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James Harris Interviewed
INTERVIEW: James C. Harris, MD
Director, Developmental Neuropsychiatry Clinic
Professor of Psychiatry & Behavioral Sciences &
Professor of Pediatrics Johns Hopkins School of Medicine
by Bruce Hershfield, MD
Q: “Please tell us about the Agnes Purcell McGavin Award that the APA gave you in San Diego.”
A: “The award is for “distinguished career service”. It is a lifetime achievement award. The areas that were highlighted included my textbook, published in 1995–-“Developmental Neuropsychiatry”. It is a single-authored two-volume textbook that is the culmination of 25 years and more of working with children and adolescents with developmental disabilities. I wanted to write it a textbook from a developmental perspective. I wanted to explain how understanding neurogenetic disorders that involved brain function could help us better understand how brain systems emerge and perhaps help us also understand the neurological basis of obsessive compulsive disorder, compulsive self-injury, and other types of behaviors.
I also received the award because of my activities in residency education, as President of the Society of Professors of Child & Adolescent Psychiatry, which is the organization that represents the various academic divisions in child & adolescent psychiatry, as President of the Maryland Regional Council of Child and Adolescent Psychiatry, and my involvement with the American College of Neuropsychopharmacology and the Society for Neuroscience.”
Q: “You’ve been working in neurodevelopment for quite some time.”
A.: “Since 1976. When I finished my residency in Adult & Child Psychiatry, I was made Director of Psychiatry at the Kennedy Krieger Institute. Later I directed the Division of Child Psychiatry at Hopkins for four years and combined the Kennedy Krieger program and the Hopkins program into one program in Child and Adolescent Psychiatry. After Joe Coyle followed me as the Division Director in 1982, I continued to direct the training program in Child and Adolescent Psychiatry, During that time I basically had two hats. One was to direct the training program. (We had NIMH funding training most of those years.) The other hat was to direct the developmental neuropsychiatry program, as we started to call it, at Kennedy Krieger. Eventually, it seemed to me that there was not enough emphasis within Psychiatry on neurodevelopment. I was granted a Sabbatical to write a textbook, which I hoped would emphasize a developmental approach and eventually lead to a subspecialty area within Psychiatry.”
Q: “Is that the way it turned out?”
A: “There isn’t a subspecialty “per se”, but it is considered to be a area of special focus within Psychiatry and reviewers suggested that my textbook could pave the way for an eventual specialty area. The developmental pediatricians were seeing these many of children at the time the book was written, but they weren’t emphasizing their behavioral and emotional needs. Surprisingly Developmental Neuropsychiatry was chosen “Medical Book of the Year” out of 2500 books in 76 medical specialties in the year of its publication. When I received the book of the year citation I was told that the decision was made because of my focus on a new specialty area within Psychiatry.”
Q: “Are you communicating with colleagues in the field and are there other indications that it is becoming a new specialty?”
A: “I think that is happening incrementally as with the greater focus on clinical neuroscience in psychiatry and ongoing efforts to understand the neurobiology in of different types of psychiatric disorders in children. I focused on neurodevelopmental and neurogenetic disorders, but other investigators are now looking at brain function in bipolar disorder and OCD and other conditions.
My NIH funded research has focused on brain mechanisms in Lesch-Nyhan syndrome. That‘s a rare genetic disorder, but practically everyone knows it because of the characteristic severe compulsive self-injury. We did the first PET scans to try to understand the role of the dopamine and the serotonin systems in self-injurious behavior. Since then, in looking at those mechanisms, I’ve been interested as well in self-injury in eating disorders and particularly in bulimia nervosa.
The outcome of continued focus on neurodevelopment is that having done the book on developmental neuropsychiatry, I wrote another book, published in 2006, that’s called “Intellectual Disability”. The reason I wrote it was that it had become increasingly clear that “mental retardation” was a stigmatizing term. By writing a textbook, I’d hoped to focus attention on a new name, which is increasingly being adopted “intellectual disability”. In 2007 the American Association on Mental Retardation changed its name to the American Association of Intellectual & Developmental Disabilities. So I think that we’re moving forward and that this is will be the accepted diagnostic term in DSM-V.
Q: “Please tell us more about your other interests, too.”
A: “I’m interested in dealing with stigmas as they relate to mental illness in children. Particularly, stigma as it relates to children with intellectual disabilities and developmental problems. I think that increasingly we’re educating the public and stigma is less of an issue than in the past.
As the Director of the education program in the division of child and adolescent psychiatry at Hopkins. I focused on psychotherapy and I taught seminars to the general psychiatry residents on the developmental perspective in Bowlby, Erikson, and Jung. In one series of seminars we talked about neurodevelopment and neurocognitive functions of the brain and in a complementary series we talked about how psychotherapy may be effective. The second series is titled “the uses of the imagination in psychotherapy.” The way we use the imagination to facilitate emotional and cognitive integration in psychotherapy is critical. I’ve had a longstanding interest in trying to understand integrated brain functioning by studying how the brain gives meaning to events and puts them in context. For psychotherapy this involves a deep understanding of the interface between narration and reflection. Jerome Bruner’s paper on two kinds of thinking brought home to me how, in psychotherapy, there is a continuous process of narrative dialogue and reflective responsiveness. That process is inherently integrative linking, as it does, affect and cognition. For example, a child in therapy would draw a picture and then tell a story and we would go back and forth between the meaning of the story and the context that could be used to put that story into meaningful perspective in the individual’s life
Q: “Is that how you came to edit the commentaries about the covers in the “Archives of General Psychiatry?”
