Inspiration
Bringing bipolar into focus
Bringing bipolar into focus
Everyone’s looks a little different
By Elizabeth Forbes
Imagine a big museum filled with widely varied portraits. The shimmering figure in an ornate gold frame runs up his credit cards, cruises the bars and takes off on spontaneous trips every spring. Next to him is a monochrome image with just a splash of red—a man who mostly lives with depression but has a one-off manic episode in his past.
Over here is a woman photographed in vibrant color, reflecting the exuberant feeling of her hypomanic episodes. Facing her is a Cubist image which conveys an uncomfortable mix of twitchy energy, irritability and a kind of wired-up unhappiness. A tiny canvas represents symptoms that pass in days, while a mood that persists for weeks takes up a wall-sized tapestry.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM for short), psychiatry has done its best to capture all those individual shades of experience and boil them down to a set of common criteria for bipolar disorder—or rather, bipolar disorders, because there are a handful of different diagnoses under the bipolar umbrella.
If you can’t count on that stability, it makes life extremely difficult.
At the far manic end of the spectrum sits bipolar I disorder. Next comes bipolar II: depression with a helping of hypomania. Then there’s cyclothymic disorder, which describes frequent mood shifts that never reach a full-blown episode of depression or mania, and a category previously known as “not otherwise specified,” used for conditions that don’t precisely fit the other categories.
Bipolar II is often seen as a milder or “softer” form of the illness than bipolar I. Not so, says Ellen Frank, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at the medical center’s Western Psychiatric Institute and Clinic.
In bipolar II, she says, “the depressions … can be so disabling and so long-lasting. The manias of bipolar I disorder are very dramatic and get people’s attention and yes, people can do a lot of financial and interpersonal damage during mania, but we know how to treat mania quite well. We’re not so good at treating either bipolar I or bipolar II depression.”
Cyclothymic disorder may seem milder yet, but by definition the diagnosis means that a person’s stable periods don’t last more than two months. “If you can’t really count on whether you’re going to be excessively energetic or optimistic or excessively pessimistic and not able to get anything done—if you can’t count on that stability, it makes life extremely difficult,” Frank says.
“By definition” gets back to those common criteria in the DSM, which is the standard reference clinicians use for figuring out how to label a set of symptoms—and thus how to treat the underlying illness. Unfortunately, life doesn’t always play by the book. And when your particular portrait of bipolar disorder doesn’t mesh neatly with the DSM descriptions, it can be harder to develop a treatment plan that will really help.
Revisions to the DSM take aim at that disconnect. Frank was part of a group tasked with updating the section on bipolar disorder in the DSM-IV (or fourth edition), which the American Psychiatric Association put out back in 1994. She says the new fifth edition, called DSM-5, tries to get closer to what clinicians see in actual practice.
She says the group set out to address several problems, including “the incredible time lag between first symptoms and an accurate diagnosis … individuals who have bipolar disorder often wait 7 to 10 years for a correct diagnosis. That means they often wait 7 to 10 years for appropriate treatment.”
There are some things no amount of revising can fix. If someone doesn’t seek help because of stigma or some other reason, they’re not going to be diagnosed with anything. And an initial diagnosis of depression may actually be correct in the early stage of the illness, because hypomania or mania may not emerge until a good while later.
It’s really hard to pin down changes in mood.
What DSM-5 does try to tackle is the tricky job of ferreting out signs that indicate bipolar rather than unipolar depression. Primary care physicians may be getting more familiar with recognizing depression, but limited time with their patients and lack of comprehensive screening tools mean those elusive signs tend to go undetected. Even experienced clinicians may have a hard time “unless the individual is in a flagrant episode of mania,” Frank says.
According to clinical psychologist Eric Youngstrom, PhD, “There isn’t anything in the snapshot of bipolar depression that’s any different from any other kind of depression. The only way that we’re going to recognize that is by playing lifetime mood bingo, asking about all the different types of mood episodes in the past and in the present.”
Youngstrom is acting director of the Center of Excellence for Research and Treatment of Bipolar Disorder at the University of North Carolina at Chapel Hill, where he is also a professor of psychology and psychiatry. His clinic has been working on a “roadmap to better assessment” that plugs in a lot of information beyond DSM symptoms to make diagnosis more accurate.
