Clinical Social Work Practice in Behavioral Mental Health Toward Evidence Based Practice 3rd Edition Ebook

Clinical social work practice in
behavioral mental health : toward

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Contents vii
The Therapeutic Relationship 170

The Nature of Cognitive Therapy 170
The Process of Cognitive Therapy 171
Methods of Cognitive Therapy 173
Case Example 174
Mindfulness Cognitive Therapy 177
Evidence-Based Practice: Interpersonal Therapy 178
The Therapeutic Relationship 178
The Intervention Process 179
Methods of Interpersonal Therapy 183
Evidence-Based Practice: Problem-Solving Therapy 185
Medication 187
Antidepressant Medication 187
Instruments Used to Assess and Monitor Depression 190
Complementary and Alternative Therapies 190
Summary and Deconstruction 191
Chapter 9 Evidence-Based Practice for Clients with Anxiety Disorders 196

Anxiety Disorders and Older Adults 198
Epidemiology of Anxiety Disorders in Later Life 198
The Case of Subthreshold Anxiety 199
Types of Anxiety Disorders 199
Explanatory Theories 201
Biological Aspects 201
Social Dimensions 201
Psychological Theories 202
Cognitive-Behavioral Treatment of Anxiety Disorders 203
Systematic Desensitization 203
Flooding and Implosive Therapy 204
In Vivo Exposure 204
Response Prevention 205
Thought Stopping 205
Cognitive Restructuring 206
Stress Inoculation Training 206
Evidence-Based Practice: Cognitive-Behavioral Treatment for Panic
Disorder and Panic Disorder with Agoraphobia 206
Assessment 207
Treatment Components 208
viii Contents
Intervention Sequence 209

Evaluation 210
Case Example: Integrated Methods 211
Reliable Instruments Used to Assess and Monitor Anxiety 214
Medications Used to Treat Anxiety Disorders 214
Selective Serotonin Reuptake Inhibitors 214
Tricyclic Antidepressants 214
Monoamine Oxidase Inhibitors 216
Benzodiazepines 216
Buspirone 217
Pharmacological Treatment 217
Research on Medication and Psychotherapy 218
Pharmacological Treatment for Anxiety in Older Adults 218
Other Ways of Healing 219
Chapter 10 A Framework for Intervention with Persons with Severe

Mental Illness 225
Defining Severe Mental Illness 226
Relevant Perspectives, Concepts, and Models 229
Biopsychosocial Perspective 229
Stress-Diathesis and Attention-Arousal Models 230
Expressed Emotion 231
Recovery 232
Psychiatric Rehabilitation 235
Community Integration and Supportive Services 236
Evidence-Based and Empirically Supported Practices 238
Instruments Used to Assess and Monitor Severe Mental Illness 241
Chapter 11 Evidence-Based and Best Practices with Adults with Severe

Mental Illness in a Community Context 246
Case Scenario 247
Recovery Orientation 248
Case Management and Community-Based Care 249
Functions of Case Management 250
Case Management Models 253
Assertive Community Treatment: An Evidence-Based
Practice 255
Contents ix
Assumptions Underlying Community Care Practice with Persons

with Severe Mental Illness 258
Community Support Services and Resources 260
Inpatient Treatment Services 261
Outpatient Treatment Services 261
Housing Options and Best Practices 262
Crisis Services 267
Partial Hospitalization 268
Integrated Treatment for Schizophrenia and Substance Abuse:
An Evidence-Based Practice 269
Vocational Rehabilitation and Supported
Employment Programs 269
Supported Education: A Best Practice 271
Peer Support Specialists: A Best Practice 272
Clubhouses, Drop-In Centers, and Consumer-Run
Organizations 273
Citizen Advocacy Groups 274
Health Care 275
Entitlements 275
Supports for Clients Who Are Parents 276
Support Networks 276
Ethnic-Specific Behavioral Mental Health Centers 277
Chapter 12 Evidence-Based Interventions for Individuals with Severe Mental

Illness and Their Families 283
Evidence-Based Practice: Illness Management and Recovery 284
Format and Structure 285
Evidence-Based Practice with Family Caregivers 287
Impact of Serious Mental Illness on the Family 288
Family Psychoeducation 289
Family Education 296
Family Consultation 297
Cognitive Rehabilitation 298
Antipsychotic and Mood Stabilizing Medication 299
Antipsychotic Medication 299
Mood Stabilizing Agents 303
Implications for Clinical Social Work Practice 305
x Contents
Chapter 13 Clinical Practice with Persons with Co-Occurring Substance Use

and Serious Mental Illness......by Kathleen J. Farkas 313
Terminology 314
Alcohol and Other Drug Use/Abuse/Dependence Continuum 314
Substance Abuse and Substance Dependence 315
Substance-Induced Disorders 316
Prevalence 316
Prevalence of Alcohol and Other Drug Problems 316
Prevalence of Co-occurring Substance Use and Serious Mental
Illness 317
Conceptualization, Assessment, and Treatment of Co-occurring
Disorders 317
Conceptualization 317
Assessment Process and Tools 319
Onset and Severity of Symptoms in the Assessment Process 321
Treatment Models 325
Use of Medications 326
Abstinence and Harm Reduction Approaches 327
Evidence-Based Practices with Clients with Dual Disorders 327
Motivational Interviewing 329
Integrated Dual Disorders Treatment 330
Index 339
PREFACE
We are in the dawn of a new era in the field of mental health. Expanded biopsychosocial knowl-
edge and increased experience applying this knowledge to practice have resulted in new, evidence-
based methods of intervening with clients for whom there was little hope in the past. The
growing presence of clients with serious and moderately disabling conditions that can be helped
and clients from diverse cultures has heightened the need for clinical and cultural competence.
Public policy has called for “transforming mental health care in America.”1 Through Clinical
Social Work Practice in Behavioral Mental Health: Toward Evidence-Based Practice, third
edition, we hope to prepare social workers to use advances in knowledge to contribute to this
transformation.
Social workers are one of the principal providers of mental health services in the United
States. They are ubiquitous in mental health centers, psychiatric rehabilitation programs, emer-
gency services, hospitals, housing and residential programs, and other behavioral health entities.
Social workers provide clinical services to clients who need time-limited psychotherapy and
those who require continuing supportive care. They work in both the pubic sector and private set-
tings. Members of a profession that sees itself at the interface between the person and the envi-
ronment, social workers offer a critical link between the client, the behavioral health treatment
team, and the community.
This book is written for those who wish to gain specialized knowledge of social work prac-
tice with adults in the field of mental health/behavioral health. One of the book’s audiences is so-
cial work graduate students who are taking courses in or are specializing in mental health.
Advanced undergraduate students who are interested in mental health or are preparing for a ca-
reer in this field constitute another audience. A third audience is mental health practitioners.
Although this book was written from a social work perspective, clinicians and students of related
professions, such as nursing and psychosocial rehabilitation, may benefit from reading this
volume. This book does, however, assume prior foundation knowledge of human behavior and
social work practice theory, counseling skills, and some familiarity with the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR).2
The third, substantially revised edition of this book has some new features that are espe-
cially relevant to the contemporary behavioral health environment. First, this book has a new
focus on recovery and recovery models for consumers with serious and persistent mental illness.
Second, it highlights evidence-based practices with clients with depressive disorders, anxiety
disorders, serious mental illness, and dual disorders (severe mental illness and substance abuse)
and has an updated focus on best and promising practices. A third novel feature is that it gives
increased attention to the mental health of older adults.
Other special features of this volume are that it:
1. describes research evidence supporting practice interventions.
2. gives special attention to SAMHSA’s evidence-based toolkits for interventions with
clients with severe and persistent mental illness.
3. addresses cultural disparities in the chapter on cultural competence.
4. discusses feminist theories and violence perpetrated against women and human traffick-
ing in the chapter on feminist mental health practice.
5. explains legal and ethical issues related to mental health, including documentation.
xi
xii Preface
6. provides a historical context for understanding mental health policies.

