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i

Clinical Assessment and Diagnosis

in Social Work Practice
ii
iii

Clinical Assessment and Diagnosis

in Social Work Practice
Third Edition

JACQUELINE CORCORAN

J O S E P H WA L S H

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2016

First Edition published in 2006

Second Edition published in 2010
Third Edition published in 2016

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Corcoran, Jacqueline, author. | Walsh, Joseph (Joseph F.), author.
Title: Clinical assessment and diagnosis in social work practice / Jacqueline Corcoran,
Joseph Walsh.
Description: Third edition. | Oxford ; New York : Oxford University Press, [2016] |
Includes bibliographical references and index.
Identifiers: LCCN 2015047840 | ISBN 9780190211011 (alk. paper)
Subjects: LCSH: Mental illness—Classification. | Mental illness—Diagnosis. |
Diagnostic and statistical manual of mental disorders. | Psychiatric social work. |
Social service.
Classification: LCC RC455.2.C4 C72 2016 | DDC 616.89001/2—dc23
LC record available at http://lccn.loc.gov/2015047840

9 8 7 6 5 4 3 2 1

Printed by Sheridan Books, Inc., United States of America

v

To my parents, Myra and Patrick Corcoran

—​Jacqueline

To the memory of Ruth and Gus Simpson, for their

kindness and support over so many years
—​Joe
vi
╇ vii

CONTENTS

Acknowledgments ix

 Introductionâ•… 
2 Social Work and the DSM: Person-╉in-╉Environment versus
the Medical Modelâ•… 9

I Disorders with Onset in Childhood

3 Neurodevelopmental Disorders: Intellectual Disabilityâ•… 33

4 Neurodevelopmental Disorders: Autism Spectrum Disorderâ•… 6
5 Neurodevelopmental Disorders: Attention-╉Deficit/╉Hyperactivity
Disorderâ•… 9
6 Oppositional Defiant Disorder and Conduct Disorderâ•… 26
7 Anxiety Disordersâ•… 64

II Disorders with Onset in Adolescence

8 Obsessive-╉Compulsive and Related Disordersâ•… 20

viii

9 Post-​Traumatic Stress Disorder 220

with lisa brown

0 Gender Dysphoria 247

 Eating Disorders 270
2 Depression 302
3 Substance Use Disorders 346
4 Paraphilic Disorders: Pedophilic Disorder 389

III Disorders with Onset in Adulthood

5 Bipolar and Related Disorders 423

6 Personality Disorders 45
7 Schizophrenia and Other Psychotic Disorders 486

IV Disorders with Onset in the Elderly

8 Neurocognitive Disorders 523

Index 555

viii Contents
ix

ACKNOWLEDGMENTS

We wish to acknowledge the valuable help of several students and

professionals who offered case studies and assisted with other material in
chapters: Jennifer Crowell, Vicki Cash Graff, Marty Ford, Angela Gannon,
Catherine Johnson, Liat Katz, Sarah Koch, Susan Munford, Susan Parrott,
Benjamin Smith, Silvana Starowlansky-​ Kaufman, and Candace Strother.
Thank you particularly to Francesca Tiexeira, whom we credit with the
revision of the measures appendices for each of the chapters and to Aubrey
Harrington for her assistance with the copyediting and proofreading
process.
x
xi

Clinical Assessment and Diagnosis

in Social Work Practice
xii
1

 Introduction

Social workers in clinical settings need to demonstrate facility with client

diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is
the preeminent diagnostic classification system among clinical practitioners
in this country. Knowledge of the DSM is critical so that social workers
can converse with other mental health professionals and are eligible to
receive reimbursement for services they deliver. The challenge for a social
work book on mental, emotional, and behavior disorders is to teach social
workers competence and critical thinking in the diagnostic process, while
also considering diagnosis in a way that is consistent with social work
values and principles. These values include a strengths-​based orientation,
concern for the worth and dignity of individuals, and an appreciation for
the environmental context of individual behavior.
To meet these challenges, this book will integrate several perspectives:
• The DSM
• A critique of the DSM
• The risk and resilience biopsychosocial framework
• Evidence-​based practice
• Measurement tools for assessment and evaluation
• A life-​span approach

1
2

Here we discuss in general terms how these perspectives affect social work
diagnosis and how they are integrated into the book.

The DSM

The DSM catalogs, codes, and describes the various mental disorders
recognized by the American Psychiatric Association (APA). The manual was
first published in 1952 and has undergone continual revisions during the
past 50 years. The latest version is DSM 5, published in 2013 (APA, 2013).
Much of the terminology from the DSM has been adopted by mental
health professionals from all fields as a common language with which to
discuss disorders. Chapter 2 provides much more information on the history
of the DSM. Other chapters cover many of the mental, behavioral, and
emotional disorders found in the DSM. The disorders that were selected for
inclusion are those that social workers may encounter in their employment
or field settings.

Critique of the DSM

Despite the widespread use of the DSM, critiques have emerged from social
work and related professions. These are covered in more detail in Chapter 2.
They include the DSM’s lack of emphasis on the environmental influences
on human behavior (Kirk, Gomory, & Cohen, 2015). Social work considers
the reciprocal impacts of people and their environments in assessing human
behavior. From this perspective, problems in social functioning might result
from stressful life transitions, relationship difficulties, or environmental
unresponsiveness. None of these situations needs to assume the presence or
absence of “normal” or “abnormal” personal characteristics. In this volume,
we offer a critique of the diagnosis for each disorder, usually applying it to
the DSM diagnosis.