To diagnose a mood episode according to DSM criteria, clinicians go down a checklist of symptoms that are set up in a “one from column A, three to five from column B” format. For mania or hypomania, Column A has included just one major symptom: “abnormally elevated, expansive, or irritable mood.” If you don’t answer yes to that, it’s usually game over.
However, mood symptoms tend to be an unreliable marker in clinical practice. For one thing, many people experience hypomania simply as better-than-usual life, a period of brilliant ideas, abundant energy and feeling great—so what’s the problem? This is known as “lack of insight.”
“We talk about onion and garlic symptoms,” says Youngstrom, using a metaphor he credits to the late Dennis Cantwell, MD. “Onion symptoms would bug us when we’re having them and garlic symptoms bug everyone else around us first. Depression is a bunch of onion symptoms. Hypomania is a bunch of garlic symptoms.”
From the perspective of people who are hypomanic, “They’re not talking too much, they’ve just got really exciting stuff that’s more interesting than anything anyone else is trying to say,” he says.
That goes double for mania—and the effect seems to linger even after an episode has passed.
In general, Frank says, “It’s really hard to pin down changes in mood. But when you ask someone, ‘Did your level of energy change or your level of activity change?’ generally retrospective memory is better.”
So the DSM-5 moves questions about changes in energy and activity level up from the “other” column to the top-priority section, in hopes of making it easier to identify people who belong on the bipolar spectrum.
According to Youngstrom, “it tends to be more culturally accurate as well. Thinking about bipolar as a mood issue tends to be a white, middle-class American way of thinking about the problem. Thinking about changes in behavior and activity level seems to work better across cultures.”
In another attempt to improve diagnosis, the former “mixed episode” is no more. Frank says very few people actually met the full criteria for a manic and major depressive episode at the same time, which was the requirement for a diagnosis of mixed episode, so the term was almost useless. DSM-5 substitutes “with mixed features” as a description (or specifier) that can be attached to the other types of mood episodes.
The clinician now has a way to indicate “depression mixed with a little bit of hypomania or mania mixed with some depression,” Frank says. Not only is that far truer to reality, but it’s another opportunity to shorten the time to a bipolar diagnosis—even if it’s that amorphous “not otherwise specified” (now dubbed “other specified” in DSM-5 for bookkeeping reasons.)
Beyond that, the new mixed-features specifier “has implications for prognosis, in that we know that this episode is going to be more difficult to treat,” Frank explains.
That’s really the end goal of the naming game: matching medications and psychotherapeutic approaches to the situation at hand. Of course, there’s no way a rigid set of criteria can account for the many facets of experience. A thorough psychiatric evaluation will look at much more, such as an individual’s work and home life, risk factors such as family history, and relevant medical conditions.
Individuals…often wait 7 to 10 years for a correct diagnosis.
“The DSM doesn’t cover all the possibilities, all the pictures that clinicians see as we’re working with people,” Youngstrom notes. On the other hand, “it gives us a language and a set of descriptions to use.”
When someone seems to fit the definition for bipolar II, for example, “it tells us that their depression is not going to respond the same way to antidepressants or to other treatments, so we would want to manage the depression differently.”
To make it easier for you to join the conversation, here’s a rundown of the various bipolar diagnoses.
Bipolar I
Although depression is the prevailing mood state for many people who have a bipolar diagnosis, it’s the manic symptoms that dictate which particular diagnosis is given. Even one full-blown manic episode during a person’s lifetime—regardless of history of depression—equals bipolar I. However, there is an exception in each category for mood episodes caused by a medical condition or drug, legal or otherwise. Manic episodes are hard for observers to miss (although the person in mania may not see it), so that a diagnosis of bipolar I often occurs when someone has been hospitalized or has a brush with the law, or relatives insist on getting help.
Bipolar II
This diagnosis calls for at least one lifetime episode of major depression plus at least one hypomanic episode. It can be challenging for clinicians to distinguish bipolar II from major depressive disorder because people may not even recognize hypomania. “They’ve got more energy than usual, they’re more creative than usual, but they’re not experiencing it as a problem,” Youngstrom says. And when he’s asking about past history, “people will remember if they’ve been hospitalized or gotten arrested, but anything less severe than that doesn’t seem as important once time has passed.”