7. describes interventions and provides stimulating case examples.
8. includes four chapters on working with adults with severe and persistent mental ill-
ness (including one on co-occurring severe mental illness and substance abuse).
9. suggests instruments that can be used to monitor progress and evaluate outcomes of
treatment of clients with particular mental health problems.
10. provides extensive information about medication.
11. uses a postmodern lens to critically examine the contents of chapters.
12. includes case studies within and at the conclusions of chapters.
The mental/behavioral health practice described in this book is with adults with moderate
to severe mental health difficulties. These difficulties include depression, anxiety, severe mental
illness, and substance abuse (including dual diagnoses). Consistent with today’s practice envi-
ronment, the locus of treatment that is emphasized is the community and outpatient settings, but
many of the interventions that are described can be used within hospitals and other institutions.
Although efforts have been made to be comprehensive, certain boundaries had to be drawn. This
book does not discuss intervention with persons who simply have “problems in living” or diffi-
culties that are principally environmental. Moreover, it does not give attention to treatment of
children and adolescents, persons with personality disorders and dementia, and adults with
co-occurring mental illness and mental retardation/developmental disabilities and co-occurring
severe mental illness and anxiety and personality disorders.
The book is organized as follows. It begins with an orienting chapter, in which the reader
is introduced to the leading concepts, themes, and contexts that are addressed in the field of
mental/behavioral health and in the book. The book then is divided into two parts. Part One, “A
Framework for Practice,” consists of six chapters. The first (Chapter 2) looks at the historical
context of social work practice in the field of mental health. The next, the conceptual framework,
describes the terms, theories, and perspectives related to the book’s integrated biopsychosocial
perspective. In keeping with the conceptual framework, Chapter 4 describes components of a
comprehensive biopsychosocial assessment. Here the mental status examination, a functional
assessment, and the biopsychosocial summary are described, and model formats are provided.
Chapter 5 is concerned with legal and ethical issues that social workers face when they practice
within the framework of their professional values and the legal system, and includes background
on the decisions and information on record keeping. The next two chapters address culture and
gender. Chapter 6 provides a framework for culturally competent mental health practice and
gives attention to practice with African Americans, American Indians/Alaska Natives, Asian
Americans and Pacific Islanders, and Hispanics/Latinos/Latinas. Chapter 7 describes feminist
theories and practice and discusses violence and trauma, particularly in relation to intimate part-
ner violence and human trafficking.
Part Two contains six chapters on intervention. Although the primary emphasis here is on
psychosocial modalities, information on psychotropic medication is provided as well. Chapters 8
and 9 describe evidence-based practices with persons suffering from depression and anxiety,
respectively, provide illustrative case examples, and identify medications that are used. Because
persons with severe and persistent mental disorders constitute a prominent population in the field
of mental health, four chapters are devoted to their treatment. Chapter 10 defines terminology
and describes various concepts and perspectives, including recovery, psychosocial (psychiatric)
rehabilitation, stress-diathesis, and community integration. Chapter 11 discusses evidence-based
and best practices that operate on the community level, including case management and the
Preface xiii
Assertive Community Treatment (ACT) model. This chapter also describes a range of community
resources appropriate for persons with severe and persistent psychiatric disorders and a couple of
best practices. The third chapter on treatment with this population (Chapter 12) focuses on the
evidence-based practices of “Illness and Recovery” and “Family Psychoeducation,” but also dis-
cusses other family interventions, cognitive rehabilitation, and medication. Chapter 13, which
was written by Kathleen J. Farkas of Case Western Reserve University, Mandel School of
Applied Social Sciences, is on clinical practice with clients with the co-occurring severe mental
illness and an addictive disorder. This chapter provides definitions, reviews epidemiological
research, and describes two evidence-based practices with this population. Notably, this chapter
has rich case examples.
The authors gratefully acknowledge the help of a number of individuals who made this
revision possible. Both of us would like to thank Phyllis Solomon, our colleague at the
University of Pennsylvania School of Social Policy and Practice, who helped clarify many of
the points we are making in this book. Other colleagues at Penn who have been part of our
“support team” include Yin-Ling Irene Wong and Joretha Bourjolly. Roberta Sands would like to
thank members of the PRIME (Partners Reaching to Improve Multicultural Education) for
furthering her knowledge of culture. She thanks Laurene Finley for her suggestions on revising
this chapter and Anita Pernell-Arnold for the insights that she provided through PRIME and
collaborative writing projects. Roberta Sands would especially like to thank Samuel Klausner,
whose support has been constant throughout this project. Zvi Gellis would like to thank Stan
McCracken for his insights and assistance on the topic of mental health and older adults. Finally,
we gratefully acknowledge the assistance of staff of Allyn & Bacon for their contributions to this
publication.
NOTES
1. Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health
and Human Services. (2005). Transforming mental health care in America: The federal action agenda:
First steps (DHHS Publication No. SMA 05-4060). Rockville, MD: Department of Health and Human
Services. See also President’s New Freedom Commission on Mental Health. (2003). Achieving the
promise: Transforming mental health care in America. Final report (DHHS Publication No. SMA
03-3832). Rockville, MD: U.S. Government Printing Office.
2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev). Washington, DC: Author.
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C H A P T E R
1
Getting Oriented
Themes and Contexts
Social workers should base practice on recognized

knowledge, including empirically based knowledge relevant to
social work and social work ethics.
—NATIONAL ASSOCIATION OF SOCIAL WORKERS,
“NASW CODE OF ETHICS,” 1996/2008
Clinical social workers are one of the foremost professionals in the field of mental health.
They are the most numerous clinically trained mental health personnel working in mental
health settings, with a preponderance in direct service roles (Duffy et al., 2006). Among mem-
bers of the National Association of Social Workers, mental health is the leading field of prac-
tice, with close to 40 percent indicating that this is their primary area (Gibelman & Schervish,
1997). Mirroring practitioners, more students in master’s programs that offer concentrations in
fields of practice or social problems are enrolled in mental health or community mental health
than any other specific area and more master’s degree students are situated in mental health
field placements than any other practicum types (Council on Social Work Education [CSWE],
2007). The Bureau of Labor Statistics of the U.S. Department of Labor (2010–2011) projects
that social workers in mental health and substance abuse will be in increasing demand in
the future.
1
2 Chapter 1 • Getting Oriented
This book aims to equip social workers with up-to-date contextualized knowledge about
scientific developments, theories, and methods of social work practice in mental health settings. In
the decade preceding the publication of this edition, federal initiatives such as the report of the
President’s New Freedom Commission on Mental Health (2003) have put forth a new agenda for
the field of mental health. The agenda includes evidence-based practices, consumer- and family-
centered services and treatment, the promotion of recovery, and the elimination of ethnic, racial, and
gender-based disparities in the delivery of mental health services. The third edition of this book is
responsive to this report as well as the federal action agenda, Transforming Mental Health Care in
America (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005), which
endorsed culturally competent services, prevention and treatment of co-occurring psychiatric and
substance abuse disorders, and “promising” as well as evidence-based practices (EBPs). Consistent
with these documents and the Surgeon General’s (U.S. Department of Health and Human Services,
1999) report on mental health and the Institute of Medicine’s (2001) report on health care reform
and accessibility, this book also encompasses the mental health of older as well as younger adults.
This book is directed at social work students and practitioners who wish to advance their
knowledge and skills in clinical practice in the field of mental health. Clinical social workers prac-
tice with and on behalf of individuals, families, and small groups to help reduce their distress and
improve their psychological and social functioning. Knowledgeable about human behavior theories,
as well as a variety of modes of intervention, clinical social workers make psychosocial assessments,
formulate goals, and provide psychotherapeutic interventions or treatment. Although professionals
of other disciplines share some of the same knowledge and engage in similar activities, clinical
social workers have a broader perspective than their colleagues in other disciplines. Social workers
view clients and their problems in relation to the contexts in which these difficulties occur and
intervene in the social environment as well as the psychological and interpersonal domains. They are
especially committed to enhancing clients’ strengths and fostering connections between clients and
the community. When interpersonal and institutional barriers interfere with clients’ ability to obtain
resources, clinical social workers promote changes to eliminate obstacles, ensure clients’ rights, and
create linkages and resources. Professionals with a mission to promote human welfare and social
justice, clinical social workers are particularly concerned with the plight of vulnerable populations.
This description of clinical social work encompasses what is also called direct social work
practice, a general term that applies to practice in a wide range of field settings among various
populations and problem areas. Direct practitioners in most specialized fields draw from diverse
sources of knowledge, theories, and methods. They work with clients and systems to prevent
and/or solve problems, change maladaptive behaviors, resolve psychological issues, develop
social networks, and use community resources. Intervention is psychological and social and
adapted to the needs of the client or client system.
In the field of mental health, clinicians’ therapeutic and case management roles predomi-
nate and are interconnected. As therapists, clinical social workers use their knowledge of prac-
tice theories, differential diagnosis, and treatment modalities, as well as empirically supported
and evidence-based methods of practice, to promote psychological and/or behavioral changes,
enhance clients’ psychosocial functioning, and improve their situations. They foster clients’ de-
cision making and promote their recovery from the effects of mental illness and/or substance
abuse. As case managers, clinical social workers link consumers with resources, monitor their
treatment plans, and engage in advocacy. Those who work as case managers for individuals with
severe mental illness promote clients’ use of personal and community supports and provide that
support themselves. (See Chapter 11 for a discussion of case management in relation to the se-
verely mentally ill.) Within these two roles, clinical social workers take on numerous functions,
Chapter 1 • Getting Oriented 3
which include diagnosis, mediation, crisis intervention, skills training, collaboration on interdis-
ciplinary and interagency teams, family and consumer consultation, and education (Bentley,
2002). They have extensive contacts with colleagues in related disciplines, staff of a variety of
human service agencies, landlords, physicians, lawyers, clergy, and others. Through these con-
tacts, clinical social workers connect clients with community resources and work to reduce bar-
riers to mental health services.
Social work practice in mental or behavioral health takes place in a number of different
settings. Among these are community mental health centers, outpatient clinics, psychiatric
hospitals or units within general hospitals, assertive community treatment teams, psychosocial re-
habilitation services, substance abuse treatment programs, supported apartments, group homes,
and managed behavioral care carve-outs, as well as Veterans Affairs hospitals and employee assis-
tance programs (Gibelman, 2004). Aside from services that specialize in mental health, family
service and child welfare agencies, homeless shelters, and private practices also serve clients with
mental health and substance abuse issues. This book was written with the former set of treatment
centers in mind, but much of what is described here applies to other settings as well.
This chapter aims to orient readers to the context of behavioral or mental health practice
today and the themes that run through this book. It begins with a description of community
mental health, the predecessor of today’s system of behavioral health under managed care. It
explains the ideology of behavioral or mental health, its relation to deinstitutionalization, and its
public health model. Next, behavioral health under managed care is described. The third topic
that is introduced in this chapter is scientific knowledge and EBP, which include knowledge of
psychiatric epidemiology, biological research, and EBP research. This is followed by definitions
that are important to understanding the field. The chapter concludes with an explanation of the
postmodern perspective that is used as a critical framework for chapters in this book.
COMMUNITY MENTAL HEALTH