Risk and Resilience Biopsychosocial Framework

In response to the critique that the DSM tends to view mental disorders as
arising from pathology inherent to the individual, Clinical Assessment and
Diagnosis in Social Work Practice draws on the risk and resilience biopsychosocial
framework. “Risk and resilience” considers the balance of risk and protective
processes at the biological, psychological, and social levels that interact
to determine an individual’s propensity toward resilience, or the ability to
function adaptively and achieve positive outcomes despite stressful life
events. The “strengths” perspective underlies the concept of “resilience,”

2 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
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in that resilient people not only are able to survive and endure but also can
triumph over difficult life circumstances.
Risks, on the other hand, can be understood as hazards or problems at
the biological, psychological, or social levels that may lead to poor adapta-
tion (Bogenschneider, 1996). Protective factors may counterbalance or buffer
the individual against risk (Pollard, Hawkins, & Arthur, 1999; Werner, 2000),
promoting successful adjustment in the face of risk (Dekovic, 1999). Risk and
protective factors are sometimes the converse of each other. For instance, at
the individual level, a difficult temperament is a risk factor, and an easy
temperament is a protective factor. Indeed, researchers have found many
pairs of risk and protective factors that are negatively correlated with each
other (Jessor, Van Den Bos, Vanderryn, Costa, & Turbin, 1997).
The biopsychosocial emphasis expands the focus beyond the
individual to a recognition of systemic factors that can create and ame-
liorate problems. The nature of systems is that the factors within and be-
tween them have influence on each other. For instance, the presence of a
certain risk or protective factor may increase the likelihood of other risk
and protective factors. Wachs (2000) provides the example of how an
aversive parenting style with poor monitoring increases children’s risk
for socializing with deviant peers. If parents are overwhelmed by many
environmental stressors, such as unemployment, lack of transportation
and medical care, and living in an unsafe neighborhood, their ability to
provide consistent warmth and nurturance may be compromised. This
phenomenon also operates for protective factors. For example, adolescents
whose parents provide emotional support and structure the environment
with consistent rules and monitoring tend to group with peers who share
similar family backgrounds (Steinberg, 2001). Supportive parenting will, in
turn, affect the characteristics of the child in that, through receiving it, he or
she learns to regulate emotional processes and develop cognitive and social
competence (Wachs, 2000). Systemic influences also play themselves out
from the perspective of a child’s characteristics. A child who has resilient
qualities, such as social skills, effective coping strategies, intelligence, and
self-​esteem, is more likely to attract high-​quality caregiving, and attachment
patterns formed in infancy tend to persist into other relationships across
the life span.
Although precise mechanisms of action are not specified, data have
begun to accumulate about the number of risk factors that are required
to overwhelm a system and result in negative outcomes (e.g., Fraser,
Richman, & Galinsky, 1999; Kalil & Kunz, 1999). The cumulative results of
different studies seem to indicate that four or more risk factors represent a
threat to adaptation (Epps & Jackson, 2000; Frick, 2006; Runyan et al., 1998;
Rutter, Maugham, Mortimore, & Ouston, 1979). However, risk does not
proceed in a linear fashion, and all risk factors are not weighted equally
(Greenberg, Speltz, DeKlyen, & Jones, 2001).

Introduction 3
4

The chapters in this book delineate the unique risk and protective
factors that have been identified from the research for both the initial onset
of a particular disorder, as well as an individual’s adjustment or recovery
from that disorder. This third edition provides updated information on all
these influences. Some of the risk and protective factors discussed in each
chapter are not specific to that particular disorder; in other words, certain
risk and protective factors play a role in multiple disorders. In a prevention
and intervention sense, these common risk factors occurring across multiple
domains are good targets for reduction or amelioration, and these protective
factors are good targets for enhancement. More research has been done
on protective factors than on risks, but understand that protective factors
are often the converse of risk. Case examples illustrate how the risk and
resilience biopsychosocial framework can be used for assessment, goal
formulation, and intervention planning. Our focus is the micro-​(individual
and family) level of practice.

Evidence-​B ased Practice and Measurement

Evidence-​based practice (EBP) formally began in medicine in the early

1990s (Sackett et al., 1997) and was defined as the integration of the
best available research knowledge informed by both clinical expertise
and consumer values. In other words, evidence-​ based treatment is
a process of using research knowledge to make decisions about intervening
with particular clients. The process of gathering the available research
knowledge involves formulating specific questions, locating the relevant
studies, assessing their credibility, and integrating credible results with
findings from previous studies (Sackett et al., 1997). In the current
environment, however, the term “evidence-​based” has come to mean
that there is an empirical basis to treatments and services (Zlotnik, 2007).
The process of clinical decision-​making according to EBP is therefore
distinguished from the product, which involves compilations of the
research evidence (Proctor, 2007). In this book, we provide compilations
of the evidence for the best treatment(s) for each disorder. We will mainly
rely upon systematic reviews and meta-​analyses for our evidence basis.
These concepts will be briefly defined here, although more information is
available in Littel, Corcoran, and Pillai (2008).
A systematic review aims to comprehensively locate and synthesize the
research that bears on a particular question, using organized, transparent,
and replicable procedures at each step in the process (Littel et al., 2008).
Meta-​analysis is a set of statistical methods for combining quantitative
results from multiple studies to produce an overall summary of empirical
knowledge on a given topic. Results of the original studies are converted to
one or more common metrics, called effect sizes, which reveal the strength

4 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
5

or magnitude of the relationships between variables. In meta-​analysis,

effect sizes are calculated for each study, weighted by sample size, and
then averaged to produce an overall effect. The most commonly discussed
effect size in this book will be the standardized mean difference (SMD), also
known as Cohen’s d (Cohen, 1988), which is the mean difference divided
by the pooled standard deviation (SD) of the two groups. For the SMD,
a negligible effect ranges from 0.0–​0.2; a small effect ranges between 0.2
and 0.5; a medium effect ranges from 0.5–​0.8; and a large effect is greater
than 0.8 (Cohen, 1988).
Whenever possible, we relied on Cochrane Collaboration systematic
reviews for treatment evidence for our mental health disorders. The Cochrane
Collaboration is an international, nonprofit organization devoted to high-
​caliber systematic reviews on health and mental health care (see their
website, http://​www.cochrane.org). If a Cochrane review for a certain
topic is not available, other published systematic reviews and meta-
analyses are discussed in this volume, although the criteria for their
​
inclusion were their use of conventional and up-​to-​date meta-​analytic
techniques.
Another part of evidence-​based practice involves using evidence to
assess people for the presence of mental disorders and to determine that they
are responding in the desired way to intervention. For this second component
of evidence-​based practice, information on measurement tools for particular
disorders is presented in each chapter. Social workers can use these measures
as appropriate to assess the effects of their practice. This book emphasizes
client self-​report measures and ones that do not involve specialized training
on the part of the social worker.

