holroyd, Reynolds, & Wigal, 1989), the notion of temporality appears to fuel much of their content and functional ingredients. For example, in making a distinction between coping and defensive processes, while adopting a psychodynamic approach, Haan (1977) argued that the ego processes inherent in defense mechanisms are mostly past propelled and distort those psychological facets required for present functioning. In contrast, coping processes were viewed by her as future oriented, while taking account of present needs and the reality of the present situation. In a somewhat similar manner, Nolen-Hoeksema and her colleagues (Nolen-Hoeksema & Larson, 1999; Nolen-Hoeksema, Parker, & Larson, 1994) carefully researched the nonadaptive emotional-focused coping strategy of “rumination” (hers is a different approach to coping than Haan’s) and concluded that unmitigated rumination reflects “being stuck” in the past rather than moving forward toward acceptance of the stressful situation (e.g., loss of a loved one). In other words, it is those negative memories from the past that result in viewing the present more negatively and in preventing active and adaptive problem solving from combating depression.

Another example of the intimate link between coping and temporal orientation can be seen in the five-tier phase classification of coping. According to this classification (Aspinwall & Taylor, 1997; Folkman & Moskowitz, 2004; Livneh & Martz, 2007a; McGrath & Tschan, 2004; Schwarzer & Knoll, 2003), coping efforts can be directed toward (a) long-range anticipated future events (preventive or proactive coping), such as age-linked illnesses; (b) short-range anticipated future events (anticipatory coping), such as awaiting the results of potentially life-threatening diagnosis; (c) dynamic or crisis-like (present) situations, such as facing intractable pain or a natural disaster; (d) proximal (immediate) past events (reactive coping), such as the aftermath of a recent car accident; and (e) distal (remote) past events (residual coping), such as dealing with early life onset CID.

The intriguing close relationship between temporality, coping, and psychosocial adaptation to CID also implicates the former’s association with notions derived from the field of positive psychology (Chou, Lee, Catalano, Ditchman, & Wilson, 2009). Recognizing the interdependence of positive psychology and temporality, Seligman and Csikszentmihalyi (2000) made the following observation: “The field of positive psychology at the subjective level is about valued subjective experiences: well-being, contentment, and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present)” (p. 5). Indeed, the very essence of concepts such as posttraumatic growth (Tedeschi & Calhoun, 2004), benefit finding (McMillen & Cook, 2003), adversarial growth (Linley & Joseph, 2004), hope (Snyder, Irving, & Anderson, 1991), optimism (Scheier & Carver, 1985), and self-efficacy (Bandura, 1977) strongly indicate the inception of a positive growth trajectory and nonlinear adaptive transformation (i.e., future-oriented thrust) that follow the aftermath of adversarial life events. They also suggest a departure from ruminative reflections (i.e., past-oriented thrust) and other nonadaptive fatalistic schemas derived from the loss (e.g., onset of CID) and, instead, using the traumatic experience as a springboard for the search of meaning in life and the attainment of a positive future. For example, O’Leary, Alday, and Ickovics (1998), in their model of resilience and thriving, which embodies many of the essential components of positive psychology and posttraumatic growth, discuss three possible psychosocial outcomes. Each of the outcomes follows a different temporal trajectory in the aftermath of trauma. The first outcome, survival, depicts an individual who has never gained his or her prior level of psychosocial functioning. This outcome suggests a person who is “stuck” in the past and has failed to overcome the burden of present restrictions. The second outcome, recovery, describes a person who has regained earlier level of psychosocial functioning (e.g., recovered homeostasis) and has resumed earlier level of functioning in his or her current life. This outcome suggests an individual whose functioning is balanced in the present but lacks future-oriented thriving. Finally, in thriving (or growth), the third possible outcome, the person flourishes beyond the earlier level of psychosocial functioning, thus manifesting transformative and trauma-transcending capabilities. This transformation is described as reflecting a “quantum change” (Miller & C’deBaca, 1994; O’Leary et al., 1998; Tedeschi & Calhoun, 1995) and can best be explained as a subjective, nonlinear, noncontinuous temporal leap (i.e., a sudden, unexpected, abrupt change) in the person’s level of psychosocial functioning following the onset of a traumatic event.