Community mental health is a concept, philosophy of intervention, social movement, ideology,
and policy that dominated the field of mental health during the last few decades of the twentieth
century. In its initial conceptualization by Gerald Caplan (1961), the community was thought to
generate stress that, in turn, produced psychopathology. Public policies in keeping with the
community mental health concept supported the creation and expansion of services close to
consumers in their local communities.
Caplan (1964) incorporated a public health model of prevention into his philosophy.
Accordingly, intervention on three levels would reduce the incidence, duration, and degree of
impairment associated with mental illness.
Three Levels of Prevention

The first level of mental health prevention, primary prevention, has the goal of reducing the inci-
dence (rate of new cases) of mental disorders by addressing their causes. This level focuses on
the community and the conditions within it that may be toxic. Primary prevention invites
research into potential biological, environmental, and psychological causes. When this research
identifies groups that are at a high risk of developing a particular problem, preventive interven-
tions, such as education, can be directed at that sector of the population. Primary prevention
focuses on providing supports, which may be physical (food, housing), psychosocial (relation-
ships), and sociocultural (cultural values, customs, and expectations), and preventing barriers to
the flow of supports, such as racism (Caplan, 1964).
The second level, secondary prevention, has the goals of reducing the prevalence of actual
cases (old and new) in the community and shortening the duration of time in which individuals
experience problems, thus preventing existing problems from getting worse. Early identification
(case finding), assessment, and intervention (crisis intervention and short-term therapy) are some
ways in which this level of prevention is implemented. Prompt and effective individual, family,
and group psychotherapies also apply to the secondary level.
The third level, tertiary prevention, has the goal of reducing the rate of mental disability in
the community through rehabilitation. This level focuses on restoring individuals with serious
psychiatric problems to as high a level of functioning as possible and on preventing complica-
tions (Langsley, 1985b). Tertiary prevention is directed at the community as well as at clients and
their social networks (Caplan, 1964). On the community level, efforts are made to prevent or
reduce stigma, ignorance, and other barriers to recovery through advocacy and community
education. When applied to individuals with severe mental disabilities, tertiary prevention aims
to thwart decompensation, homicide, and suicide.
In addition to the three levels of prevention, several principles guided the community men-
tal health practice from the beginning. Many of these principles also operate in today’s behav-
ioral health/managed care environment.
Principles of Community Mental Health Practice

The community mental health movement embraced a set of principles that constituted a belief
system or ideology. These include comprehensiveness, continuity of care, accessibility, multidis-
ciplinary teams, and accountability. One of the foremost principles was that services should be
comprehensive (Langsley, 1985a). This meant that communities should provide a wide range of
mental health services at various levels of intensity from outreach programs to outpatient clinical
services to day treatment to hospitalization. Within these services, alternatives such as
psychotherapies (individual, family, and group), social skills training, and vocational rehabilita-
tion were to be offered. The community itself was to have a diverse range of residential settings,
such as halfway houses and supported housing, in which clients may live (Bachrach, 1986).
Community treatment was to be responsive to all age groups (including children and older
adults), to be available around the clock and on an emergency basis, and to address special
problems such as substance abuse. Services were to be flexible and adapted to the needs of the
populations served (Bachrach, 1986).
A related principle was that continuity of care was to be assured (Langsley, 1985a). This
was a way to prevent clients from falling through the cracks in the context of a service delivery
system that was complex, fragmented, and bureaucratic. It meant that services should be linked—
“a system of services with easy flow of patients among its component parts” (Bloom, 1984, p. 4).
For example, clients leaving psychiatric facilities were to be connected to treatment services when
they were discharged. The case manager made sure that linkages were made and acted on.
Community mental health services were supposed to be accessible to those who sought
treatment (Langsley, 1985a). This meant that they were to be located near clients’ residences or
places of work, reachable by public transportation, and available during evenings (at least for
emergencies) and weekends. To assure this, community mental health services were distributed
into catchment areas or service units that served residents in a particular geographic area.
Facilities were also to be accessible to persons with physical disabilities, and provisions were to
be made for communicating with those who could not hear. Furthermore, services were to be
culturally and gender sensitive.
Another principle of community mental health was that treatment providers should organ-
ize into multidisciplinary teams (Langsley, 1985a). Teams were comprised of psychiatrists,
psychologists, community mental health nurses, social workers, recreation therapists, and coun-
selors, among others. Indigenous mental health workers (paraprofessional), who lived in the
neighborhood, also participated (Bloom, 1984). Multidisciplinary teams make it possible for the
knowledge, skills, and perspectives of diverse members to contribute to a holistic understanding
of the client and the provision of multidimensional treatment or rehabilitation.
A further principle was accountability (Langsley, 1985a). The citizen board members who
governed mental health agencies were responsible not only to those who sought treatment but
also to those who were well (Langsley, 1985a). Accountability also applied to consumers, who
participated increasingly in the governance of community mental health agencies. As consumers
recognized their potential power, they asserted themselves increasingly over time.
Although community mental health and deinstitutionalization were distinct movements
within the mental health field, their ideologies converged. Community mental health practi-
tioners identified with some of the attitudes toward hospitalization assumed by advocates of
deinstitutionalization.
Deinstitutionalization
Deinstitutionalization is a philosophy, process, and ideology (Bachrach, 1976; Mechanic, 2008)
that began to unfold in the United States in the late 1950s when the principal locus of treatment
began to change from hospitals to the community. In 1955, the number of patients residing in
state and county psychiatric hospitals peaked at 559,000. After that time, these facilities were
substantially (but not completely) depopulated. By 2002, the inpatient population was down to
57,263 residents (Duffy et al., 2006), a substantial reduction. This process was facilitated by the
development of medications that could be prescribed and taken in the community. Another
condition that supported deinstitutionalization was a switching of costs from the state to the
federal level in the 1960s, which made it possible for persons who were formerly long-term
hospital residents to live in the community (Mechanic, 2008).
Although some advocates of deinstitutionalization hoped that hospitals could be entirely
eliminated, the philosophy in practice revolved around the appropriate use of hospitals. Instead
of maintaining a large cadre of persons with severe mental illness in custodial care, hospitals
would care for persons with acute exacerbations (flare-ups) for a brief period of time in which
they would be stabilized. Short-term hospitalizations could be provided in psychiatric units of
local general hospitals (rather than state facilities located some distance from clients’ homes),
with follow-up treatment to help them maintain their gains provided in the community.
Deinstitutionalization was supposed to involve two processes—(a) the avoidance of hospi-
talization and (b) the concurrent development of community services that would serve as alterna-
tives to institutionalization (Bachrach, 1976). The first process meant that community treatment
strategies, such as placement in a day treatment program, were to be pursued before considering
hospitalization. This mechanism of diversion was dependent on the second process, the existence
or creation of community alternatives such as crisis and emergency services, group homes, sup-
ported residential programs, outpatient treatment centers, vocational rehabilitation programs,
and other options (for today’s options, see Chapter 11). Unfortunately, many communities did
not develop community alternatives. Many discharged patients were “dumped” on city streets
without a place in which to live and without outpatient care. Another consequence of deinstitu-
tionalization was the development of a revolving door syndrome, with the same individuals
flowing in and out of the hospitals on a regular basis. The increase in admission rates that fol-
lowed deinstitutionalization suggests that brief hospitalizations were not long enough to allow
recovery to take place and/or that some clients did not receive or follow up on referrals to
agencies providing aftercare. A further flaw in the implementation of this policy was that some
residents of psychiatric hospitals were reinstitutionalized in nursing homes and prisons. With the
passage of time it has become clear that state hospitals continue to be needed in some areas to
care for persons who are poor community risks, “revolving door” patients, and those who require
long-term hospitalization (Bachrach, 1996).
Deinstitutionalization evolved as a public policy during the 1960s, a period of heightened
social consciousness and advocacy for the rights of marginalized populations. In the 1960s and
1970s, practices such as involuntary commitment, custodial care without treatment, and coercive
forms of intervention were successfully challenged in courts on constitutional grounds. (See
Chapter 2 for a review of this history and Chapter 5 for a discussion of legal issues.) But deinsti-
tutionalization was also an ideology that was associated with certain values (Mechanic, 1989).
First, hospitalization was considered undesirable, adversely affecting patients (Mechanic, 2008).
Second, it was considered desirable for persons with mental health difficulties to be free to live
normal lives, integrated as fully as possible into the fabric of the community (cf. Wolfensberger,
Nirje, Olshansky, Perske, & Roos, 1972).
Although proponents of deinstitutionalization and community mental health identified
with these values, there were others who saw in the emergence of deinstitutionalization an
opportunity for taxpayers to save money. Hospitalization is the most expensive form of psychi-
atric treatment that there is. States had been bearing a significant economic burden for long-term
hospital care. When liberal thinkers depicted institutionalization as undesirable, conservatives
responded by closing state hospitals. Other policies such as limiting admissions to those who
were a danger to themselves and others and retaining people in the hospital over relatively short
periods of time also appeared to be economically advantageous to taxpayers. Cost-mindedness
continues to drive policy under managed care.
Behavioral Health under Managed Care