Cyclothymic Disorder
This diagnosis indicates “there’ve been mood issues that haven’t gotten all the way to a depression, haven’t gotten all the way to mania, but they’ve lasted a long time,” Youngstrom says. Specifically, periods of manic symptoms and periods of depressive symptoms occur frequently over the span of at least two years, causing significant distress but never qualifying as a diagnosable mood episode. Moreover, the individual doesn’t stay symptom-free for more than two months at a time.
Other Specified Bipolar
Formerly called Bipolar Disorder Not Otherwise Specified, this is a kind of stopgap when symptoms don’t clearly indicate one of the other bipolar diagnoses. For example, hypomanic periods recur without any depressive interludes, or there are near-hypomanic episodes that don’t last four days or don’t have the right number of symptoms. DSM-5 gives more specifics on the various options for “other specified” and pushes for more documentation on “why the person doesn’t meet the full criteria for bipolar I or bipolar II,” Frank says. “It gives us more clinical information about how to treat, about prognosis, and so on.” (The name change makes DSM-5 consistent with the International Statistical Classification of Disease and Related Health Problems, a listing compiled by the World Health Organization.)
Rapid cycling
This is not actually a diagnostic category. Rather, it’s a “specifier” that is added to the diagnosis to indicate that four or more separate mood episodes of any stripe occurred within a single year. It’s also a widely misunderstood term, often used to describe symptoms that fluctuate by the day or even the hour. Youngstrom prefers “rapid relapsing” or “rapid episoding” to indicate the pattern of distinct but recurring mood shifts. “What that tells us is that even if we get you back to where we want you, we have to be on guard for relapse because this has jumped you already four different times in the past year,” he explains.
With psychotic features
This specifier can be applied to either a manic or depressive episode to indicate a break with reality, such as hallucinations (seeing or hearing things which aren’t there) and delusions (believing things that aren’t true). Hearing voices, receiving special messages, taking on a different identity (often that of a religious or famous figure), and being convinced of a special mission (again, often religious) are common psychotic symptoms. Paranoia and disordered thinking (not making sense) are other hallmarks of psychosis. Catatonia (paralysis of movement and speech) can occur during severe depression.
With mixed features
This new specifier takes the place of “mixed episode” and can be applied when depressive features are present during an episode of mania or hypomania—Youngstrom uses the metaphor of vanilla ice cream with fudge swirled through—or features of mania or hypomania are present during an episode of major depression, which would be chocolate ice cream with marshmallow swirls.
With anxious distress
This specifier was added to indicate symptoms of anxiety that don’t meet the full criteria for panic disorder, generalized anxiety disorder or one of the other anxiety disorders. “This is an attempt to recognize the fact that even anxiety that doesn’t meet the full criteria for a disorder is something important to note and has implications for treatment,” Frank says.
Manic episode
Several elements must be present to diagnose a manic episode. First, there must be a distinct period during which there are marked changes in mood—abnormally elevated (on top of the world), expansive (flamboyant, filters off), or irritable—and goal-directed activity or energy level. Next, the uncharacteristic behavior or mood must last at least a week, or require hospitalization. Third, there must be at least three other symptoms (or four if the abnormal mood is irritability) from the following checklist:
• inflated self-esteem or grandiosity
• decreased need for sleep (for example, feeling rested after just a few hours’ sleep)
• more talkative or sociable than usual, or pressure to keep talking
• flight of ideas or the feeling that thoughts are racing
• easily distracted by unimportant or irrelevant things
• Increase in activity levels, either goal-directed (such as taking on new projects or socializing more) or a restless busyness
• plunging into reckless activities like buying sprees, promiscuity or high-risk business deals
Furthermore, symptoms must significantly affect the ability to manage at work or school, pursue usual social activities, or maintain relationships.
Hypomanic episode
If manic symptoms last at least four days but less than a week, the episode is deemed hypomanic. Symptoms don’t interfere too much with work, relationships and usual pursuits—in fact, hypomania often brings a sense of feeling energized and able to accomplish more—but changes in sleep and behavior mark a distinct departure from the norm and are noticeable to others. Judgment may be shaky. Hypomania is often a border state leading into or out of mania, and sometimes alternates with depression. For some people, hypomania can induce irritability and agitation (dysphoria) rather than a productive high (euphoria).