The subjectivity and relativity inherent in perceived (i.e., psychological) time are markedly influenced by a host of personal experiences and environmental conditions, including those associated with the onset, nature, progression, and treatment of CID (Livneh & Martz, 2007a). Following the onset or diagnosis of CID, the individual must navigate among personal perceptions and recollections of the pre-CID past; current cognitive schemata including coping modalities and novel biochemical, physiological, and physical experiences; and the uncertainty and unpredictability of the future. The impingement of these perceptual, motivational, cognitive, and affective experiences combine to affect time perception and orientation and, as a result, the process of adaptation to CID. As discussed earlier in this article, gradual deterioration of bodily processes and functions, and ultimately the sentence of death, are inextricably linked to the passage of clock time. The onset of CID, however, embodies an unexpected discontinuity in the normal progress of physical aging (Seymour, 2002). CID, therefore, disrupts the passage of physical and psychological time, results in disorganization of temporal adaptation, and is a concrete testament to the vulnerability of the human body (Kielhofner, 1977; Seymour, 2002). With its associative symbolism of death, time assumes a far more urgent role in the lives of people with CID (Adam, 1990; Seymour, 2002). Indeed, Seymour (2002) maintained further that “living with a disability is living a life dominated by time” (p. 138).

The notion that normal time flow is disrupted by the onset of CID further suggests the following corollaries. First, with the disruption of the passage of time, the individual’s future time perspective, along with personal expectations, hopes, and wishes, is likely to undergo a foreshortened flow of time as the future is no longer a “safe place” for psychological dwelling (Kielhofner, 1977; Lilliston, 1985). Second, with distorted time flow, uncertainty about and unpredictability of one’s future, even the proximal future, permeate the entire process of psychosocial adaptation to CID (Seymour, 2002). Third, with the impact of traumatic CID, the subjective experience of time becomes mostly present oriented with time flow moving gradually slower (recall discussion of depression and the perception of time). Furthermore, leading to temporal disorientation are the often associated experiences of pain, the disruption of the normal sleep–wake cycle, and preoccupation with present bodily sensations and functions (Lilliston, 1985). Fourth, with the resultant uneven temporal flow, the onset of sudden CID frequently leads to distortions of “daily life spaces” because of the amount of time that is now demanded to accomplish daily activities and the imposed necessity for domestic, social, and vocational changes (Kielhofner, 1977). Fifth, if following the aftermath of sudden onset CID (e.g., SCI, traumatic brain injury [TBI]), treating the condition necessitates acute care environment, the affected individual is likely to experience disorientation in time and space because of severe mobility restrictions, continuous sensory deprivation, side effects of medication, and interrupted sleep–wake cycle associated with the dispensation of various medical procedures and regimens (Trieschmann, 1988). Finally, as time can be regarded as the mediator between past health status (e.g., wellness, physical intactness, order) and the present CID (e.g., illness, disorder status, chaos), it is also capable of mediating between present feelings of experienced emotional turmoil and the reconstruction of an ordered and more controllable future. Indeed, the ensuing rehabilitation process following the onset of CID may be viewed as the re-embracement of time (Adam, 1990; Seymour, 2002).

Unlike the large body of literature aggregated over the past several decades on the relationships between time orientation and/or time perspective (the two are often treated interchangeably in the empirical literature on CID) and psychiatric disabilities, empirical data on time orientation and perspective, and psychosocial adaptation to physical CID are scarce at best. In the following paragraphs, an attempt is made to summarize these findings. Before doing so, however, it is important that the reader becomes acquainted with those instruments typically applied to measuring time.