The term behavioral health is used in today’s managed care environments to describe the preven-
tion and treatment of mental health and substance abuse. Managed care is a means of structuring,
financing, and administering health care that aims to be cost-effective, efficient, and high in quality.
It came to the fore at a time when health care costs in the United States were skyrocketing and
appeared to be out of control. It has changed the face of health care and mental health practice
and introduced certain terms and concepts that require explanation.
In contrast to the fee-for-service, indemnity model in which third-party payers, such as health
insurance companies, pay for each medical visit or procedure, with managed care, physicians are
paid for services at a negotiated rate. A primary care physician (PCP) coordinates services and
makes decisions about the need for outside referrals and procedures. Under managed care, inter-
ventions must be preapproved, reauthorized at intervals, and evaluated in terms of outcomes.
Behavioral health services may be provided under a managed health care insurance plan.
There are two main types: health maintenance organizations (HMOs) and preferred provider or-
ganizations (PPOs). HMOs are prepaid plans in which the member uses specific health providers
that are part of the organization’s network. These providers may be employed directly by the
HMO or may be groups or individuals who contract with the HMO. In a PPO, the member has
the option of using the organization’s preferred network or going outside the network, in which
case there are additional costs. Consumers in PPOs pay a modest copayment for each visit
(Jackson, 1995). One can use providers outside HMO and PPO networks in an emergency. A third
type, the point-of-service (POS) plan, which may be a separate alternative or part of an HMO or
PPO, also allows consumers flexibility in using network and nonnetwork providers, with different
terms applying to different sets of providers (Corcoran & Vandiver, 1996). Behavioral health care
in HMOs and PPOs may be provided through a kind of carve-out arrangement, a contract with
a managed behavioral healthcare organization (MBHO) that provides mental health and/or
substance abuse services (Edmunds et al., 1997). Alternatively, behavioral health may be integrat-
ed into the health care provider system. Providers of behavioral health services under any of these
managed care arrangements usually agree to accept what is called a capitated rate. This is a
specific amount per user that the provider is given for a particular time period (e.g., per month).
In 1995, about 60 percent of people living in the United States were in some kind of man-
aged health care plan (Health Insurance Association of America, 1996). About 25 percent had
other kinds of coverage. Many states have obtained waivers from the Health Care Financing
Administration, making it possible for some people on Medicaid to enroll in managed care plans
(McGuirk, Keller, & Croze, 1995). Similarly, Medicare beneficiaries may receive their benefits
through a managed care arrangement. Full-time employees of relatively large companies provide
individual (and sometimes family) coverage as a fringe benefit, with some or no cost sharing
between the employer and the employee. In 2007, 15.3 percent of the U.S. population had no
health insurance (DeNavas-Walt, Proctor, & Smith, 2008). With the passage of President
Obama’s Patient Protection and Affordable Care Act in March of 2010, it is expected that the
proportion of uninsured will be substantially reduced after the act is put into operation.
Clients in need of mental health or behavioral health services may or may not have health
insurance. Some lose their private insurance when mental health problems make it difficult for
them to maintain their jobs. For those who are insured, behavioral health benefits may be limited.
The Health Maintenance Organization Act of 1973 (Pub. L. No. 93-222) established a minimal
level of behavioral health coverage by HMOs at twenty outpatient visits and thirty days of
inpatient treatment a year (Jackson, 1995). The Mental Health Parity Act of 1996 required equity
in insurance coverage between physical and mental health problems, but this legislation had a
number of loopholes. The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008
strengthened the previous act.
The introduction of managed care into mental health and substance abuse practice has
centered attention on cost-effectiveness and prevention. Cost-effectiveness refers to the need to
assess the connection between cost and outcomes to assure the best outcome at the least cost.
Expensive treatment strategies, such as hospitalization and long-term psychotherapy, are avoided
if alternative, less expensive approaches are feasible, available, and sound. When more expensive
treatment is authorized, it is monitored to determine whether it is working and the amount of
time this level of intensity of intervention is required. In general, brief, time-limited treatment or
crisis intervention is preferred. Managed care organizations do not support time- and money-
consuming psychotherapy that aims to restructure the personality (Furman, 2003; Poynter,
1998). Reduction of symptomatology, restoration of functioning, and behavioral change are the
primary goals (Poynter, 1998). Effectiveness is measured through the use of indicators deter-
mined by the managed care organization, an external group that conducts a utilization review, the
provider, and/or the behavioral health delivery system. Although outcomes are usually measured
on a system basis, individual practitioners can use instruments that measure the outcome of
treatment, the extent to which goals are attained, and (in the case of clients with long-term prob-
lems) intermittent progress. (Suggestions for practitioner instruments are offered elsewhere in
this volume.) Another means of assessing effectiveness is to ask consumers how they found serv-
ices. Managed care organizations use client satisfaction surveys that they tailor to the needs of
the particular program (Corcoran & Vandiver, 1996).
Prevention is an integral part of managed care. Managed health care plans in the private
sector emphasize wellness and health promotion strategies such as giving up smoking and drink-
ing, and stress management. Public managed care, which will be described next, uses prevention
approaches such as family education, peer support groups, and psychosocial rehabilitation
(Corcoran & Vandiver, 1996).
Clients on Medicaid in most areas of the country can receive health and mental health care
under a managed care arrangement. States may arrange to use existing HMOs, contract with
community mental health centers, or contract with a behavioral health care company (Mechanic,
2008). Local mental health authorities or boards, which have administrative and financial over-
sight of their districts, have an important role in the provision of care for these public sector
clients (Hoge, Davidson, Griffith, Sledge, & Howenstine, 1994). Although public sector man-
aged care arrangements in different parts of the country vary (Hoge, Jacobs, Thakur, & Griffith,
1999), the following six core functions are needed to provide comprehensive treatment for
clients who are recipients of public support (Hoge et al., 1994):
1. Gatekeeping. At points of entry into the system, efforts are made to admit clients that the
mental health authorities define as target populations, to limit admission to more expensive
services by adhering to restrictive criteria, and to divert clients to alternative, less expen-
sive forms of treatment.
2. The community is the locus of activity. Treatment is to be in the local community where
clients, their support networks, and services are located.
3. Provision of comprehensive services. Local mental health authorities and service
providers are to assess needs, allocate resources, and overcome barriers to access, so that
the needs of the target population can be met.
4. Continuity of care is to be facilitated by coordinating services that are currently needed
and those that will be needed over time.
5. Maximizing economic efficiency can be realized by consolidating funding streams,
using these funds flexibly, and introducing incentives to providers to deliver efficient, ef-
fective services.
6. Accountability should be established at the delivery level by assigning a particular staff
member, such as a case manager, as the point person. Local mental health authorities are
accountable to the public for the effective operation of the mental health service delivery
system.
Notably, several of these functions (2, 3, 4, and 6) were tenets of the community mental
health movement. In addition, the three levels of prevention under community mental health con-
tinue to be relevant. It also remains important that services are accessible to consumers by hav-
ing twenty-four-hour coverage, being nearby, posing no architectural barriers, and being respon-
sive to diverse cultures.
The Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral
Care, which developed a framework to guide the evaluation of behavioral health care arrangements,
found that arranging wraparound or enabling services to address clients’ social needs was also an
important function. The committee recommended services such as social welfare, housing, voca-
tional, and other rehabilitative services for persons with severe mental illness and chronic substance
abuse problems (Edmunds et al., 1997). Another recommendation was that behavioral health
programs should be responsive to racial and ethnic minorities and persons with co-occurring mental
illness and substance abuse. The committee stated that efforts should be made to employ providers
who are culturally competent and use innovative and alternative treatments, even if research on the
effectiveness of these strategies has not as yet been conducted (Edmunds et al., 1997). Elsewhere in
this book, services for persons with severe mental illness (Chapter 11), culturally competent prac-
tice (Chapter 6), and treatment of persons with co-occurring disorders (Chapter 13) are discussed.
IMPLICATIONS OF BEHAVIORAL HEALTH FOR

CLINICAL SOCIAL WORK
Behavioral health under managed care introduces some procedures and expectations that affect
social workers. In some agencies and practices, clinical social workers are extensively involved
in requests for authorization and reauthorization of services. These may involve telephone calls
and/or the submission of paperwork. Social workers may experience requests to justify contin-
ued work with a client as intrusive and object to an outside party’s weighing of cost saving over
what they consider the best interest of the client. Differences in judgment and values can raise
troubling ethical issues for social workers. In addition, the introduction of administrative require-
ments and paperwork can complicate the client–worker relationship (Poynter, 1998). Although
utilization reviews and quality assurance have been part of mental health delivery for some time,
documentation requirements have increased.
At the very least, behavioral health care has made the already complicated mental health
scene more complex. Interactions with clients need to be considered in the context of their be-
havioral health insurance, the agency, the availability and accessibility of services, and the best
interest of the clients. Mental health agencies are funded by multiple sources, public and private,
including sponsors of supportive services. With so many parties that expect accountability, it is a
challenge for social workers to maintain a primary focus on the needs of clients.
Another consideration for clinical social workers is that the behavioral health scene has
become increasingly competitive. Managed care organizations may be biased toward physicians
and providers with Ph.D.s, although social workers can provide similar services at a lower rate
(Jackson, 1995). The best way to overcome these biases is for social workers to be knowledge-
able and competent. We turn next to some areas of research knowledge that inform competent
social work practice.
SCIENTIFIC KNOWLEDGE AND EVIDENCE-BASED PRACTICE