Major depressive episode
Diagnosis relies on five or more symptoms co-occurring nearly every day, for most of the day, during a two-week period. One of the symptoms has to be either low mood (feeling sad or empty, crying frequently) or significant loss of interest or pleasure in usual activities. Other possible symptoms include:
• weight gain or weight loss (when not dieting), or an increase or decrease in appetite
• inability to sleep or sleeping too much
• observable restlessness or moving uncharacteristically slowly
• fatigue or loss of energy
• feelings of worthlessness, excessive guilt or inappropriate guilt
• diminished ability to think, concentrate, or make decisions
• recurring thoughts of death or suicide
In addition, the symptoms must cause significant distress or impairment in everyday life.
Metaphors in psychotherapy
Good Friday to everyone! Are you ready for the weekend? 
I have had a good day at work, with interesting meetings and memorable conversations. I have also had some time to read a bit, and came across two interesting metaphors. In addition, a doctor I work together with, also pulled a metaphor up his sleeve, and when I came down to my office, I had to write them all down. Then I got the idea? Wouldn`t it be great with a book full of metaphors (it probably exists already, but an update is always welcome) ? And then I started to wonder:
Do you have metaphors fitting for life in general and for psychotherapy?
The sound of spinning around
Have you noticed the fact that many of the most famous songs, are about circles. A song is actually the same: A wheel turning, back to the chorus like a boomerang. Have you heard “spinning around” by Kylie Minogue? “Round round” by Sugababes, “Circles” by christina aguilera? “Circle the drain” by Katy Perry? Or why not roll through the river, sit down on a burning ring of fire, while what goes around, comes around? Or do you just sit there, waiting for the circle full of life?
Life is a cycle. From one period of time, the wheel turns. We are born, grow up and die. Our bodies sink into the earth, where we are transformed to something else. The universe turns around itself, creating new worlds and stars. It expands and creates at the same time as it collides and destroys. We have spiral galaxies, with forces that hold the parts furthest away, in their place. In that way, you can be turned and twisted and still stand safe in one place. You can be in the eye of the storm, and look up at the sun and moon that turns around you, showing you how everything continues even when you feel it has all stopped.
In our lives, we repeat patterns, afraid of getting stuck or getting into something that hurts. But what we don`t see, is that even if things go around and around, even when it feels like nothing changes, we bring things with us everytime we go around in circles. We find objects that can catapult us forward, that can bend the neverending rollercoster and let us travel in a safe line. We learn to fly, to soar and look down at where we are and where we need to go. We meet people on our way going through the same recycling pattern, but in the other direction, showing us that it is possible to go back and forth. That there is so much we can see around us even when we feel everything is the same.
Every time another cycle begins, there are slight changes. Animals and nature changes through evolution, until something new and stronger is created.
Dropping a stone in a calm pool of water will simultaneously raise waves and lower troughs between them, and[citation needed]this alternation of high and low points in the water will radiate outward until the movement dissipates and the pool is calm once more. Yin and yang thus are always opposite and equal qualities. Further, whenever one quality reaches its peak, it will naturally begin to transform into the opposite quality: for example, grain that reaches its full height in summer (fully yang) will produce seeds and die back in winter (fully yin) in an endless cycle.
Sometimes the natural cycle is completely halted as a mutation or catastrophe in the environment change the direction, that smooth turning of the wheel. When this happens, adaption is necessary. It is a chance to create something new, to put a new vehicle on the wheel, making it go faster and further than before.
These thought keep going around in my mind. Spinning before they stop on the same idea that has been circling in my mind for three years now. What if we started a new cycle? What if we all tried to set a date to do one good thing for another human being and see where the cycle leads us? What if we jump unto the wheel all of us, using the force of many to drive forward?
More:
My kindness to a stranger idea
Survivors of Psychiatry
Image credit: Alex Widdowson ©2012
THE JOURNEY
Belgium, 1992. I completed my psychiatric residency. Five years of training gives me, among other things, a good psychodynamic foundation and an exposure to a range of psychiatric medications, including the newest ones being touted as, ironically, both scientific and miraculous. In my heart there is an eagerness to learn more, a penchant towards borderline pathology and a desire to relieve souls in suffering.