A Life-​S pan Approach

This book is organized according to a life-​span approach, which means that

disorders typically appearing in childhood and adolescence are discussed
first, followed by those with an onset in adulthood, and then those that
begin in older age. Despite the assignment of disorders to different phases of
the life span, each chapter shows how the particular disorder is manifested
across the life span, with accompanying assessment and intervention
considerations.
The section on childhood includes autism spectrum disorders,
intellectual disability, oppositional defiant disorder, attention-​ deficit/​
hyperactivity disorder, post-​traumatic stress disorder, and anxiety disorders.
Most of these disorders begin in childhood. However, conduct disorder
may begin either in childhood or in the adolescent years. (It is discussed
along with oppositional defiant disorder because the symptoms of these
two disorders, as well as the research, overlap considerably.) Although

Introduction 5
6

anxiety disorders can occur at any stage of the life span, we balance our
discussion on how the disorder presents in both childhood and adulthood,
with assessment and intervention considerations specific to particular
developmental stages.
The section on disorders in adolescence refers to disorders with typical
onset in adolescence: post-​traumatic stress disorder, obsessive-​compulsive
disorder, eating disorders, depression, substance-​ use disorders, gender
dysphoria, and pedophilia. We recognize that onset is not always in ado-
lescence for these disorders, and there is much discussion in each of these
chapters on presentation in adulthood (or childhood, as warranted).
Disorders in adulthood include bipolar disorder, schizophrenia and
other psychotic disorders, and personality disorders (borderline and an-
tisocial personality disorders). While there is increasing evidence that bi-
polar disorder may appear in childhood and adolescence, we consider
it as primarily a disorder of adulthood, where the majority of research
has been focused. Disorders associated with older adulthood include the
dementias.
Disorders chosen for inclusion in this book had to meet the following
criteria:
• They are disorders that clinical social workers may encounter,
irrespective of clinical setting.
• They have sufficient research backing them to warrant discussion.
For instance, reactive attachment disorders and intermittent
explosive disorders were not included because of the lack of research
information on them.

Format of the Book

The second chapter provides a historical overview of the DSM, its principles
and components, and critiques of the DSM and its biological basis. Each of
the subsequent chapters on the mental, emotional, and behavior disorders
includes the following:
• A summary description of the particular mental disorder, including its
prevalence, course, and common comorbid disorders
• Assessment factors, including relevant measurement instruments
• The risk and protective factors for both the onset and course of the
particular disorder
• Evidence-​based interventions
• A critique of the diagnosis from the social work perspective
• A case study and illustration of the DSM system, with application of
the biopsychosocial framework and a suggested treatment plan

6 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
7

Our goal in developing this format was to guide you through the
assessment and intervention process with various mental, emotional, and
behavior disorders that may occur throughout the life span. You will gain
in-​depth knowledge about important aspects of these disorders and the
social work roles connected with them. Most important, you will learn
about diagnosis and disorders in a way that is consistent with social work
principles and values.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders 5. Washington, DC: APA.
Bogenschneider, K. (1996). An ecological risk/​protective theory for building
prevention programs, policies, and community capacity to support youth.
Family Relations: Journal of Applied Family & Child Studies, 45, 127–​138.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale,
NJ: Erlbaum.
Dekovic, M. (1999). Risk and protective factors in the development of problem be-
havior during adolescence. Journal of Youth and Adolescence, 28(6), 667–​685.
Epps, S., & Jackson, B. (2000). Empowered Families, Successful Children. Washington,
DC: American Psychiatric Publishing.
Frick, P. J. (2006). Developmental pathways to conduct disorder. Child and Adolescent
Psychiatric Clinics of North America, 15, 311–​331.
Fraser, M., Richman, J., & Galinsky, M. (1999). Risk, protection, and resilience: Toward
a conceptual framework of social work practice. Social Work Research, 23, 131–​143.
Greenberg, M., Speltz, M., DeKlyen, M., & Jones, K. (2001). Correlates of clinic
referral for early conduct problems: Variable-​and person-​oriented approaches.
Development & Psychopathology, 13, 255–​276.
Jessor, R., Van Den Bos, J., Vanderryn, J., Costa, F. M., & Turbin, M. S. (1997).
Protective factors in adolescent problem behavior: Moderator effects and
developmental change. In G. A. Marlatt & G. R. Van Den Bos (Eds.), Addictive
behaviors: Readings on etiology, prevention, and treatment (pp. 239–​264).
Washington, DC: American Psychological Association.
Kalil, A., & Kuntz, J. (1999). First births among unmarried adolescent girls: Risk and
protective factors. Social Work Research, 23, 197–​208.
Kirk, S. A., Gomory, T., & Cohen, D. (2015). Mad Science: Psychiatric Coercion,
Diagnosis, and Drugs. Piscataway, NJ: Transaction Publishers.
Littel, J., Corcoran, J., & Pillai, V. (2008). Systematic Reviews and Meta-​analysis.
New York: Oxford University Press.
Pollard, J., Hawkins, D., & Arthur, M. (1999). Risk and protection: Are both
necessary to understand diverse behavioral outcomes in adolescence? Social
Work Research, 23, 145–​158.

Introduction 7
8

Proctor, E. K. (2007). Implementing evidence-​based practice in social work

education: Principles, strategies, and partnerships. Research on Social Work
Practice, 17(5), 583–​591.
Runyan, D. K., Hunter, W. M., Scololar, R. R., Amaya-​Jackson, L., English,
D., Landsverk, J., et al. (1998). Children who prosper in unfavorable
environments: The relationship to social capital. Pediatrics, 101(1), 12–​19.
Rutter, M., Maugham, N., Mortimore, P., & Ouston, J. (1979). Fifteen Thousand Hours.
Cambridge, MA: Harvard University Press.
Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-​
Based Medicine—​How to Practice and Teach EBM. New York: Churchill
Livingstone.
Steinberg, L. (2001). We know some things: Parent–​adolescent relationships in
retrospect and prospect. Journal of Research on Adolescence, 11, 1–​19.
Wachs, T. (2000). Necessary but Not Sufficient. Washington, DC: American Psychiatric
Association.
Werner, E. (2000). Protective factors and individual resilience. In J. Shonkoff & S.
Meisels (Eds.), Handbook of Early Childhood Intervention (2nd ed., pp. 115–​132).
New York: Cambridge University Press.
Zlotnik, J. (2007). Evidence-​based practice and social work education: A view from
Washington. Research on Social Work Practice, 17(5), 625–​629.