A: “Ultimately it is the outcome of the seminars on uses of the imagination in psychotherapy and the seminars that I have given on creativity and the developmental perspective. When Joe Coyle became the Editor of the “Archives of General Psychiatry”, he asked me if I would write a commentary and choose the cover for the journal each month. I started by considering the life stories of individual artists and psychiatric themes linked to them. I wanted to see how we could understand the role of creativity in mental health by examining the lives of artists. Almost routinely artists with emotional problems seems to find ways to use the creative imagination to provide images that could give solace to themselves and, in many ways, solace to others, the viewers. And I began to understand how art can be a window on brain functioning.
Van Gogh was probably the most successful in this, in the images that he painted. For that reason, in the very first issue of the “Archives” with Joe as editor I used Van Gogh’s “Starry Night” for the cover and commentary in November, 2002. That was the one painting that he did that incorporated both his imagination with what he saw outside the window of his asylum window. Most of his earlier work consists of images of what he’d seen, but in this instance he was in the asylum, looking out the window at the night sky on one particular night. He had recently had a psychotic episode, probably after taking too much absinthe. As he recovered from his psychosis he began to reintegrate psychologically and to me this painting illustrated that psychological reintegration as I described in the commentary. Since that first issue with Van Gogh, I’ve looked at other artists with psychiatric difficulties. Edvard Munch is a good example of how he began to deal with his anxiety through his art. The September, 2007 issue of the “Archives” deals with Munch’s loss of both his mother and his sister to tuberculosis and how those pivotal life events allowed him to find a meaningful way to express himself emotionally in his art.”
Q: “How is the feature in the ‘Archives’ turning out?”
A: “To me, it brings everything together–-my interest in neuroscience and my interest in psychotherapy. For example in the Van Gogh story I wrote not only about this life but also the physiology of abstinthe and the social implications of its use. When I wrote about Toulouse-Lautrec, who had a congenital orthopedic disorder, I was able to include the most recent work on genetics of his orthopedic disorder as well as to talk about the impact of short stature on his self-esteem and how he began to compensate for his short stature, his addiction, and his other stressful events in his life and his efforts to create beautiful illustrative paintings.
The August, 2007 issue was the most fun. I did a commentary on Magritte. His mother committed suicide when he was 13. I tried to show how Magritte, who was very critical of psychological interpretation and in particular of psychoanalysis, actually used active imagination to work through the loss, although he would never acknowledge it. The concealed face of the woman is a regular feature in his art. His mother drowned and she was found with her nightgown wrapped around her face and he witnessed her recovery from the river. So the image of the concealed face occurs continually in his work, until eventually, later in life, he draws the concealed face one final time, but now it’s concealed by a beautiful bouquet of flowers. It’s as if he has now come to terms and reveals to us a memorial to his mother. Around, the time of her death he became interested in detective fantasy and it seemed as if he was the investigator who was trying to discover new ways and new links between images, but I also believe that he was investigating his mother’s loss and did this in a particularly interesting, and ultimately psychologically effective, way.”
I was originally trained in Pediatrics. I was stimulated to go into Psychiatry partly by my experiences working with a child with autism. Working with that child intensively made me very curious to understand the brain and development in autism, but particularly the uses of the imagination. Here was an example of a failure of the use of the imagination. Autistic children may play things out, but they play out themes that they’ve seen on television. You don’t see the imaginative inner life in the same way that you do with other children. On the one hand there was a failure of the uses of imagination in autism and some other developmental disorders, where children couldn’t use their imagination in a way that they could participate in typical kinds of therapies. In other children who had the capacity to imagine we could begin to see how they used creative expression to adapt. Now I think I’ve taken that to the next step, by looking at how artists have produced artwork that’s universal and that can influence the viewer in a psychologically meaningful and helpful way.”
Q: “Would you like to make any predictions about Child Psychiatry?”
A: “I think that it will become more comprehensive again. We need to understand brain mechanisms in disease but we also need to understand how the brain functions in an integrative way. In my own research, we’ve focused on clinical neuroscience and I think that that’s important. One way that Child Psychiatry is likely to go is that we will continue to understand neurodevelopment and the transitions that take place in the brain. I think that that research is moving along very quickly. But I think that the uses of imagination needs to be looked in a new way now that we know more about the brain.
The more we know about genetics, the more compelling it is that we look at the impact that life experience has on development We need to focus much more on life experience and the environment, and how our life experiences begin to change brain functioning. I think that we’re going to be focusing more on the environment, but from a different perspective because we have new techniques to help us understand how life experience can sculpt the brain and behavior.
There really are two modes of thinking, a narrative mode and a reflective mode. If you understand the relationship between the two, you can do psychotherapy. If you don’t understand it, you’ll focus excessively on pharmacotherapy you may lose sight of the role of narrative dialogue in modulating affect and other brain functions.
But if you put too much emphasis on the interpersonal, then you may not recognize fully that there are certain limitations that are the result of our constitutional brain development and genetic make up. Both sides need to be emphasized and I think that in the future there is going to be a greater emphasis on applying what we know about brain development to individual therapeutics.”