Since then I have journeyed through very different places: from hospitals and private practice in the European system of universal healthcare (albeit only for its citizens), to the streets, prisons, outpatient services and psychiatric emergency rooms of Los Angeles, a multicultural jungle, and a place where extremes either collide or else ignore each other completely.
Although I was a young psychiatrist convinced of the effectiveness of psychotherapy, there was definitely something thrilling in the ‘Decade of the Brain’ and its ’intelligent molecules’, which were presented as having no serious side effects. Not only would they be a cure for debilitating chronic illnesses but the molecules themselves (or the imbalance thereof) would be the long-awaited scientific explanation of mental illness itself. Suddenly, my new profession, whose ethics were so often questioned (remember the Gulag and lobotomies) and challenged as to its ‘real’ scientific value (Popper and psychoanalysis), acquires the seal of scientific respectability.
Almost overnight, the psychiatrist-prescriber becomes the expert of the new sciences of chemical imbalance, methodical classifications of illnesses and evidence-based treatment. The new science of human consciousness has arrived, a modern discipline where pesky existential questions seem obsolete. In the euphoria of the late twentieth century, pharmaceutical companies and psychiatrists discover one another and embark on a risky love affair. Lavish international conferences are organized during which prestigious panels of experts attempt to give concrete meaning to the inexplicable and in doing so propel the exponential expansion of the market base of the drug industry.
Clinicians (of which I am one) and academics, in a surprising moment of “méconnaissance intéressée” in the words of Derrida, do not seem (or want) to be aware of the potential conflicts of interest in this thrilling adventure. Very quickly, both international psychiatric research and physician’s education become more and more dependent on money from pharmaceutical lobbies.
In medical school, psychotherapy starts to look outmoded. Young doctors are amazed (and perhaps reassured) by the molecular and genetic versions of human passions, and build themselves a new identity, that of the psycho-pharmacologist. The psychosocial model in force in the mental health community no longer seems to apply to a ‘modern’ psychiatry. In libraries, Freud and Frankl are taken off the medicine shelves and end up in the literature department with Albert Camus and Jean Paul Sartre.
At the same time, other voices are speaking up – those of the mental health patients themselves and their families. As part of the wave of civil rights movements that were rushing through America in the 1960s and ‘70s, patients and former patients, some calling themselves “Survivors of Psychiatry”, demand an active role in their own care. “Nothing about us without us”, is their war chant. Under their influence, terminology changes, too. The word ‘patient’, with its implication of suffering and passivity gives way to ‘users’, ‘clients’, and ’consumers’ in keeping with the more active participation of a patient in his or her own treatment. Importantly, this new terminology is also more in sync with a capitalist world where ‘care’ becomes more than ever an object of consumption with profit its underlying goal.
It is into these turbulent waters that I dove when, in 1999, I came to the United States to continue my interest in borderline personality disorders (BPD). Curiously, in these times of medical exhilaration, this group of patients seems to balk at any reductionist classification. BPD doesn’t respond to the “pill-to-heal-everything” approach. BPD patients’ long resistance to both psychiatric and psychoanalytic treatment has earned them a history of rejection and disqualification, the alleged reason being that these patients are difficult, manipulative, or worse, not really sick. It appeared as if only a categorical diagnosis or a treatment validated by modern science could bestow on these sufferers the seal of authenticity.
In my new American reality, I am on the frontlines observing how theoretical, political and social contexts can affect the expression or the occurrence of a symptom, its recognition and what we choose to do (or not do) about it. With BPD patients in particular, the fact that there is no pill to treat them encourages some ER staff members to discharge them swiftly without really addressing their issues. Verbal complaints and “scratches” that may lead to necessary treatment in my previous home of Belgium will generally bring disdain in a US emergency room, where much deeper self-mutilations is required in order to hold the patient long enough to initiate therapeutic engagement . So, the self-inflicted wounds of Otto Kernberg’s and Marsha Linehan’s patients in the US somehow appear more threatening and bloodier than the ones I observed in my small European country. It seems necessary to shout louder in the US in order to have our healthcare system decide finally to take care of you.
Social and political contexts also influence the writing of a prescription. An antipsychotic medication identified as “very safe” in Belgium, might suddenly bring a lawsuit in the United States, due to the fact that a rare side-effect is emphasized in a ‘Black Book’, a tome sold primarily to lawyers.