8 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
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2 Social Work and the DSM

Person-​in-​Environment versus
the Medical Model

This book is based on the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM) (APA, 2013) classification system because it is the
standard resource for clinical diagnosis in this country and has been for
more than 60 years. The DSM is intended to “serve as a practical, functional,
and flexible guide for organizing information that can aid in the accu-
rate diagnosis and treatment of mental disorders” (APA, 2013, p. xli). It is
important for social workers to recognize, however, that the DSM represents
a medical perspective, only one of many possible perspectives on human be-
havior. There has always been tension between the social work profession’s
person-​in-​environment perspective and the requirement in many settings
that social workers use the DSM to “diagnose” mental, emotional, or be-
havioral disorders in clients. The purpose of this chapter is to explore this
uneasy relationship of social work with the DSM. As an introduction to the
process, the concept of disorder will be reviewed.

The Concept of “Disorder”

There is no single definition of normalcy in any discipline. Many of the

human service professions, all of which have their own unique value and

9
10

knowledge bases, develop formal standards for evaluating and classifying

the behavior of clients as normal or abnormal, healthy or unhealthy, rational
or irrational. Since its beginnings, the profession of social work has made
efforts to put forth such classification systems (one of which is described
later in the chapter), but at the same time it has always been uncomfortable
with the act of labeling behavior.
The current definition of mental disorder utilized by the American
Psychiatric Association (2013) is a “syndrome characterized by clinically
significant disturbance in an individual’s cognition, emotion regulation,
or behavior that reflects a dysfunction in the psychological, biological,
or developmental processes underlying mental functioning” (p. 20). The
syndrome or pattern must not be an “expectable and culturally approved
response to a common stressor or loss.” Furthermore, “socially deviant be-
havior … and conflicts between the individual and society are not mental
disorders unless the deviance or conflict results from a dysfunction in the
individual, as described above.” This medical definition used in the DSM-​
5 focuses on underlying disturbances within the person and is sometimes
referred to as the disease model of abnormality. This implies that the abnormal
person must experience changes within the self (rather than environmental
change) in order to be considered normal, or healthy, again.
The profession of social work is characterized by the consideration
of systems and the reciprocal impact of persons and their environments
(the psychosocial perspective) on human behavior (Andreae, 2011). Social
workers tend not to classify individuals as abnormal or disordered, but
consider the person-​in-​environment (PIE) as an ongoing transactional
process that either facilitates or blocks one’s ability to experience
satisfactory social functioning. The quality of a person’s social functioning
is related to the biological, psychological, and social factors in his or her
life. Three types of PIE situations likely to produce problems in social
functioning include stressful life transitions, relationship difficulties,
and environmental unresponsiveness (Gitterman, 2009). All of these are
transactional and do not emphasize the presence or absence of “normal”
personal characteristics.
Social work interventions may thus focus on the person or on the
environment. Still, clinical social workers specialize in working with client
populations at the “micro” level of the PIE spectrum. Practitioner and
scholar Eda Goldstein (2007) defined clinical social work practice as the appli-
cation of social work theory and methods to the treatment and prevention
of psychosocial dysfunction, disability, or impairment, including emotional
and mental disorders, in individuals, families, and groups. She adds that
it is based on an application of human development theories within a
psychosocial context. The fact that this definition includes references to
emotional and mental disorders indicates that a tension also exists between
the philosophy of the profession and the focus of many direct practitioners.

10 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
11

Classifying Mental, Emotional,

and Behavioral Disorders

The first edition of the DSM reflected the influence of two previous works
that had been widely used in the United States during the prior 30 years
(APA, 1952). Each of these volumes was the result of efforts to develop a
uniform nomenclature of disease. First, the American Medico-​Psychological
Association and National Council for Mental Hygiene collaborated to
produce a standard reference manual in 1918 (initially titled the Statistical
Manual for the Use of Institutions for the Insane). It included 22 categories of
mental illness and reflected this country’s primary focus on psychiatric
hospitals and severe forms of mental illness. In addition, the New York
Academy of Medicine published the Standard Classified Nomenclature of
Disease in 1933, which, although it was focused on medical diseases, made
great strides in developing a uniform terminology.
The Statistical Manual, responsibility for which was eventually assumed
by the American Psychiatric Association, was used until World War II.
During the war, observations of relatively mild mental disorders among
soldiers uncovered the manual’s limitations. Psychiatrists began to treat
problems such as personality disturbances, psychosomatic disorders, and
stress reactions. The Statistical Manual was not helpful for diagnosing
these cases, and the Armed Forces and Veteran’s Administration actually
developed their own supplemental nomenclatures. In 1948, with the war
over, the APA initiated new action for the standardization of diagnosis
(Grob, 1991). The need for change was felt most strongly by practitioners in
clinics and private practice, reflecting the gradual movement of psychiatry
out of the institutions and into the communities. The result was publication
of the first edition of the DSM in 1952.
Since its beginning, the DSM has relied on symptom clusters, or categories,
as the basis for diagnosis. An accurate diagnosis is important because it
implies that certain interventions should be used to “treat” the problems
inherent in the diagnosis. There are other ways that the process could be
advanced, however. For example, clients could be classified on the basis of
dimensions of behavioral characteristics (First, 2005a). From this perspective,
human behavior is seen as occurring on a continuum from normal through
problematic. “Dimensions” may refer to the severity of defined sets of
symptoms, individual traits, or underlying vulnerabilities. For example,
rather than diagnosing a “personality disorder,” a client could be assessed
as having certain scores for a limited set of common personality traits along
a continuum from normal to problematic. A client might not be diagnosed
as having a certain disorder, but as exhibiting certain personality character-
istics to a problematic degree. A dimensional system would probably result
in fewer categories of disorder and reflect the reality that similar behaviors
may serve different functions across individuals. In fact, several subgroups

Social Work and the DSM 11

12

of the DSM-​5 task force promoted just such a change, most prominently for
the personality disorders (Gore & Widiger, 2013). In the end, this proposal
was rejected by the larger task force as premature, although the work of that
subgroup is featured in detail in Section 3 of the manual. We will have more
to say about dimensional approaches to diagnosis later in this chapter.