The two most frequently used measures are (a) the Zimbardo Time Perspective Inventory (ZTPI; Zimbardo & Boyd, 1999) and (b) the Future Time Orientation Scale (FTOS; Gjesme, 1979). The former measure is a 56-item questionnaire that is composed of five scales that depict the respondent’s preference for experiences that are temporally related (past, present, or future time). Past perspective is divided into two scales, namely, Past Negative (i.e., reflecting an aversive view of the past) and Past Positive (i.e., indicating a positive recollection of the past). Present perspective is also broken down into two scales. These are Present Fatalistic (i.e., characterized by resignation toward fate and holding mostly a negative orientation toward the present) and Present Hedonistic (i.e., depicting a pleasure-oriented, risk-taking attitude toward the present). Finally, the Future scale reflects a goal-oriented attitude toward the future. The second measure, the FTOS, is a 14-item instrument that focuses on the respondent’s general concern and personal involvement with the future. Lower scores are typically indicative of foreshortened sense of future whereas higher scores suggest greater orientation toward the future. In addition to these two measures, other instruments have been also infrequently used to address temporal orientation. These include researcher-developed (a) projective scales such as story telling/writing measures and (b) ad hoc temporally constructed items selected specifically for that study.

Past time orientation/perspective and adaptation to CID

As discussed above, according to Zimbardo and Boyd (1999, 2008), past time orientation can take the form of either positive or negative valence.¹ Two studies reported findings on the relationship between scores on the ZTPI and psychosocial adaptation to CID. Hamilton, Kives, Micevski, and Grace (2003), in a sample of older people with cardiac disease, reported that participants who scored higher on positive past orientation also engaged in more health-promoting lifestyle activities and experienced higher levels of spiritual growth. In contrast, those individuals who scored higher on negative past orientation coped poorly in managing their stress. In a sample of people with diabetes, Livneh and Martz (2007b) found that positive past orientation was associated with lower levels of anxiety and depression and also with higher levels of psychological adjustment, whereas negative past orientation was related to higher levels of depression and anger. Finally, in a comprehensive study that sought to examine temporal orientation among people who experienced major life traumas (i.e., adult women who experienced childhood incest, war veterans, and survivors of fire-damaged residences), and using responses to open-ended semistructured questionnaire, Holman and Silver (1998) reported that participants who were past oriented also experienced higher levels of distress. An additional observation of interest was that past orientation was linked to temporal disintegration at the time of the traumatic experience. In other words, those for whom, during the traumatic insult, present perceptions were isolated from the past and the future (and thus experienced interference with normal assimilation of the traumatic event into their ongoing mental processes) were found to be “stuck” in the past and experience higher levels of distress.

Present time orientation/perspective and adaptation to CID

As discussed, present time orientation has also been divided into two separate, affectively based dimensions by Zimbardo and Boyd (1999, 2008), namely, pleasure oriented or hedonistic and resignation oriented or fatalistic. In their study, Hamilton et al. (2003) found that among cardiac rehabilitation patients, present hedonistic orientation was positively associated with health-promoting practices and more intimate interpersonal relationships. Livneh and Martz (2007b), in a sample of people with diabetes, reported that hedonistic present orientation was positively and significantly related to successful adjustment whereas fatalistic present orientation was positively and significantly linked to measures of anxiety, depression, and anger, and negatively to psychological adjustment. Using items derived from the Hypertension Temporal Orientation scale (Brown & Segal, 1996), and adopting these items to experiences by individuals diagnosed with osteoarthritis, Alberts and Dunton (2008) examined the relationships between time orientation and illness management strategies. Results demonstrated that among older women with osteoarthritis, focus on the present was associated with less proactive illness management coping (i.e., fewer efforts at planning for future benefits) and greater reliance on reactive coping strategies to manage the illness and its symptoms (i.e., focusing mostly on immediate benefits to remove threats and improve symptoms).