During my second residency, I was lucky enough to be trained in cognitive and behavioral therapies (CBT). Contrary to the naïve and/or arrogant belief of the psychoanalytical circles in which I did my original training, I realized how well these techniques can work and how easily teachable they are. I have been impressed by the willingness of practitioners of cognitive therapy to prove the effectiveness of their methods, thus gaining ‘scientific’ legitimacy and resulting financial reimbursement.
Forced to question my theories and techniques, I discovered research that suggests that, for a majority of conditions treated in psychotherapy, all the major modes of psychological treatment produce similar outcomes . In fact, this research suggests that only 8% of the variance is due to the type of therapeutic technique, while 70% is due to the overall effect of treatment itself, such as the factors of empathy, a good working relationship between the therapist and his or her client etc. The residual 22% of the variance remains unexplained.
Fascinated by these oddly un-‘modern’ results, I felt reassured in my belief that the individual caregiver’s role is central to the therapeutic process. After all, isn’t modern psychiatry but a new iteration of the age-old combination of witches and wardens?
While the paths of neuroscience and psychology may seem to diverge, an expert interested in both disciplines, Eric Kandel, is trying to force a dialogue between them. In the early 2000s, armed with his recent Nobel Prize for research in neuroplasticity, he proposed a “biological” legitimacy to psychotherapeutic techniques . He has helped us to understand how environment affects the development of our brains as much or more than a chemical molecule does.
If only something biological gives legitimacy to a ‘modern’ treatment, then we must recognize that the interaction between two human beings is also a biological treatment , because it affects our brain’s function and development. For example, the environment may affect the way our genome is translated into proteins, building blocks of cellular receptors essential to our learning mechanisms .
Along this line, researchers have started studying the interactions between the modalities of attachment and molecular genetics , and a new Society of Neuro-psychoanalysis has been created. In borderline patients, neuro-imaging studies have discovered abnormalities specific to their struggles . This is apparently what is needed for science to finally recognize them as real patients.
More:
Breaking news from a mental institution
This post was from the site Rethinking psychiatry. Read more for inspiration!
Image credit: Alex Widdowson ©2012
50 shades of normality: Rethinking psychiatry
What mental disorder do you have? With the danger of offending you already, I ask you to not hate me yet. I`m asking this provoking question because I want to philosophize for a bit. So let me continue asking blood-pressure elevating questions: Have you ever done something wrong? Then you might have a antisocial personality disorder! Do you have mood swings? Well, that must mean you`r suffering from an affective disorder. Do you sometimes see things that aren`t there? Poor you, you must be schizophrenic. I could go on, but I know my readers are smart enough to get my point. But to clarify: No matter which questions I`d ask, I could interpret the result and make them fit neatly into a psychiatric box handmade for you.
Off course, I`m exaggerating wildly. We have extremes, and we have normality. But no matter what problems you have or don`t have, isn`t the most important thing that you figure our for yourself what you need to do, to change your life? Some mental issues are more important to get the correct label on, than others. If you are bipolar, medication might be a life or death prerequisite. If you are psychotic and think that you can fly if you jump from a building, medication might again be useful. Serious depression also must be addressed with medication and therapy. I don`t mean that we should forget about mental health and do nothing, I just want us to think about how we think about it. We must never forget to look for the normal in the abnormal. 50 % of us will have some mental health issues during our lives, and that means that 50 % of us will benefit from care and love from someone else. Actually, a 100 % of us needs this, more than anything else.
We have a whole manual for categorizing mental health issues, but unlike somatic disorders, our DSM-IV bible don`t give us exact answers. A patient might have five different diagnosis’s because symptoms overlap. Some doctors scratch their heads when this happens, and try one medication after another. When a patient is readmitted to a psychiatric unit, they frustrate as him/her must have gone off their medication. They might try another cocktail. My questions when this happens is: If someone is readmitted 10-50 times, might it not be an idea to try something different, too? Aren`t we obliged to do everything we can for our patients and our society?
We are all unique. There are 50 shades of normality and abnormalities. This isn`t a bad thing, it is what makes life and people fascinating. Considering this, we need tailor-made treatments addressing all these differences.
More:
Delirious
Good afternoon!