The Relationship Between Social Work

and the DSM

Social workers account for more than half of the mental health workforce
in the United States (Whitaker, 2009). Many social workers in direct
practice need to diagnose clients, to make judgements upon which to base
professional actions for which they will be held accountable. It is our view
that the DSM has benefits and limitations with respect to clinical social
work practice. The DSM classification system is a product of the psychiatric
profession and as such does not fully represent the knowledge base or
values of the social work profession. Still, it is extensively used by social
workers (and many other human service professionals) nationwide for the
following reasons (Kirk, 2005; Miller, 2002):
• Worldwide, the medical profession is preeminent in setting standards
for mental health practice. Thus, social workers, along with members
of other professions, are often expected by agency directors to use the
DSM in their work.
• Accurate clinical diagnosis is considered necessary for selecting
appropriate interventions.
• Competent use of the DSM helps social workers claim expertise
similar to that of the other professions.
• Practitioners from various disciplines can converse in a common
language about mental, emotional, and behavioral disorders.
• The DSM perspective is incorporated into professional training
programs offered by members of a variety of human service
professions.
• Portions of state social worker licensing exams require knowledge of
the DSM.
Throughout the remainder of this chapter, the manual will be examined
with regard to both its utility and limitations.

The Evolution of the DSM Since 952

Because the “medical” perspective may sometimes be at odds with social

work’s “person-​
in-​
environment” perspective, it is important for social

12 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
13

workers to understand the evolution of the manual. Social workers can

see how some diagnostic categories have social as well as medical and
psychological origins. They can also get a sense about the relative validity of
the various diagnostic categories.

DSM-​I

The first edition of the DSM (APA, 1952) was constructed by a small
committee of APA members who prepared drafts of the material and sent
them to members of the APA and other related organizations for feedback
and suggestions. The final product included 106 diagnoses, each of which
had descriptive criteria limited to several sentences or a short paragraph.
The manual had a psychodynamic orientation, reflected in the wide use
of the term reaction, as in “schizophrenic reaction” or “anxiety reaction.” It
included many new diagnoses specifically intended for use with outpatient
populations.
DSM-​I’s two major categories included (a) disorders caused by or as-
sociated with impairments of brain tissue function, and (b) disorders of
psychogenic origin without clearly defined physical causes or structural
changes in the brain. The former category included acute and chronic brain
disorders resulting from such conditions as infection, dementia, circula-
tory disturbance, and intoxication. The latter category included problems
resulting from a more general inability to make successful adjustments to
life’s demands. It included psychotic disorders (such as manic depression,
paranoia, and schizophrenia), autonomic and visceral disorders, psycho­
neurotic disorders (anxiety, dissociative, conversion, phobic, obsessive-​
compulsive, and depressive reactions), personality disorders, and situational
personality disturbances.

DSM-​II

The DSM was revised for the first time in 1968, following three years of
preparation. The APA’s decision to do so was justified by its desire to bring
American nomenclature into closer alignment with that of the International
Classification of Diseases (ICD), the worldwide system for medical and
psychiatric diagnosis that was updated and published that same year. Still,
the DSM-​II was not so much a major revision as an effort to reflect current
psychiatric practice. The committee wanted to record what it “judges to be
generally agreed upon by well-​informed psychiatrists today” (APA, 1968,
p. viii). Its process of construction was similar to that of DSM-​I. Following
its adoption by APA leadership, it attracted little attention from the general
public. Psychiatry at that time was far less of a social force than it was to
become during the next 10 years.

Social Work and the DSM 13

14

The DSM-​II included 182 diagnoses, occupying 10 classes of disorder

described in less than 40 pages, as follows:

• Mental retardation
• Psychotic organic brain syndromes (such as dementia, infection, and
cerebral impairments)
• Nonpsychotic organic brain syndromes (epilepsy, intoxication,
circulatory disturbances)
• Psychoses not attributed to physical conditions (schizophrenia, major
affective disorders)
• Neuroses
• Personality disorders
• Psychophysiology (somatic) disorders
• Transient situational disturbances
• Behavior disorders of childhood and adolescence
• Conditions without manifest psychiatric disorder

The term reaction was eliminated from the manual, but the neurosis descriptor
was retained for some categories, indicating an ongoing psychodynamic
influence.
Through DSM-​II there was no serious effort by the profession of
psychiatry to justify its classifications on the basis of scientific evidence. The
manual was empirically weak with regard to validity and reliability (Kirk &
Kutchins, 1992). Nevertheless, it was popular among clinical practitioners
and far more useful to them than it was to researchers.
After the publication of DSM-​II, a conflict erupted within psychiatry
over whether homosexuality should be classified as a mental illness
(Kutchins & Kirk, 1997). While generally considered to be a disorder up to
that time, it first appeared as a separate diagnostic category in DSM-​II. The
gay rights movement had become powerful by the early 1970s, however,
and protests were directed against the APA for its perceived stigmatization
of those persons. The psychiatry profession was divided about the issue,
and the conflict reached a resolution only in 1974 when a vote of the APA
membership (note how far the APA had to go to live up to any claims of
science) resulted in homosexuality being deleted from further editions
of the manual. Still, as a kind of compromise measure, it was retained
in subsequent printings of DSM-​II as “sexual orientation disturbance”
and in DSM-​III as “ego dystonic homosexuality.” The diagnoses were
intended for use only with persons who were uncomfortable with
their homosexuality and wanted to live as heterosexuals. This episode
provides a good example of the “politics” of mental illness. Such a debate
later raged with regard to the diagnosis of gender identity disorder (see
Chapter 10).

