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PsychiatristLucIsebaert is the former head of department of theSintJans hospital in Brugge.Isebaert has not yet published his ideas about the treatment of chronic cases in psychiatry. For the first time, he speaks to a broad public about this.

The self-help program 15Minutes4Me has been online for 3 years by now, so it is time to refine the algorithm and to deepen it in the form of an upgrade to version 2.0. As we find more chronic patients among our users than expected, I took the airplane to Spain to find inspiration with an international expert of the cause: the Flemish psychiatrist Luc Isebaert, MD, who decided on a sunnier place to live after retirement. As former head of department of the Psychiatry department in the AZ Sint-Jan in Brugge, he has focused for years on the problems of chronic patients.
During our conversations it became clear to me that his core concert regarding the treatment of chronic cases in psychiatry had not been published yet, and I found him to be willing to share his thoughts in an article for ’15Minutes4Me’ in Psyche & Brain. So this is a world premier!

Definition and classification of chronicity

‘We can define and classify chronicity in two different ways’, Isebaert starts off.
‘The first defines chronicity according to the time during which the patient suffers from their symptoms. In general medicine, a limit of 6 months is often used, while this limit is at one year in psychiatry. The logic behind this is that this time frame often mirrors the resistance to the therapy proposed: the longer it takes, the more attempts at treatment and recovery have failed. many addictions fall under this category: alcoholism, nicotine abuse, and so on.
A second way to classifychronicity in psychiatric disorders, is according to the “existential perspective of a better life”. This leads to two categories ofchronics: theperspective-lackingchronics versus the hopefulchronics. The perspective-lackingchronics are the ones who have lost the perspective of a better life. The hopefulchronics are those who do still have a perspective of a better life.

This difference was implicitly noticed for the first time by the Viennese psychiatrist Viktor Frankl during his stay in the concentration camp. A few weeks before they were freed, the rumour was spread that Americans would be there within two or three weeks to save the prisoners. The days went by, and it actually took five to six weeks until the liberation was a fact. An interesting phenomenon which Frankl noticed, is that many of the prisoners died in the few extra weeks before the liberators arrived.Frankl wondered what the difference was between the survivors and those who died in the last weeks.

He noticed that those who had died had only been looking forward to the solution itself (the liberation), while the ‘survivors’ were those who had a ‘project’ regarding what they wanted to do with their lives after liberation. Many of those who only looked forward to the liberation itself but had no idea what to do with their lives after that, died during the period between the third week after the first messages about the Americans’ advances and the actual liberation.’

Perspective-lacking versus hopeful chronics

‘Analog to this observation by Viktor Frankl, we notice in our psychiatric department that some chronic patients have this same perspective-lacking pattern, namely that they do not know what to do if they were to be cured from their disorder. Those are theperspective-lackingchronics. So there is a contrast when comparing them to hopefulchronics, who do still have a sight of their desired future.

In both groups of chronics, it is important in therapy that they make clear what type of person they want to be. The solution focused perspective namely implies that they learn to look past the issue. The doctor wants to help the patient to answer the questions: “What type of person do I want to be? What type of man do I want to be (in my relationship)? What type of friend do I want to be (in my friendships)? What type of mother do I want to be (for my child)?”
One can ask them about their desired future: “If your problems were solved and your life could continue the way it is now, how would your life look then?” The answer to that question is then a description of the desired life of the patient with their existential life choices, altered and embodied into the daily habits.
The miracle question by SteveDeShazer – the father of solution focused therapy – is a good example, thereof, as is the ‘cristal-globe-technique’ byhypnotherapist Milton H. Erickson, or his hypnotic technique of ‘pseudo-orientation in the future’. However, if you ask such questions to the ‘perspective-lackingchronics’, they cannot formulate and answer to them. They cannot formulate how their life would be and what their days would look like in a scenario where they would say: “This is how my life may continue”. They cannot imagine anything like this. They have lost that ‘optative’.’

A special type of verb

‘The optative is a time in the conjugation of verbs that expresses ‘what I wish’. This form existed in the old languages, like the ancient Greek, ancient Persian and in Sanscrit, and still now in modern Japanese and in Finnish.
There are two types of optative: 1. What do I hope will happen?
2. What do I wish would happen?
In the perspective-lacking chronics, the hope is completely absent, and they cannot possibly answer the question “What do I hope will happen?”, while sometimes the wishing aspect is still there: “I would wish that … happened, but that is not possible really.”
The result of that lack of perspective is that, when there is no hope of improvement, there will not be any motivation to do anything, either. As a result of that, the positive goal ‘I wish to do x, I want to do y’ can no longer be formed.’

Observation in the rehab clinic

‘This difference between hopeful and perspective-lackingchronics first became clear to us in the medical history of the patients, four years after treatment for alcoholism in our department. After four years, 45 percent still lived under abstinence, not drinking anymore, 30 percent had their drinking under control, 10 had passed away, and 15 percent still drank too much.

We then wondered if this 15 percent had a different profile than the 75 percent who had gotten good results. It showed that these patients could not imagine a desired future anymore. THe ‘optative’ had disappeared, and often even the conditionals were as good as inaccessible: “If you want a nice glass of beer but you know you should not drink, then what would you do in order not to drink?”

This type of unconditional question, too, remained unanswered. That is why these patients could not develop a strategy to resist the craving. When looking deeper into this, it showed that not only the perspective of a desired future had disappeared. These patients could not either learn from the things which happened to them.

I will illustrate this with an example: a patient who had lost all contact with his children, told me that his son had called him the evening before for the first time, and had told him about the grandchildren.
I asked him if this had made him happy, and he replied: “Of course”. Then I asked him: “WHat could you do to continue this contact with your son?”
He could not think of an answer to this question, while it was obvious that he could call his son himself.
These patients in one way live in an “endless now”, where the desired future can no longer be imagined and the past no longer is relevant.
It is obvious that this development has to do with the atrophy of the prefrontal brain. We know that in chronic alcoholism this part of the brain is damaged first. The prefrontal brain is home to the consciousness, as well as the sense of responsibility, goals, and self-rating.’

The wisdom of Epicurus

‘This knowledge of the brain did invite us to see if there was anything we could do. Here, Epicurus helped us. It is namely so that patients could no longer answer the question: “What would you like to do today?”, but they could answer the question: “What have you done today which made you feel satisfied?”
If I do something which makes me feel satisfied, then this per definition is something which is in accordance to my ‘existential life choices’. For example, if I do something for my wife which makes me feel satisfied, then this is in accordance to the picture of myself as a good husband.
Epicurus, of all philosophers from the Greek world, is the one who focused most on the question: “What should a person do in order to be happy?”
His vision was that, in order to be happy, one would need enough ‘hedone’. This is often wrongly translated to ‘enjoyment’. For Epicurus, ‘hedone’ would rather mean ‘contentment’: “I am at peace with myself, I have done enough!”
You can summarize the vision of Epicurus in the following two commands:
1. If I do things which make me feel satisfied about myself and about the people around me, I can be content, then I can be happy.
2. If I am content with what I have, then I can also be happy.
Both of these commands are not fulfilled in perspective-lacking chronic patients. We therefore developed a series of epicural questions. We asked both chronic alcoholics and post-treatment chronic depressed patients to answer these at least once a day, preferably shortly several times per day. This led to a clear improvement in the problems in many of them. Alcoholics who would relapse time and time again now remained abstinent, and depressed patients clearly improved too. We see these results, too, in the patients who follow your online self-help program’. That is because the way 15Minutes4Me works helps them to bring back the optative into their lives. This explains why the program does not only work for people with acute problems, but also for chronics.’
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