FTO/perspective and adaptation to CID

FTO guides many of our psychological processes and functions and is further associated with the development and maintenance of a sound judgment and decision making, purposeful behavior and goal-directed efforts, a sense of identity, mental health, life satisfaction, and perceived well-being (Holman & Silver, 1998; Jaques, 1982; Lewin, 1943; Melges, 1982, 1990; Sherover, 2003). Reasonable FTO affords the individual the ability to engage in preparatory behaviors during the present; however, when the individual’s focus is on the highly remote future, the needed present urgency and potency of planning for the future may be lost (Frank, 1939). FTO may not represent a unitary construct but may consist of at least two independent aspects, namely, extension and coherence (Wallace & Rabin, 1960). Whereas the former refers to the quantitative length or span of projected FTO, the latter refers to the logical structure or organization of anticipated events during the future. Three essential factors that have been introduced to explain FTO development include (a) motives (motivational), (b) delay of gratification (impulse control/affective), and (c) ability to use symbols to conceptualize the future (cognitive; Gjesme, 1983; Heckhausen, 1977; Nuttin, 1985). FTO, then, refers to the degree of involvement in the future; it is a set of subjective expectations and beliefs about one’s future. As such, FTO also embodies three temporal-based aspects often encountered in the CID literature, those of unpredictability of CID onset, uncertainty about its progression, and uncontrollability of its consequences.

In one of the earliest studies that sought to examine the role played by FTO in coping with CID, Agrawal and Pandey (1998) obtained data from a sample of 22 women diagnosed with a variety of chronic conditions including cancer, diabetes, cardiovascular diseases, and asthma. FTO was assessed with a combined approach of story writing technique and a semantic differential scale. Results showed that FTO was positively related to measures of optimism, life satisfaction, and adaptive coping strategies (e.g., acceptance, planning, positive reinterpretation). Similar findings were reported by Anubhuti (2008), also using a semiprojective technique of story writing to assess FTO. In that study, 30 individuals with type 2 diabetes provided data on quality of life (QOL) and life satisfaction. Those with higher scores on FTO also reported higher levels of life satisfaction and perceived social support (one of the QOL measure subscales). The author interpreted these findings as suggesting that the cognitive and motivational aspects of FTO are associated with such personal attributes as hope and optimism, thus resulting in greater perceived life satisfaction.

In their study of individuals who underwent cardiac rehabilitation, Hamilton et al. (2003) reported that those who scored higher on the ZTPI Future Scale also engaged in more responsible health-promoting behaviors. This relationship, however, was no longer statistically significant once sociodemographic variables (e.g., chronological age) were controlled for. The authors posited, based on the totality of their findings, that the reason FTO failed to successfully predict indicators of psychosocial adaptation to cardiac condition (i.e., spiritual growth, stress management, and interpersonal relationships) stems from the fact that the daily stressful experiences typically associated with cardiac disease and the accompanying threat to life truncate future and present time perspectives, and concomitantly increase cognitions about the past. This increased attention to the past is seen as reflective of efforts to reaffirm feelings of intrinsic value of one’s life, especially among elderly cardiac populations. Martz (2004) studied psychosocial predictors of FTO among 317 veterans and civilians with SCI. Her results indicated that the three most salient predictors were those of depression (associated with foreshortened FTO), shock (defined as experiencing feelings of psychic numbness and disorganization during the time of the injury; associated with foreshortened FTO), and acknowledgment (defined as cognitive acceptance of disability; associated with lengthened FTO). In a related study, Martz and Livneh (2003), analyzing data from the same sample of SCI survivors, further found that truncated FTO was also predicted by increased levels of death anxiety and experienced pain after controlling for the influence of sociodemographic (i.e., gender, age, marital status, education) and disability-related (i.e., existence of pressure sores, duration of disability) variables.