14 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
15

DSM-​III

The publication of the DSM-​III in 1980 represented a major turning point

in the field of psychiatry. This third edition represented a clear effort by
psychiatry to portray itself as an empirical, scientific enterprise. It promoted
a non-​theoretical approach to diagnosis, a five-​axis diagnostic system, and
behaviorally defined criteria for diagnosing disorders. For the first time,
the DSM included an official definition of “mental disorder.” It included
265 disorders, and for each of them information was presented about
diagnostic features, coding information, associated features, age at onset,
course, impairment, complications, predisposing factors, prevalence, and
sex ratio. It was a much larger manual than its spiral-​bound predecessors
were. Disorders were classified into 17 categories, usually by shared
phenomenological features, although there was some inconsistency in this
process. For example, there were two chapters devoted to “Not Elsewhere
Classified” groups of disorders, and the infancy, child, and adolescent
disorders were all classified together.
The development of DSM-​III was far more intensive, and involved many
more participants, than the earlier editions. It was put forth as a scientific
document, based on research findings. Even so, the APA recognized that
supporting these claims was difficult. In addition to literature reviews and
field trials, criteria for the inclusion of many disorders were based on whether
they were used with relative frequency, whether interested professionals
offered positive comments about it, and whether it was useful with outpatient
populations. This final criterion indicates the psychiatry profession’s desire
to continue moving away from its roots in the public mental hospitals.
The multiaxial system of diagnoses (see Exhibit 2.1) introduced in
DSM-​III was in use through 2013, although it was amended in DSM-​IV. Its
justifications were a desire to make the process of diagnosis more thorough

Exhibit 2.
The Multi-​Axial Classification of Mental Disorders

Axis I Mental disorders

Other conditions that may be a focus of clinical attention
Axis II Personality disorders
Mental retardation
Axis III General medical conditions
Axis IV Psychosocial and environmental problems
Axis V Global assessment of functioning

Source: Adapted from the American Psychiatric Association (2000).

Social Work and the DSM 15

16

and individualized, and to recognize both the medical and psychosocial

factors that contribute to the process of diagnosis.
One rationale for differentiating Axis I from Axis II disorders was the
perceived etiology of the disorders. Transient disorders—​those for which
a client would be more likely seeking intervention—​were placed on Axis
I, and more “constitutional” conditions on Axis II. Other rationales for
differentiating Axes I and II were their formal structure (psychological
versus organic components) and their temporal stability (those on Axis
II were presumed to be either long term or permanent) (APA, 1980). The
division was also intended to highlight the personality disorders that had
become of great interest to psychiatrists, even though they had already been
included in previous editions. Over the years, however, professionals began
to perceive less conceptual support for the distinction between the two axes
(Cooper, 2004).
Axes IV and V, which bring attention to environmental influences on
a client’s functioning, were of great interest to social workers. No method
was presented to systematically identify and record these factors on Axis IV,
however. It was left to the practitioner to briefly describe the stressor and
rate its severity on a scale of 1 to 7 between “none” and “catastrophic.” This
approach changed over subsequent editions. Furthermore, there was confu-
sion over whether the identified stressors were intended to represent a cause
or a consequence of the Axis I disorder (Brubeck, 1999). To regard the stressors
as a consequence of a disorder contradicted social work’s interest in person–​
situation interactions as contributing to the development of problems in
living; social workers are more likely to consider stressors as causes of
disorders. Axis V, the global assessment of functioning (GAF), also broadened
the scope of diagnosis, as the practitioner was asked to summarize the level
of a client’s social, occupational, and leisure functioning on a scale between
1 (superior) and 7 (grossly impaired).
Another innovation of the DSM-​III that was conceptually appealing to
the social work profession was the introduction of V-​codes, “conditions not
attributable to a mental disorder that are a focus of attention or treatment”
(APA, 1980, p. 331). They included relational problems and thus represented
the only coding category for problems that were recognized to exist outside
the individual. V-​codes are interpersonal issues that complicate the treatment
of another disorder or arise as a result of it. Listed on Axis I when they will
be a major focus of the intervention, they include the following:
• Problems related to a general mental disorder or general medical
condition (a client’s main difficulty is related to interaction with a
significant other who has a mental disorder or physical disease)
• Parent–​child relational problems
• Partner relational problems
• Sibling relational problems