The knowledge that informs social work practice comes from a variety of sources and disci-
plines. The sources that will be highlighted in this book are multidisciplinary—psychiatric epi-
demiology, biology, and EBP research. Research findings from these sources have an impact on
priorities within the mental health field and the practitioner’s selection of interventions. (From
this point on, the terms mental health, behavioral health, and behavioral mental health, which
combines the two concepts, will be used interchangeably.)
Psychiatric Epidemiology
Clinical social work practice in behavioral mental health is informed by psychiatric epi-
demiological research. Epidemiology is “the study of the distribution, incidence, prevalence, and
duration of disease” (Sadock & Sadock, 2007, p. 170). A project of significance to public health,
it looks at biological, social, and environmental conditions that might point to the origin, cause,
and distribution of pathology, such as the transmission of body fluids and acquired immunodefi-
ciency syndrome. Epidemiological research involves the use of sophisticated methods of
sampling and statistical methods of analysis.
Epidemiological research is predicated on the paradigm of “host/agent/environment”
(Kellam, 1987). The host is the person with the disease; the agent is the causal factor. When
epidemiology has been applied to psychopathology, research has rarely been able to identify a
specific agent that causes a mental disorder. Unlike physical diseases, psychological disorders
are not infectious. Their causes are multiple and interactive. Epidemiological studies have found
varying levels of association among a number of social, environmental, and demographic
variables and the disorder.
Two terms that are widely used in epidemiological research are incidence and prevalence.
Incidence refers to the number of new cases of a particular disorder that occur in a given period
of time (e.g., in a year). Prevalence refers to the total number of cases (new cases and existing
cases) in a population. Point prevalence refers to the prevalence at a particular point of time (e.g.,
today), period prevalence to a period of time longer than a day (e.g., six-month prevalence), and
lifetime prevalence to any time in a person’s life (Sadock & Sadock, 2007). Epidemiologists also
look at variables that may be associated with the incidence and prevalence of particular disorders
such as age, race, gender, and socioeconomic status.
Psychiatric epidemiology refers to “the study of the distribution of mental illness and pos-
itive mental health and related factors in human populations” (Sadock & Sadock, 2007, p. 170).
Research in this area has advanced tremendously in the last 60 years. Early research looked at
both aggregated data of cases in treatment and large community samples, but each of these
strategies had methodological problems. The focus on cases in treatment, usually in public facil-
ities, resulted in the exclusion of people who did not seek help (for various social and cultural
reasons) and those who were treated privately. Epidemiological studies of communities have the
advantage of being more inclusive, but early studies were hampered by their collection of mental
status data by lay interviewers and by the difficulty of converting findings about symptoms into
diagnoses. Among the classic early investigations were Hollingshead and Redlich’s (1958) study
of the community and persons in treatment in the area of New Haven, Connecticut, which found
a relationship between social class and diagnosis and treatment; Leighton’s (1959) Stirling
County study of a rural county in Nova Scotia, which found around one third of the population
significantly impaired; and Srole’s Midtown Manhattan Study (Srole & Fischer, 1986; Srole,
Langer, Michael, Kirkpatrick, & Rennie, 1962), which found that 14 percent of the population
studied were considered impaired in 1954 and 12 percent in 1974.
During the last two decades of the twentieth century, psychiatric epidemiological research
benefited from the development of instruments that were capable of generating diagnostic infor-
mation and could be administered by nonprofessional interviewers (Weissman, Myers, & Ross,
1986). Among these are the Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan, &
Ratcliff, 1981), the Composite International Diagnostic Interview (CIDI) (World Health
Organization, 1990), and, in this century, the World Mental Health Survey Initiative Version of
the World Health Organization Composite International Diagnostic Interview (WMH-CIDI)
(Kessler & Ustun, 2004).
The DIS was used in the National Institute of Mental Health (NIMH) Epidemiological
Catchment Area (ECA) Program, a group of studies implemented in the late 1970s and early 1980s
(Regier et al., 1984). These extensive studies took place in five urban areas—New Haven,
Connecticut; Baltimore, Maryland; Durham, North Carolina; St. Louis, Missouri; and Los
Angeles, California. Both institutionalized and noninstitutionalized residents of these communities
were surveyed once and then again a year later, thus providing comprehensive and longitudinal data
(Freedman, 1984). These studies gathered information on the prevalence of specific psychiatric
disorders, associated demographic factors, and patterns of usage of physical and mental health
services for mental health problems. This ambitious program of research has provided fruitful
information about the distribution of mental disorders in the United States. The findings are limit-
ed, however, because the five surveys took place in urban areas with university-based psychiatric
facilities; it is not clear to what extent the results apply to people who live in rural areas and other
locations where mental health services are not so accessible (Kessler, Abelson, & Zhao, 1998).
The National Comorbidity Survey (NCS), also funded by NIMH, attempted to remedy
limitations of the ECA studies (Kessler et al., 1994). The NCS sample was more representative
of the United States, but the age range was limited to persons between the ages of 15 and 54. This
study used the CIDI to assess diagnoses. Whereas the DIS was compatible with the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association
[APA], 1980), the CIDI converted to the DSM-III-R (APA, 1987). Neither the NCS nor the ECA
Study included personality disorders other than the antisocial type (Kessler et al., 1998).
Subsequently (2001–2003), the National Comorbidity Survey Replication (NCS-R) expanded
the age parameters of the CIDI by including individuals who were 55 years of age and older. The
findings of the NCS-R were converted to DSM-IV diagnoses (Kessler, Berglund, et al., 2005;
Kessler, Chiu, Demler, & Walters, 2005). The replication excluded schizophrenia and autism
(Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005).
Regardless of the limitations of the ECA and the two NCSs, these epidemiological studies
have contributed substantially to knowledge about the distribution of the disorders that are includ-
ed, as well as knowledge about the use of treatment facilities. For example, the NCS produced
two startling findings. First, the twelve-month and lifetime prevalences of any CIDI disorder
among persons ages 15 to 54 are 30.9 and 49.7 percent, respectively. Second, comorbidity (the
co-occurrence of two or more disorders) was the rule rather than the exception for twelve-month
and lifetime prevalences (Kessler et al., 1994). The NCS-R arrived at similar findings, clarifying
that comorbidity was associated with greater severity (Kessler, Berglund, et al., 2005; Kessler,
Chiu, et al., 2005). Other results of these studies will be referred to elsewhere in this book.
Biological Research
Another avenue that informs mental health practice is biological research. With increasing
evidence that many mental disorders are diseases of the brain, attention has been focused on
understanding how the brain works, the causes of brain dysfunction, and the use of pharmacolog-
ical means to overcome biochemical deficiencies. This has resulted in a vast body of research on
neuroanatomy, genetics (including molecular biology), brain imaging, and psychopharmacology.
For example, the Human Genome Project has succeeded in sequencing the human genome,
which has the potential of contributing to understanding and treatment of mental disorders.
During the twentieth century, there was considerable dissension within the mental health
field about the role of biology in the etiology of mental disorders. Freud’s seminal work on the
role of early life experiences in generating mental conflict directed attention to developmental,
family environmental, and personality factors that contribute to mental illness (particularly
neuroses). One consequence of Freud’s work and that of others who focused on early life experi-
ences was that families were blamed for causing mental illness in their progeny. It was not until
after the breakthroughs in psychopharmacology that began to occur in the middle of the twentieth
century and spurred the process of deinstitutionalization that the biological viewpoint became
prominent. During and following the 1990s, a new generation of medications has shown promise
to enhance the functioning and quality of life of persons with mental illnesses.
With its focus on person–environment interactions, the field of social work has been reluc-
tant to incorporate biological knowledge into its own knowledge base, even though the biopsy-
chosocial perspective is recognized as central to understanding practice (Johnson et al., 1990;
Saleebey, 1992). But increasingly, social workers in the field of mental health have been writing
about the importance of biological knowledge (Johnson, 1996) and, in particular, the need for
practitioners to understand the structure of the brain and psychopharmacology (Bentley &
Walsh, 2006). Chapter 3 of this volume provides an introduction to some important information
drawn from biology and related scientific disciplines (neurophysiology, psychopharmacology,
genetics). Later chapters on intervention show how this knowledge applies to understanding and
intervening with clients with different kinds of mental health problems.
In this book, biological and psychosocial dimensions are viewed as integrally related.
Although professions may carve knowledge into spheres that each claims as its own, individuals
are complex biopsychosocial (and spiritual) wholes whose lives are constituted and created
through varied relationships and experiences. The integrative biopsychosocial conceptualization
that is used in this book is described in Chapter 3.
Evidence-Based Practice
In the 1990s, the social work profession was concerned with promoting a more scientifically based
practice and appeared to have shifted from the practitioner-as-scientist using single-subject design
(SSD) methods to the utilization of empirically tested interventions. A decline in interest in SSD has
been attributed to feasibility problems in agency application and criticisms of its usefulness. The ap-
plication of intervention research findings to actual social work practice had begun to emerge as the
catalyst for advancing the movement of science in social work. As the foregoing has suggested, a
critical mass of experimentally tested interventions began to take shape in social work and related
fields during the past two decades—sufficient to provide a basis for forms of clinical practice that
have been variously called “scientifically based,” “empirically supported,” or “evidence-based.” The
current trend is to refer to such practice as EBP—that is, practice based on tested interventions.
In the social work field, two major conceptions of EBP have emerged. The first of these
was developed by Gambrill (2003) and Gibbs (2003), who derived their view from Sackett and
his colleagues (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sackett, Straus,
Richardson, Rosenberg, & Haynes, 2000) and Gray (2001), who have been among the prime
movers of the EBP movement in medicine. Accordingly, EBP consists of five steps: (a) needs for
knowledge are translated into answerable questions; (b) track down scientifically based evidence
that can answer the questions, primarily through a search of computerized databases; (c) the evi-
dence is critically appraised; (d) review results with client and then apply to the clinical decision
at hand; and (e) the outcome of the application is recorded and evaluated. The emphasis rests on
the client’s concerns and expectations, the sharing of evidence with the client, and the collabora-
tive decision making about the course of action suggested by the evidence (Gambrill, 2003;
Gibbs & Gambrill, 2002).
The other major conception of EBP generally refers to practice that uses knowledge and in-
terventions with research validation but leaves open the question regarding how to implement this
practice. For example, Rubin (2008) suggests that EBP is a “process for making practice decisions
in which practitioners integrate the best research evidence available with their practice expertise
and with client attributes, values, preferences, and circumstances” (p. 7). Drake et al. (2001) and
Torrey et al. (2001) discuss implementation of EBP on the assumption that such practice consists of
service practitioners using research-supported treatment guidelines. Both of these notions of EBP
are equivalent to empirically supported practice; in fact, the terms are often used interchangeably.
This second conception of EBP has become dominant in the mental health services literature.
Current EBP paradigms stress the role of the practitioner as a user of scientific findings as is seen
in the book by Corrigan, Mueser, Bond, Drake, and Solomon (2008) on the practice of psychiatric
rehabilitation. In these paradigms, interventions are tested through randomized controlled trials
(RCTs). Those interventions that prove to be efficacious are then “transported” to service programs
for implementation by line practitioners. The evidence in this form of EBP is generated by group
experiments. Little attention is given to the evidence that practitioners might obtain in the applica-
tion of these presumably efficacious interventions. Largely set aside is the conception of the
scientifically oriented practitioner using single-subject methods to test and guide implementation
of these interventions. An alternative definition of EBP would result from broadening the notion of
evidence to include not only evidence obtained from research studies but also evidence garnered by
practitioners in their work with clients, that is, practice-based evidence. A key idea in this concep-
tion would be an integration of the two kinds of evidence in ways that would provide a stronger
scientific base for practice than would be the case if only one kind were used.
Evidence-based practice in mental health has been influenced by many approaches adapted
from current service models, some of which were developed by demonstration grants or other
government or private funding streams. During the past three decades, major advances have been
made in the development of clinical practices and service interventions for the seriously mentally
ill (SMI). Robust research evidence demonstrates that there is abundant empirical evidence to
suggest the availability of interventions with positive outcomes that can be termed EBPs. The most
compelling of these practices is delineated in a report by the Schizophrenia Patient Outcomes
Research Team (PORT) with thirty-five recommendations for psychosocial and pharma-
cological interventions for individuals with schizophrenia (Lehman, Steinwachs, and PORT
Co-Investigators, 1998) with subsequent updates (Kreyenbuhl, Buchanan, Dickerson, & Dixon,
2010; Lehman et al., 2004). In 1998, the Robert Woods Johnson Foundation held a national con-
sensus meeting of experts, researchers, administrators, consumers, family caregivers, and providers
who described six EBPs for individuals with SMI (Drake et al., 2001). These practices include (a)
assertive community treatment, (b) illness management and recovery, (c) family education, (d) sup-
ported employment, (e) medication management, and (f) integrated dual disorders interventions.
This book describes several such evidence-based interventions, as well as others that are
exemplars of best practices and those that are promising. The criteria for inclusion come from
quantitative and qualitative reports of results, meta-analyses, meta-syntheses, frequent references
to them in the literature, and their congruence with social work values. Examples are introduced
in the intervention chapters (8 to 13). Before becoming conversant with research findings of
epidemiological, biological, and practice-effectiveness research, it is necessary to become
grounded in the basics. The next section will describe some of the definitional issues that are
fundamental to understanding mental health.
DEFINITIONAL ISSUES
Many of the terms used in the field of mental health are not transparent. Fundamental concepts
such as normality, mental health, and mental illness have been contested (e.g., Szasz, 1961). The
centrality of diagnosis of mental illness and the DSM obscures personal strengths and the
potential for recovery.
Normality, Mental Health, and Mental Illness