Chalfant, Bryant, and Fulcher (2004) examined the prevalence of PTSD in a sample of 58 individuals diagnosed with multiple sclerosis (MS). Although no specific time orientation measures were directly used, from their access to participants’ audiotaped reports, the authors categorized reexperiencing symptoms as either past- or future oriented. Results showed that a foreshortened sense of future orientation, as indicated by distress regarding unknown future and concern about deterioration of symptoms, was the most predictive symptom of PTSD in this sample. The authors argued that individuals with MS who are threatened by their unpredictable medical condition may also be susceptible to experiencing PTSD. Research based on a sample of 105 individuals diagnosed with diabetes by Livneh and Martz (2007b) and Martz and Livneh (2007) further demonstrated that FTO is negatively related to feelings of anxiety, depression, and also anger, and positively associated with successful psychosocial adjustment to diabetes. Moreover, FTO was also found to be negatively correlated with all three subscales (Reexperiencing, Hyperarousal, and Avoidance) of the Purdue Posttraumatic Stress Disorder–Revised (PPTSD-R; Lauterbach & Vrana, 1996) scale, although only scores from the latter subscale reached statistical significance level. Finally, in their study of women with osteoarthritis (Alberts & Dunton, 2008), findings revealed that women scoring higher on FTO engaged in more planned proactive and preventive behaviors to manage their illness and resorted to fewer reactive efforts at illness management (focused less on only immediate symptom reduction) than women who scored lower on FTO.

From the somewhat scarce available theoretical and clinical literature and the limited empirical findings (based on seven available studies and obtained from relatively small samples of people with cardiac disease, diabetes, arthritis, SCI, and MS), it could be argued that time perspective/orientation, in the context of CID, is influenced by a host of interacting variables, including, but not limited to, the following:

Organismic or sociodemographic variables, such as the individual’s chronological age and age of onset of CID. It may be speculated that younger people may be more future oriented (or at least future conscious) than older people mostly by virtue of anticipating a longer future. In contrast, older people may be more past oriented (or past conscious) primarily because of having accumulated more past events and experiences during their longer life span. These broad speculations, however, could be countered by notions that stem from considering age of onset of CID. Although empirical data are lacking, it may be reasoned that time perspective may be differentially affected by traumas that occurred early in life (when time perception is still undergoing formative transformation; see, for example, Piaget’s work [Piaget, 1969]) in comparison with those which are of late onset when time perspective is anchored in a more stable life fabric.

Medically linked variables, such as the type of onset, nature, scope, severity level, and functional limitations imposed by the CID. These variables appear to exert appreciable influence on how time is perceived and processed following the onset of CID. Within this context, factors such as onset of CID (i.e., congenital, gradual, or traumatic/sudden onset), degree of life threat encountered, progression of the condition (i.e., stable or static, such as seen in individuals with amputation; SCI or cerebral palsy vs. those whose condition is deteriorating or progressive, as seen in people with amyotrophic lateral sclerosis [ALS]; certain forms of cardiac disease and cancer vs. fluctuating or episodic, as seen in people with MS, rheumatoid arthritis, and epilepsy), degree of experienced pain, (un)certainty and (un)predictability of condition progression, and extent of compromised functionality (e.g., effects of sensory, mobility, consciousness/awareness, or energy-expansion limitations on time perspective).

Pre- and post-CID personality characteristics. Personality attributes may play a major role in time perspective and orientation. For example, the experience of time may be influenced by, or interact with, such characteristics as degree of anxiety and depression (see empirical findings), hope and optimism (which, by definition, suggest positive future orientation), locus of control (LOC; which suggests present and future orientations, but ranging from the personally negative [external LOC perception] to the personally positive [internal LOC perception]), rumination (which is marked by its past oriented, negatively valenced properties; Nolen-Hoeksema, Parker, & Larson, 1994), and coping strategies. An intriguing question that has not yet been successfully resolved is the nature and causality of the relationships between coping and time perspective/orientation. Is the latter directly interwoven into the fabric of coping strategies or does it stand apart from them? In a similar vein, do coping strategies believed to be mostly adaptive or of the engagement type (e.g., planful problem solving, cognitive restructuring, seeking social support) rely exclusively on positive present and future orientations, whereas nonadaptive or disengagement-type coping strategies (e.g., problem avoidance, wishful thinking, venting emotions) are immersed mostly in past orientation, negative present orientation, and foreshortened future orientation?