16 C l i n i c a l A s s e s s m e n t a n d D i ag n o s i s i n S o c i a l Wo r k P r ac t i c e
Another random document with
no related content on Scribd:
of the rest. It was a scene of fiends: but in vain; for though they
appeared ready enough to quarrel and fight amongst themselves,
there was no move to attack the enemy. All was confusion; the
demon of discord and madness was among them, and I was glad to
see them cool down, when the dissentients to the assault proposed
making a round to-night and attacking to-morrow.”
And so this precious game of “if you will I will,” and “you hit me
first,” was continued for many days,—more days indeed than the
reader would guess if he were left to his own judgment. The row
between Subtu and Illudeen took place on the 31st of October, and
on the 18th of the following January the enemy was routed and his
forts destroyed.
One of the most favourite of Dayak war weapons is the
“sumpitan,” a long hollow reed, through which is propelled by the
breath small darts or arrows, chiefly formidable on account of the
poison with which their tips are covered. According to Mundy and
other writers on Bornean manners and customs, the arrows are
contained in a bamboo case hung at the side, and at the bottom of
this quiver is the poison of the upas. The arrow is a piece of wood
sharp-pointed, and inserted in a socket made of the pith of a tree,
which fits the tube of the blow-pipe. The natives carry a small
calabash for these arrow heads, and on going into action prepare a
sufficient number, and fresh dip the points in the poison, as its
deadly influence does not continue long. When they face an enemy
the box at the side is open; and, whether advancing or retreating,
they fire the poisoned missiles with great rapidity and precision:
some hold four spare arrows between the fingers of the hand which
grasps the sumpitan, whilst others take their side case.
In advancing, the sumpitan is carried at the mouth and elevated,
and they will discharge at least five arrows to one compared with a
musket. Beyond a distance of twenty yards they do not shoot with
certainty, from the lightness of the arrow, but on a calm day, the
range may be a hundred yards. The poison is considered deadly by
the Kayans, but the Malays do not agree in this belief. “My own
impression is,” says Captain Mundy, “that the consequences
resulting from a wound are greatly exaggerated, though if the poison
be fresh death may occasionally ensue; but, decidedly, when it has
been exposed for any time to the air it loses its virulence. My servant
was wounded in the foot by an arrow which had been kept about two
months; blood flowed from the puncture, which caused me
considerable alarm; but sulphuric acid being applied in conjunction
with caustic directly afterwards, he felt no bad effects whatever.”
All the tribes who use the sumpitan, from their peculiar mode of
fighting, and the dread of the weapon, are called Nata Hutan, or
“Wood Devils.” Besides the sumpitan they also wear the “ilang,” or
sword, which is carved at the angle in the rude shape of a horse’s
head, and ornamented with tufts of hair, red or black; the blades of
these swords are remarkable, one side being convex, the other
concave. They are usually very short, but of good metal and fine
edge. These warriors wear coats of deer hide, and caps of basket
work, some fantastically decorated; and a shield hung over their
backs of stout wood, in addition to the weapons already mentioned,
forms their equipment for service. It is really curious to witness their
movements when the order is given to go out to skirmish—one by
one, with a quick pace, yet steady and silent tread, they glide into the
bushes or long grass, gain the narrow paths, and gradually
disappear in the thickest jungle.
The chief weapon used by the Amazonian Indians closely
resembles the Dayak sumpitan, and is called “pucuna.” Its
manufacture and use is thus graphically described by Captain Reid:
—
“When the Amazonian Indian wishes to manufacture for himself a
pucuna he goes out into the forest and searches for two tall straight
stems of the ‘pashiuba miri’ palm. These he requires of such
thickness that one can be contained within the other. Having found
what he wants, he cuts both down and carries them home to his
molocca. Neither of them is of such dimensions as to render this
either impossible or difficult. He now takes a long slender rod—
already prepared for the purpose—and with this pushes out the pith
from both stems, just as boys do when preparing their pop-guns from
the stems of the elder-tree. The rod thus used is obtained from
another species of Iriartea palm, of which the wood is very hard and
tough. A little tuft of fern-root, fixed upon the end of the rod, is then
drawn backward and forward through the tubes, until both are
cleared of any pith which may have adhered to the interior; and both
are polished by this process to the smoothness of ivory. The palm of
smaller diameter, being scraped to a proper size, is now inserted into
the tube of the larger, the object being to correct any crookedness in
either, should there be such; and if this does not succeed, both are
whipped to some straight beam or post, and thus left till they become
straight. One end of the bore, from the nature of the tree, is always
smaller than the other; and to this end is fitted a mouthpiece of two
peccary tusks to concentrate the breath of the hunter when blowing
into the tube. The other end is the muzzle; and near this, on the top,
a sight is placed, usually a tooth of the ‘paca’ or some other rodent
animal. This sight is glued on with a gum which another tropic tree
furnishes. Over the outside, when desirous of giving the weapon an
ornamental finish, the maker winds spirally a shining creeper, and
then the pucuna is ready for action.
“Sometimes only a single shank of palm is used, and instead of
the pith being pushed out, the stem is split into two equal parts
throughout its whole extent. The heart substance being then
removed, the two pieces are brought together, like the two divisions
of a cedar-wood pencil, and tightly bound with a sipo.
“The pucuna is usually about an inch and a half in diameter at the
thickest end, and the bore about equal to that of a pistol of ordinary
calibre. In length, however, the weapon varies from eight to twelve
feet.
“This singular instrument is designed, not for propelling a bullet,
but an arrow; but as this arrow differs altogether from the common
kind, it also needs to be described.
“The blow-gun arrow is about fifteen or eighteen inches long, and
is made of a piece of split bamboo; but when the ‘patawa’ palm can
be found, this tree furnishes a still better material, in the long spines
that grow out from the sheathing bases of its leaves. These are
eighteen inches in length, of a black colour, flattish though perfectly
straight. Being cut to the proper length—which most of them are
without cutting—they are whittled at one end to a sharp point. This
point is dipped about three inches deep in the celebrated ‘curare’
poison; and just where the poison mark terminates, a notch is made,
so that the head will be easily broken off when the arrow is in the
wound. Near the other end a little soft down of silky cotton (the floss
of the bombax ceiba) is twisted around into a smooth mass of the
shape of a spinning-top, with its larger end towards the nearer
extremity of the arrow. The cotton is held in its place by being lightly
whipped on by the delicate thread or fibre of a bromelia, and the
mass is just big enough to fill the tube by gently pressing it inward.
“The arrow thus made is inserted, and whenever the game is
within reach the Indian places his mouth to the lower end or
mouthpiece, and with a strong ‘puff,’ which practice enables him to
give, he sends the little messenger upon its deadly errand. He can
hit with unerring aim at the distance of forty or fifty paces; but he
prefers to shoot in a direction nearly vertical, as in that way he can
take the surest aim. As his common game—birds and monkeys—are
usually perched upon the higher branches of tall trees, their situation
just suits him. Of course it is not the mere wound of the arrow that
kills these creatures, but the poison, which in two or three minutes
after they have been hit, will bring either bird or monkey to the