The terms normality, mental health, and mental illness are value-laden Western constructs.
Normality and mental health suggest positive psychological functioning, whereas mental illness
suggests dysfunctioning. Mental health and mental illness indicate a medical model, whereas
normality implies a statistical one. Mental health is frequently used as a euphemism for mental
illness—as illustrated by mental health centers that treat mental illness. The relatively new term,
behavioral health, adds to the confusion.
NORMALITY The terms normality and mental health have similar meanings but different con-
notations. On the surface, normality suggests a statistical criterion (Frances, Widiger, & Sabshin,
1991)—the average or mean; the most common behavior, the mode; or one or two standard devi-
ations from the mean. Studies employing statistical measures, however, have produced surprising
results. Psychiatric epidemiological studies of normal community samples have found that a sub-
stantial proportion of the population had symptoms of psychological problems, with a minority
rated as “well” (Kessler et al., 1994; Kessler, Chiu, et al., 2005; Leighton, Harding, Macklin,
Macmillan, & Leighton, 1963; Srole et al., 1962). Accordingly, mental illness seems to be
“normal.”
The term normality also suggests adaptation to the social context (Frances et al., 1991).
Normal persons accommodate to the demands of society, meet legal and social obligations, and
generally fit in with the contours of society. Although such persons are not troublesome, they are
not necessarily creative or self-actualized. Persons who merely adapt to situational demands gen-
erally do not have the “peak experiences” of insight, self-awareness, or integration described by
Maslow (1968). Furthermore, they do not necessarily have integrity, independence, or courage.
Indeed, they may acquiesce to injustices, exploitation, and persecution.
In his paper, “The Myth of Normality,” Jackson (1977) asserted, “There is no standard of
psychological ‘normality’ or ‘good health’ ” (p. 157). The dichotomy between the normal and
abnormal is false and based on the assumption that psychopathology is fixed and tangible.
Recognizing human variability, he said, “How a person acts varies with the culture, the subcul-
ture, the ethnic group, and the family group in which he lives” (p. 162). Accordingly, normality
is context-related. Assessment requires knowledge of the cultural and other contexts.
MENTAL HEALTH On the simplest level, mental health is characterized by the absence of
mental illness (Jahoda, 1958). Thus, mentally healthy individuals do not have psychiatric
disorders, such as those described in the DSM-IV-TR (APA, 2000). Gross psychopathology (e.g.,
delusions, hallucinations) is not present or observed. Such persons do not communicate feelings
of distress or present evidence of mental illness. Ordinarily, they are not receiving mental health
treatment.
The problem with this definition is that there is a sociocultural process that intervenes
between the presence of symptoms and diagnosis. Many individuals have signs of psychiatric
disorders that neither they nor others consider indicators of mental disorder. Individuals compris-
ing the person’s intimate network may view the person’s behavior as a personal idiosyncrasy, a
sign of divine powers, or an expression of a developmental stage. The group’s ideas about what
is normal may contrast with what mental health professionals consider mental illness. In order
for diagnosis to take place, someone or some system will have to establish that what was
previously considered normal is abnormal (Scheff, 1984).
Mental health also represents an optimal or ideal state. Jahoda’s (1958) concept of “posi-
tive mental health” includes attitudes toward oneself; growth, development, or self-actualization;
personality integration; autonomy; environmental mastery; and perception of reality. This defini-
tion emphasizes high levels of functioning, which go beyond well-being or the absence of disease.
A contemporary development of this perspective is positive psychology, a “science of positive
subjective experience, positive individual traits, and positive institutions” (Seligman &
Csikszentmihalyi, 2000), which provides an alternative to the psychopathological perspective.
Akin to social work’s “strengths perspective” (Saleebey, 2006), positive individual traits include
the capacity to love, interpersonal skills, perseverance, courage, spirituality, and wisdom
(Seligman & Csikszentmihalyi, 2000).
Mental health can also be viewed as an aspect of health. The constitution of the World
Health Organization (WHO, 1948) defines health as “the state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity.” This definition includes
mental health as an aspect of health and suggests positive mental health. Table 1.1 presents an
elaboration of the WHO’s (2007) conceptualization of mental health, based on a statement on
TABLE 1.1 Conceptualizing Mental Health