Environmental variables, such as the restrictive nature of the individual’s post-CID environment (including the hospital, rehabilitation center, and home environments). It has been suggested earlier that the physiological and psychological concomitants of the CID-producing trauma, along with the restrictions imposed on daily activities in hospital and rehabilitation settings (e.g., treatment regimens, scope of sensory and/or mobility deprivation, sleep–wake cycle disruptions, side effect of medication), combine to steer the individual’s time experience toward the immediate present, thus resulting in distortions of time flow. It could, therefore, be reasoned that the more (and longer in duration) temporal disruptions one encounters in these treatment environments, the more would time flow be affected, ostensibly resulting in exaggerated focus on the present and truncated view of the future.

The above speculative discussion must be tempered not only by the limited available clinical and empirical findings but also by the often very loose and unorthodox use of terms such as time perception, perspective, orientation, and attitude (for a brief description of these terms, the reader is referred to Part I of this article). Time perspective, which refers to the ability to project oneself, logically and coherently, into any of the three time components (practically speaking, mostly into the future) is conceptually quite different from time orientation, which refers to the extended subjective preference, cognitively and behaviorally, for any of the three temporal components. Furthermore, the former connotes more of a cognitive-perceptual capacity whereas the latter suggests more of an affective–motivational dimension. Curiously, the ZTPI (Zimbardo & Boyd, 1999) combines some of the ingredients inherent in time orientation and time perspective with those of time attitude, the latter addressing the negative, positive, and neutral valences assigned to each of the three time components. It may, therefore, be recommended that prior to proceeding with the investigation of the relationships between the type of onset, nature, severity, and duration of CID, and the subjective assessment of time, the empirical conceptualization and measurement of time should first be addressed. The content and structure of the various temporal elements (e.g., perspective, orientation) must be investigated and decomposed in a more lucid and comprehensive manner, and if the need arises, new and psychometrically sound measures should be developed to assess how time is perceived and processed in the context of life with CID.

Treatment Modalities and Time Distortions

Reactions of depression and anxiety have been frequently reported to be linked to the onset of CID (E. J. Lee, Chan, Chronister, Chan, & Romero, 2009; Livneh & Antonak, 1997; Shontz, 1975). As was discussed earlier, these reactions are often associated with distortions of past and future time perceptions. To combat disordered time orientations and perceptions, several approaches have been suggested in the literature. These include the following:

“Unfreezing the Future” (Melges, 1982, chap. 9). This approach is directed at helping depressed clients focus more on the immediate present and the near future. The client is directed toward combating his or her feelings of hopelessness and, in general, inducing positive expectations about the future into their cognitive schemata.

Time projection (Melges, 1982, chap. 6). Having the client project thoughts into the past (by reliving certain past life episodes), but especially toward the future (by visualizing specific future time frames as if they were occurring at the moment), can be beneficial in helping the client to gain a more comprehensive temporal perspective on the source of his or her difficulties and their possible future ramifications.

Temporally oriented psychotherapy (Rappaport, 1990). This approach, although only sketchily developed and borrowing heavily from other psychodynamic therapeutic modalities, attempts to integrate all three time zones (i.e., it is based on the premise that temporal zones form “irreducible synergism”; Rappaport, 1990, p. 189). As such, it addresses all temporal zones in concert, typically by first focusing on the client’s current life issues and then proceeding forward (i.e., “unblocking the future”) and backward (uncovering sources of anxiety, depression, etc.).

