Incorporating Brain Explanations in Psychoanalysis: Tennessee Williams as a Case Study.

Despite Tennessee Williams's genius as a playwright who could represent his inner emotional struggles in his art, psychoanalysis was unable to free him from the powerful "blue devils" within him. Williams's inability to engage with psychoanalysis presents an opportunity to discuss ways that contemporary thinking about brain structure and function might guide our understanding and treatment of patients such as Williams. One of the core defensive behaviors that made analysis difficult for Williams was his avoidance of painful emotions through compulsive writing, sex, alcohol, and drug-addictive behaviors. These pre-mentalized reactions became Williams's habitual procedural body response, which occurs below the level of the self-reflective brain. Within a relatively traditional ego psychological frame, Lawrence Kubie, Williams's analyst in 1957, attempted to prohibit the compulsive behaviors to be able to process the underlying painful affects in the analysis. However, given that this level of mind and brain functions was Williams's chief means of regulation, Williams could not engage in the psychoanalytic process and left the treatment after one year. I propose that Williams was operating in brain circuits below the level of "higher" reflection or interpretation-receptive circuits and therefore he was unable to make use of a traditional ego psychological model. A review of these brain circuits seeks to encourage therapists to utilize simplified brain explanations for patients, which can destigmatize the pathologic behaviors and enhance engagement in the treatment process.

Impaired Mind-Body Connections in Psychosomatic Patients: A Contemporary Neuropsychodynamic Model.

In alexithymia-type psychosomatic patients who do not have the capacity to mentalize, arousal is experienced non-symbolically within the body. These people also often have significant histories of attachment trauma and other adverse childhood experiences. This article extends a previous neuropsychodynamic formulation that takes into account recent work on how attachment trauma is internalized in developing brain circuits. Specifically, it considers the possibility that early attachment trauma impairs thalamo-amygdala-striatal-thalamic circuits, resulting in disconnect of subcortical arousal to the prefrontal cortex where the arousal can be mentalized. These impaired subcortical circuits perpetuate stress deep within these patients' implicit procedural circuitry, making them very resistant to psychotherapy. Knowledge of this interaction deepens our understanding of these patients, who suffer greatly, and suggests guidelines for treatment approaches with which they are more likely to engage.

Health care infrastructure post-Katrina: disaster planning to return health care workers to their home communities.

One of the greatest challenges of restoring the New Orleans health care infrastructure since the post-Katrina disaster has been shortages of health care providers. Many providers had prolonged displacements or did not return to their practices, depleting the city of valuable resources. This Open Forum chronicles the displacement of Louisiana State University's Department of Psychiatry and discusses barriers to returning health care providers to their communities expeditiously. Predisaster planning and policy changes are proposed to facilitate a quicker return and decrease the attrition of health care providers after future disasters. A community's predisaster plans should include a mechanism to allow funds to follow patients instead of hospitals, to provide bridge funding that pays local health care providers to work as first responders and serve uninsured patients while these providers rebuild their practices, and to provide funds to quickly expand services and usable space in undamaged clinics and hospitals and to shore up reparable structures.

The Louisiana emergency department behavioral health challenge.

Hurricane Katrina uncovered and exaggerated Louisiana's behavioral health crisis. Patients with mental illness are backlogged in emergency rooms across the state, unable to access inpatient psychiatric treatment. Post-Katrina, part of the department of psychiatry of the Louisiana State University (LSU) New Orleans was displaced to Huey P. Long Medical Center (HPLMC) in Pineville, Louisiana. While displaced, LSU wrote a grant to develop a psychiatric emergency room service at HPLMC and in the process experienced a number of barriers to optimal behavioral healthcare in the emergency department (ED). The ED plays an essential role in our state's system of care for the mentally ill. However, EDs throughout the nation traditionally have not had the provisions necessary for optimal behavioral healthcare. In this article, we will address barriers to implementing proper provisions for sound behavioral healthcare in the ED. We will outline an affordable and available mental health personnel infrastructure that integrates with the ED's medical model of care, and improves quality of care of the mentally ill and the functional level of the ED, as well as the morale and job satisfaction of ED healthcare providers.