Mental health is more than the absence of mental disorders
• Mental health can be conceptualized as a state of well-being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.
• In this positive sense, mental health is the foundation for well-being and effective functioning for an
individual and for a community. This core concept of mental health is consistent with its wide and varied
interpretation across cultures. . . .
Mental health is determined by socio-economic and environmental factors
• Mental health and mental health disorders are determined by multiple and interacting social, psychological,
and biological factors, just as health and illness in general.
• The clearest evidence is associated with indicators of poverty, including low levels of education, and in some
studies with poor housing and poor income. Increasing and persisting socio-economic disadvantages for
individuals and for communities are recognized risks to mental health.
• The greater vulnerability of disadvantaged people in each community to mental health disorders may be
explained by such factors as the experience of insecurity and hopelessness, rapid social change, and the risks
of violence and physical ill-health.
• A climate that respects and protects basic civil, political, socio-economic and cultural rights is also
fundamental to mental health promotion. Without the security and freedom provided by these rights, it is
very difficult to maintain a high level of mental health.
Mental health is linked to behaviour

• Mental, social, and behavioural health problems may interact to intensify their effects on behaviour and
well-being.
• Substance abuse, violence, and abuse of women and children on the one hand, and health problems such as
HIV/AIDS, depression, and anxiety on the other, are more prevalent and more difficult to cope with in
conditions of high unemployment, low income, limited education, stressful work conditions, gender
discrimination, social exclusion, unhealthy lifestyle, and human rights violations.
Source: World Health Organization, Mental health: strengthening mental health promotion, Fact sheet No 220, September 2007.
Retrieved and excerpted from http://www.who.int/mediacentre/factsheets/fs220/en/print.html. Reproduced with permission from the
World Health Organization.
mental health promotion. It recognizes that multiple interacting factors—biological, psychological,

social, economic, political, and behavioral—determine mental health and mental health
disorders.
In this volume, mental health will be considered a state of psychosocial functioning that
ranges from optimal to functional to dysfunctional. Optimal captures qualities of positive mental
health as defined by the individual’s own culture. Functional refers to the ability to take care of
oneself, assume social roles, and participate in community life purposefully and constructively.
Dysfunctional describes impairment in the capacity to take care of oneself and participate in the
community and includes patterns that are destructive of one’s self and others.
Mental health is a phenomenon of the individual, family, group, community, culture, and
nation. What affects one of these systems affects others. On the individual level, mental health
encompasses the expression of emotions, cognitions, and behavior; coping with life challenges;
and the social, occupational, and management skills needed for survival. Biological, psycholog-
ical, and social dimensions are connected.
MENTAL ILLNESS During the early 1960s, Thomas Szasz (1960, 1961) launched an attack on
the usage of the concept of mental illness. To Szasz, the term mental illness applied appropriately
to brain (organic) or neurological diseases but not to discrepant beliefs, values, behaviors,
social relationships, and the like, which were commonly viewed as symptoms of mental disease.
Many persons adjudged mentally ill hold unusual beliefs (e.g., “I am Napoleon”) or violate legal
norms (the criminally insane), but they do not have objective bodily illnesses. Although these in-
dividuals may be troubled, Szasz said, they are experiencing “problems in living,” not mental
illness. Because the term mental illness is applied where there is no evidence of medical pathol-
ogy, Szasz said, mental illness is a “myth.” Szasz was not alone in his criticism of concepts of
mental illness and related social practices. Scheff (1984) described a social process in which
deviant behavior gets defined as mental illness.
Behaviorists objected to the medical vocabulary, labeling, and assumption that there was an
inner cause of psychological problems. They preferred to look at environmental contingencies
that support the presentation of maladaptive behavior. Existential phenomenologists were critical
of the use of the scientific method in the study of mental illness. According to their thinking (see,
e.g., Esterson, 1970), it was not possible to be objective in assessing mental illness because
such determinations are made in the course of interacting with a client. In addition, many social
factors (family, environment) surrounding the client contribute to what is socially defined as
mental illness.
Some of the criticism was in response to inappropriate labeling of mental illness. During
the 1960s, for example, some young political activists who went south to register African
American voters were incarcerated in mental hospitals for alleged paranoia (Coles, 1970).
Labeling behaviors or practices that deviate from those valued by mainstream society (e.g.,
homosexuality, substance abuse, illegal acts) as symptoms of mental illness is a means of
invalidating persons who are different.
The authors of the last four editions of the DSM (APA, 1980, 1987, 1994, 2000) have at-
tempted to address some of the definitional problems that have been described, as well as ques-
tions that had been raised about the scientific merits of previous editions. First, they assigned
specific criteria to each psychiatric diagnosis. This should deter labeling and other inappropriate
uses of psychiatric diagnoses. Second, they ran extensive field tests in an attempt to arrive at re-
liable diagnoses and compare alternative criteria (APA, 1980, 1994). Third, they acknowledged
that the boundaries between physical and mental disorders, among different mental disorders,
and between a particular mental disorder and no mental disorder are nebulous (APA, 1994).
Finally, they came up with their own definition of mental disorder, the term which they use for
mental illness. The definition in the DSM-IV-TR (APA, 2000), which repeats that used in the
DSM-III, DSM-III-R, and DSM-IV, is as follows:
In DSM-IV each of the mental disorders is conceptualized as a clinically significant

behavioral or psychological syndrome or pattern that occurs in an individual and that
is associated with present distress (e.g., a painful symptom) or disability (i.e., im-
pairment in one or more areas of functioning) or with a significantly increased risk
of suffering death, pain, disability, or an important loss of freedom. In addition, this
syndrome or pattern must not be merely an expectable response to a particular event,
for example, the death of a loved one. Whatever its original cause, it must currently
be considered a manifestation of a behavioral, psychological, or biological dysfunction
in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor
conflicts that are primarily between the individual and society are mental disorders
unless the deviance or conflict is a symptom of a dysfunction in the person, as
described above. (p. xxxi)
This definition clearly places the disorder inside the person. It excludes individual reac-
tions to painful life events (e.g., bereavement) unless these events are accompanied by an
inordinate degree of distress. Furthermore, it discounts unhappiness, which often prompts people
to seek psychotherapy. Although the definition draws a distinction between mental disorders and
moral deviance, the DSM-IV-TR does not require that mental illnesses represent organic
disorders. Behavioral, affective, and cognitive evidence of distress and impairment in psychosocial
functioning are usually assessed through a diagnostic interview, not biological tests. Clinicians
make judgments about whether certain behaviors, emotions, and beliefs are to be viewed as
symptoms of mental disorders. Inevitably, these judgments are made by referring to a vague
normative model. As Wakefield (1992) asserts, the concept of mental illness lies “on the boundary
between biological facts and social values” (p. 373).
Another word used to describe mental illness is psychopathology—a medical term that
refers to the scientific study of diseases of the mind, including their etiology (origin or cause),
their nature, and the course the diseases take. This term is used in the literature interchangeably
with mental disorder, mental disease, mental illness, and abnormality. This book considers
knowledge of psychopathology, mental illness, and mental disorders to be linked with the values
of Western culture and its naming practices. Because practitioners need to work within the
constructions of the culture in which they live, the terms psychopathology, mental illness, and
mental disorder and the definition in the DSM-IV-TR will be accepted as cultural givens. With
this in mind, the following criteria are indicators of mental disorders:
1. Subjective distress. The individual must report emotional pain, somatic distress, discom-
fort, lack of control, or volitions that contradict personal values.
2. Impaired psychosocial functioning. The individual is unable to take care of personal
needs (bathing, dressing, grooming, eating) or cannot fulfill ordinary social functions
(working, going to school, household management, caring for dependents, reciprocating
in interpersonal relationships), or is destructive or self-destructive. Other expressions of
impaired psychosocial functioning include indirect strategies of problem solving (e.g.,
time-consuming rituals, approach-avoidance patterns, and passive-aggressive behavior).
3. Markedly deviant behavior. The individual initiates actions that have no instrumental
purpose and that substantially deviate from behavior that is functional within the individ-
ual’s subculture (e.g., smearing the walls with feces in mainstream U.S. society).
4. Sensory dysfunctioning. The individual’s sensory mechanisms are deficient; that is, the
senses of vision, hearing, taste, touch, or smell do not correspond with stimuli emanating
from the shared social environment.
5. Disturbed thinking. The individual has cognitions that are false, unrealistic, intrusive, or
incongruent with those that are shared by the individual’s subculture.
Individuals with severe mental illness are likely to meet all of these criteria. Others will meet
only a few. Clients who present concerns, symptoms, or behaviors that involve none of these, or
only the first criterion, probably have problems in living or display socially deviant behavior.
The polemics over what normality, mental health, and mental illness are, which have been
described, underscore how difficult it is to define and classify human experiences. Preferences
for particular terms over others seem to be rooted in differences in theoretical orientation,
which in turn are linked to ideology and power. The following discussion on definitions of recov-
ery and strengths represents a discourse that is an alternative to the dominant Western medical
discourse.
Recovery and Strengths