Temporal awareness shifting (Silver, Boon, & Stones, 1983). With the use of this approach, clients are directed to learn how to consciously shift attention away from distressing past life events and replace them with focused outlook on present opportunities for growth to maximize adaptive functioning.

Proactive illness management (Alberts & Dunton, 2008). Individuals who are mostly present oriented could benefit from a therapeutic approach that is geared toward managing their CIDs more proactively. Included in this approach are such venues as focusing on future benefits and on important life goals yet to be accomplished.

Conclusion

The concept of time is an integral part of human life and, therefore, of pain, misfortune, and even death. The mere passage of time indicates a shrinking future (and, therefore, approaching death). With time passage, the past extends in duration and, therefore, contains a larger reservoir of personal memories and experiences, thus according the past with greater significance. In a similar vein, the onset of life-threatening conditions, such as cancer and heart diseases, and that of other medical impairments such as SCI, amputation, MS, and blindness, either directly, or symbolically, triggers thoughts of death and truncated future. This is evidenced in the deployment of various coping strategies such as fatalism, escape, helplessness, and denial (whose extended use is typically viewed as inherently nonadaptive and future restrictive). Yet, the same medical conditions have also been observed to trigger more adaptive coping modalities such as fighting spirit and active planning, indicating future-oriented efforts to minimize personal suffering.

Time orientation (the preference for one or more temporal directions) and time perception (the ability to estimate time units) have been shown to be powerful correlates, and integral components, of many psychiatric disorders, including anxiety, depression, schizophrenia, and antisocial personality disorders. Indeed, the available clinical and empirical literatures suggest that the differential patterns of symptoms that are reflected in various psychiatric impairments may also be associated with how time is being experienced, processed, and distorted in individuals diagnosed with these conditions.

Finally, a review of the available theoretical, clinical, and empirical literatures on time and psychosocial adaptation to life-threatening and other severe medical CIDs, albeit somewhat rudimentary in its scope, suggests the following:

The onset of CID disrupts the continuity of age-related, normal, developmental processes and, therefore, the perception of the passage of experiential or “felt” time. This disruption affects future time perspective, which becomes foreshortened as a result of diminished future hopes and expectations. It also affects present time perspective, which appears to be perceived as temporally stretched while, at the same time, is experienced as moving more sluggishly and invested with patches of negative affect.

Consistent, yet limited, empirical support suggests that people with CID, whose past and present orientations are of positive valence, also report better psychosocial adaptation. In contrast, those whose past and present orientations are negative tend to report higher degrees of negative affectivity (i.e., anxiety, depression, and anger).

A growing body of empirical support suggests that FTO, or the ability to project oneself and plan for the future, among people with CID, is associated with indicators of successful psychosocial adaptation, such as optimism, life satisfaction, health-promoting practices, and sickness-managing behaviors. Truncated FTO, in contrast, has been linked to increased levels of anxiety (including PTSD and death anxiety), depression, and anger.

The use of psychotherapeutic procedures and rehabilitation interventions, to combat distorted time perceptions, appears at the present, despite their promising and intuitive appeal, to be tentative in nature and relies exclusively on clinical impressions. The suggested approaches are driven by the notion that early in the process of coping with CID, feelings of depression and anxiety need to be addressed within the context of the individual’s time perception. As such, the suggested approaches attempt to bolster future-oriented (mostly the proximal future) modes of thinking and planning. These approaches, then, seek to help the individual with CID in shifting attention away from painful and distressing past experiences and focusing on gaining awareness of present opportunities for growth and successful functioning. The rehabilitation professional, therefore, assists the client in combating negative feelings and cognitive schemas that are fueled by past experiences, including personal losses, missed opportunities, and shattered hopes. This is accomplished not by dwelling on the past but, alternatively, by diverting attention toward the still viable, yet frozen future that has been temporarily devoid of the necessary energy for pursuing personal hopes, expectations, and goals, yet still holds the key for successful rehabilitation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

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