Today I` going on a musimc quiz, and to prepare I`ve listened to music the whole day.
We have a lot of brilliant artists in Norway, but normally they don`t manage to get famous abroad. That is why you probably haven`t heard this song by Susanne Sundfør, that I have listened to for three months now. I`m still not tired of it.
What do you think?
In the arms of an angel
There are many beautiful songs out there, and this is one of my favorites at the moment.
McLachlan wrote it after hearing that Jonathan Melvoin, the keyboardist for the Smashing Pumpkins died after a heroin overdose in 1996.
“I wrote “Angel” after being on the road for almost two years straight and was both mentally and physically drained,” McLachlan wrote. “I went to a cottage north of Montreal to relax and write and read an article in Rolling Stone about the Smashing Pumpkins keyboard player who had OD’ed in a hotel room.”
She continued, “the story shook me because though I have never done hard drugs like that, I felt a flood of empathy for him and that feeling of being lost an lonely an desperately searching for some kind of release.”
The song has had enduring popularity and has been used in a number of different ways, with some uses (such as in a child memorial) misconstruing the lyrics. McLachan said during a Reddit AMA that she doesn’t mind that it gets used in so many different ways. “I think once an artist puts a song out there, it becomes open to interpretation, and I purposefully leave a certain amount of ambiguity in songs so that people can relate the songs to themselves and to their stories,” she said.
“And for me, it’s a great validation as an artist to know that something I’ve created has gone out there in the world and helped people to heal, or to feel something, in a profound way like that.”
For me, the song is about safety when everything feels like it`s falling apart. A symbol that at our darkest moments, there is someone who wants to protect us.
Uncommon therapy by Jay Hayley
This year I`ve read a lot. Some psychology books, but also fiction. One of the psychology books I`ve read, that I want to review here, is “Uncommon therapy” by Jay Hayley. The book is from my favorite therapist, who I wish I was. I have written about him before, and try to remember that nothing is impossible every time I have a client myself.
Milton H. Erickson, M.D. is generally acknowledged to have been the world’s leading practitioner of medical hypnosis. His “strategic therapy,” using hypnotic techniques with or without actually inducing trance, allows him to get directly to the core of a problem and prescribe a course of action that can lead to rapid recovery.
Milton Erickson was an interesting therapist and scientist: With creativity he tailored therapy to each client so that it fitted perfectly. He was the perfect “mirror” for others, so much that he actually could “talk” exactly like the client in front of him. He strongly believed in the unconscious, and in letting people find their own insights. He could tell little anecdotes that were completely right for the client. An example was an alcoholic that lived in a family where everyone drank (even his own wife) and drunk for several years. He was considered a hopeless case. Milton gave him a task: He should go to a park and sit down to watch a cactus for several minutes. Erickson told him this cactus could live without water 
for three years. 5 years later his sister called Erickson and told him both he and his wife had stopped drinking. He also used Reframing, mirroring and the paradox intervention. And example of the first, is when he sent a rootless client to Flagstaff so that she created new positive associated to a place that just seemed negative before. An example of the second is when he met a patient that tore things apart. She tore and threw everything she saw: Clothes, curtains, wallpaper. Generally, she was acting out. Erickson stood beside her and did the same thing, he tore up pieces of the wallpapers and threw things here and there. He exclaimed: “This was fun! Let`s go somewhere else and do more of it”. They came to a hospital, where he ripped the clothes off a nurse.
After this event, the girl became an angel, not knowing that the nurse in on the whole thing. An example of the paradox intervention was telling a woman who had severe problems with her weight. Erickson told her to try a new method where she first would gain a certain weight before she started with dieting. When she no longer had to restrain herself, she suddenly lost the weight she needed.
The book “uncommon therapy” provides a comprehensive look at Dr. Erickson’s theories in practice, through a series of case studies covering the kinds of problems that are likely to occur at various stages of the human life cycle. The results Dr. Erickson achieves sometimes seem to border on the miraculous, but they are brought about by a finely honed technique used by a wise, intuitive, highly trained psychiatrist-hypnotist whose work is recognized as a major contribution to the field.
I loved the book, even when I was somewhat shock at how brutally honest he could be at times. But it seems like it works, since he always wants the best for his clients. Even if Erickson`s dead, his legacy lives on.
Mirrorgirl 
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