Recovery is a concept of mental health in which consumers strive to improve their lives in keep-
ing with their own values, interests, and goals (Gagne, White, & Anthony, 2007). A positive,
consumer-driven concept, it is a guiding principle for transforming the mental health system,
described in the document, Transforming Mental Health Care in America: The Federal Action
Agenda: First Steps (SAMHSA, 2005).
The concept of recovery came out of the experiences of consumers who saw themselves as
having survived, healed, or coped successfully with symptoms of mental illness (U.S.
Department of Health and Human Services, 1999). It is supported by empirical research indicat-
ing a positive trajectory (Gagne et al., 2007). Definitions of recovery are abundant, with some de-
picting it as a process and others seeing it as an outcome or vision (Onken, Craig, Ridgway,
Ralph, & Cook, 2007). Used largely in relation to severe mental illness, it also applies to addic-
tion, as in both cases the goal is to assist people who are affected “by reducing the impairment
and disability, and improve quality of life” (Gagne et al., 2007, p. 34). To clarify the meaning of
recovery, a national consensus conference held in 2004 came up with this statement:
Mental health recovery is a journey of healing and transformation enabling a person

with a mental health problem to live a meaningful life in a community of his or her
choice while striving to achieve his or her full potential. (U.S. Department of Health
and Human Services, 2004)
The concept of recovery offers hope to consumers, who, in a previous era, were written off
as incurable. Today, they can anticipate better mental health care, improved psychosocial func-
tioning, and the opportunity to take charge of their own lives. (Recovery will be explained in
more detail in Chapter 10 and will be integrated into Chapters 11 through 13.)
One of the components of recovery is that it is strengths-based. The strengths perspective
offers a standpoint that is affirmative rather than psychopathological. As explained by Saleebey
(2005), it describes possibilities, promises, and hopes that can be obscured by a label of mental
illness. Saleebey envisions a “Diagnostic Strengths Manual” in which personal qualities such as
trustworthiness and patience are described. Although a book on mental health unavoidably
addresses vulnerabilities, this volume will recognize and, where relevant, highlight strengths of
individuals.
As indicated, the mental health field is characterized by the discourses of Western medi-
cine, which emphasize psychopathology, and discourses of strength and recovery, which high-
light the humanness of consumers. Multiple discourses are characteristic of postmodernism,
which will be used as a critical framework for this book.
POSTMODERNISM AS A CRITICAL FRAMEWORK

Postmodernism is an intellectual movement that has swept across academic disciplines and fields
of professional practice over the last few decades. It is associated with the rapid changes that
have emerged—particularly mass communication, information systems, globalization, and
technology—which paradoxically have brought people closer together and farther apart.
Postmodernism challenges basic assumptions about the nature of knowledge and thought that
have characterized modern Western societies since the Enlightenment. The concerns that are
associated with this movement undermine the belief that categories are fixed, reality is real, and
knowledge is certain. Postmodernism questions the modernist project of arriving at universal,
explanatory systems of thought (including scientific ones). Because the field of mental health is
predicated on the ideas that categories of illness are determinate, misperception of reality is
symptomatic of mental illness, and mental disorders can be understood scientifically, postmod-
ernism raises serious questions about the validity of the entire realm of mental health.
Postmodern thought is a development of poststructuralist thought, the latter of which is as-
sociated with European figures such as Derrida (1978) and Foucault (1965). Poststructuralists
are critical of structuralists such as Freud and Marx, who had developed grand theories describ-
ing universal, lawful, underlying structures. Some of the philosophers associated with postmod-
ernism are Baudrillard (1988), Lyotard (1984), and Rorty (1979). The boundaries between
poststructuralism and postmodernism are hazy.
Poststructuralist/postmodern thought begins with a critique of language. At question is the
relationship between the sign (a written or spoken symbol, such as a word) and the signified
(what the sign means). Challenging the idea that language reflects a pregiven true reality, post-
structuralism asserts that language constitutes a reality that is historically and socially contingent
and, thus, fluid (Weedon, 1987). Another way of describing the reality constituted in language is
that it is “socially constructed” (Berger & Luckmann, 1966). As a consequence of the mutability
of what is immediately perceived as real, meanings become multiple, unstable, and subject to
diverse interpretations.
Poststructuralists are critical of logocentrism, the idea that there is a logical, rational, uni-
fied order that is neutral and objective (Grosz, 1989). The logocentrism, which characterizes
Western, post-Enlightenment thought, is problematic because it ignores the complexity that is
embedded in language (Derrida, 1976). First, logocentrism assumes that categories that consti-
tute knowledge are essential; that is, they are inherent. Derrida (1978) asserts that the meanings
of these categories change in relation to context. Logocentrism is also problematic in its charac-
teristic dependence on binary categories, terms that are defined in relation to their polar
opposites. Derrida notes whenever there are binaries, there is an implicit hierarchy, with one term
valued over the other (e.g., male over female, white over black). Viewing categories as binary
opposites is misleading because the two terms are not entirely different or opposite. To capture
the idea that the meanings of the binary terms may overlap and there may be meanings associated
with one term that are not captured by the other, Derrida used the term différence (Grosz, 1989).
Accordingly, one can have a situation of both/and where both meanings of terms that are
commonly viewed as opposites are applicable.
Although binary terms have multiple meanings, diverse interpretations are not immediately
accessible. Language is a site in which political interests struggle for dominance (Weedon,
1987). Foucault’s (1975, 1980) writings highlight the ways in which those who have power are
able to establish their meanings as the meanings and impose these on others. Postmodernists use
the terms master narratives and dominant discourses to describe ideas that overshadow other
coexisting narratives in the public domain. Mental illness, patriarchy, and progress are examples
of master narratives.
Even though knowledge of master narratives allows one to understand the values of domi-
nant sectors of society, it obscures the narratives of disenfranchised or “subjugated” populations,
such as persons with severe mental illness or those who are poor, members of ethnic minority
groups, or women. Postmodernists and poststructuralists have developed a method called
deconstruction to uncover meanings that are not immediately apparent because they are those of
persons who lack the power to directly voice their concerns. This is done by situating the text (a
body of written or spoken language) in the political, social, and historical contexts in which it occurs;
identifying biases and moving them to the periphery of the text; and treating marginal perspec-
tives as if they are central. In this way, subjugated voices (i.e., those of vulnerable groups) can be
heard. “The term ‘deconstruction’ has also come to mean more generally any exposure of a concept
as ideological or culturally constructed rather than natural or a simple reflection of reality”
(Alcoff, 1997, p. 353 n. 24). Here our concern is with ideology, subjugated voices, and concealed
power relations.
As is evident in deconstruction, postmodernism is attentive to the contexts in which knowl-
edge is constructed and communicated. Clinicians need to be knowledgeable about local
contexts—the norms of their particular agency and the managed care entities with which they
interact, the functions of different professions working there, and the situations of each client
with whom they work. In addition, they need to understand other contexts such as mental health
policies and concepts that are used in the behavioral health field. One of the goals of this book is
to communicate specialized knowledge that will help social workers interpret what is happening
in their agencies and with clients who come for help.
There are many implications of postmodernism for the mental health field, some of
which will be mentioned here. Clearly, the categories of mental disorders that are described
so carefully in the DSM-IV-TR (APA, 2000) and its predecessors are problematic. There is
no “essential” schizophrenia or any other label used to designate that a person’s mind is out
of order. Schizophrenia, like other categories, is heterogeneous and diverse. Every person
with schizophrenia is unique. Diagnoses are prototypes, not essences, and the diversity
among them needs to be acknowledged. And, of course, these are categories of disorders,
not people.
Furthermore, the meanings of the binary terms within the field of mental health need to be
unpacked. For example, the terms mental health and mental illness, often construed as opposites,
may overlap. One may have been diagnosed with a particular mental disorder, yet function
exceedingly well in a number of areas of life (e.g., work, friendships, self-sufficiency skills).
Accordingly, one may have both strengths and vulnerabilities.
In the field of mental health, voices of modernism—as expressed through EBP, diagnosis,
and psychopharmacology—coexist with voices of postmodernism—as expressed by consumers
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

Clinical Social Work Practice in Behavioral Mental Health Toward Evidence Based Practice 3rd Edition Ebook

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Clinical social work practice in

behavioral mental health : toward

The Therapeutic Relationship 170

Chapter 9 Evidence-Based Practice for Clients with Anxiety Disorders 196

Intervention Sequence 209

Chapter 10 A Framework for Intervention with Persons with Severe

Chapter 11 Evidence-Based and Best Practices with Adults with Severe

Assumptions Underlying Community Care Practice with Persons

Chapter 12 Evidence-Based Interventions for Individuals with Severe Mental

Chapter 13 Clinical Practice with Persons with Co-Occurring Substance Use

6. provides a historical context for understanding mental health policies.

Social workers should base practice on recognized

COMMUNITY MENTAL HEALTH

Three Levels of Prevention

Principles of Community Mental Health Practice

Behavioral Health under Managed Care

IMPLICATIONS OF BEHAVIORAL HEALTH FOR

SCIENTIFIC KNOWLEDGE AND EVIDENCE-BASED PRACTICE

Normality, Mental Health, and Mental Illness

TABLE 1.1 Conceptualizing Mental Health

Mental health is linked to behaviour

mental health promotion. It recognizes that multiple interacting factors—biological, psychological,

In DSM-IV each of the mental disorders is conceptualized as a clinically significant

Recovery and Strengths

Mental health recovery is a journey of healing and transformation enabling a person

POSTMODERNISM AS A CRITICAL FRAMEWORK

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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