ground. When the latter is struck he would be certain to draw out the
arrow; but the notch, already mentioned, provides against this, as
the slightest wrench serves to break off the envenomed head.
“These arrows are dangerous things—even for the manufacturer
of them—to play with: they are therefore carried in a quiver, and with
great care—the quiver consisting either of a bamboo joint or a neat
wicker case.”
To return, however, to our savage friends the Borneans. Like
almost all savages under the sun, they have their war dances:—
“We had one day a dance of the Illanuns, and Gillolos; they might
both be called war dances, but are very different. The performer with
the Illanuns is decked out with a fine helmet (probably borrowed from
our early voyagers) ornamented with bird-of-paradise feathers. Two
gold belts crossed like our soldiers, over the breast, are bound at the
waist with a fantastical garment reaching half-way down the thigh,
and composed of various coloured silk and woollen threads one
above another. The sword or kempilan is decorated at the handle
with a yard or two of red cloth, and the long upright shield is covered
with small rings, which clash as the performer goes through his
evolutions. The dance itself consists of a variety of violent warlike
gestures; stamping, striking, advancing, retreating, turning, falling,
yelling, with here and there bold stops, and excellent as to aplomb,
which might have elicited the applause of the opera-house; but
generally speaking, the performance was outrageously fierce, and so
far natural as approaching to an actual combat; and in half an hour
the dancer, a fine young man, was so exhausted that he fell fainting
into the arms of his comrades. Several others succeeded, but not
equal to the first, and we had hardly a fair opportunity of judging of
the Maluku dance, from its short continuance; but it is of a more
gentle nature, advancing with the spear, stealthily casting it, then
retreating with the sword and shield. The Maluku shield, it should be
observed, is remarkably narrow, and is brandished somewhat in the
same way as the single-stick player uses his stick, or the Irishman
his shillalah, that is to say, it is held nearly in the centre, and whirled
every way round.”
The following extract from Sir J. Brooke’s Bornean Journal will
serve to initiate the curious reader in the peculiarly horrid custom of
“head-hunting,” as observed in this part of the world. Close to the
Rajah’s residence were located a party of Sigo Dayaks, who happily
discovered in good time an incursion of their deadly enemies the
Singés into their territory:—
“The Sigos taking the alarm, cut off their retreat and killed two of
the Singé Dayaks, and obtained altogether five heads, though they
lost two, and those belonging to their principal warriors. This news
reaching me, I hurried up to the hill and arrived just after part of the
war party had brought the heads. On our ascending the mountain we
found the five heads carefully watched about half a mile from the
town, in consequence of the non-arrival of some of the war party.
They had erected a temporary shed close to the place where these
miserable remnants of noisome mortality were deposited, and they
were guarded by about thirty young men in their finest dresses,
composed principally of scarlet jackets ornamented with shells,
turbans of the native bark cloth dyed bright yellow and spread on the
head, and decked with an occasional feather, flower, or twig of
leaves. Nothing can exceed their partiality for these trophies; and in
retiring from the war path, the man who has been so fortunate as to
obtain a head, hangs it about his neck, and instantly commences his
return to his tribe. If he sleep on the way, the precious burden,
though decaying and offensive, is not loosened, but rests in his lap,
whilst his head (and nose) reclines on his knees.
“On the following morning the heads were brought up to the
village, attended by a number of young men, all dressed in their
best, and were carried to Parembam’s house, amid the beating of
gongs and the firing of one or two guns. They were then disposed of
in a conspicuous place in the public hall of Parembam. The music
sounded, and the men danced the greater part of the day, and
towards evening carried them away in procession through all the
campongs except three or four just above me. The women in these
processions crowd round the heads as they proceed from house to
house, and put sirih and betel-nut in the mouths of the ghastly dead,
and welcome them. After this they are carried back in the same
triumph, deposited in an airy place, and left to dry. During this
process, for seven, eight, and ten days, they are watched by the
boys of the age of six to ten years, and during this time they never
stir from the public hall: they are not permitted to put their foot out of
it whilst engaged in this sacred trust. Thus are the youths initiated.
“For a long time after the heads are hung up, the men nightly
meet and beat their gongs, and chant addresses to them, which
were rendered thus to me. ‘Your head is in our dwelling, but your
spirit wanders to your own country. Your head and your spirit are
now ours; persuade, therefore, your countrymen to be slain by us!
Speak to the spirits of your tribe; let them wander in the fields, that
when we come again to their country we may get more heads, and
that we may bring the heads of your brethren, and hang them by
your head,’ etc. The tone of this chant is loud and monotonous, and I
am not able to say how long it is sung, but certainly for a month after
the arrival of the heads, as one party here had had a head for that
time, and were still exhorting it.
“These are their customs and modes of warfare, and I may
conclude by saying, that though their trophies are more disgusting,
yet their wars are neither so bloody, nor their cruelties so great, as
those of the North American Indian. They slay all they meet with of
their enemies, men, women, and children; but this is common to all
wild tribes. They have an implacable spirit of revenge as long as the
war lasts, retort evil for evil, and retaliate life for life: and as I have
before said, the heads are the trophies, as the scalps are to the red
men. But on the contrary, they never torture their enemies, nor do
they devour them, and peace can always be restored amongst them
by a very moderate payment. In short, there is nothing new in their
feelings or in their mode of showing them, no trait remarkable for
cruelty, no head hunting for the sake of head hunting. They act
precisely on the same impulses as other wild men: war arises from
passion or interest, peace from defeat or fear. As friends they are
faithful, just, and honest; as enemies, bloodthirsty and cunning;
patient on the war path, and enduring fatigue, hunger, and the want
of sleep with cheerfulness and resolution. As woodmen, they are
remarkably acute, and on all their excursions carry with them a
number of ranjows, which, when they retreat, they stick in behind
them at intervals at a distance of twenty, fifty, or a hundred yards, so
that a hotly-pursuing enemy gets checked, and many severely
wounded. Their arms consist of a sword, an iron-headed spear, a
few wooden spears, a knife worn at the right side, with a sirih pouch
or small basket. Their provision is a particular kind of sticky rice
boiled in bamboos. When once they have struck their enemies, or
failed, they return without pausing to their homes.”
Among the Dayaks and the Samoans heads are the precious war
trophies; among the Indians of North America the scalp alone
suffices; the Tinguian of the Philippine Islands, with a refinement of
barbarism far excelling his brother savage, must have his enemy’s
brains. While La Gironiere was sojourning at Palan, one of the
seventeen villages of which Tinguia is composed, news arrived that
a battle had been fought and several renowned warriors captured.
Therefore there was to be a brain feast.
“Towards eleven o’clock the chiefs of the town, followed by all the
population, directed their steps towards the large shed at the end of
the village. There every one took his place on the ground, each party
headed by its chiefs, occupying a place marked out for it beforehand.
In the middle of the circle formed by the chiefs of the warriors were
large vessels full of basi, a beverage made with the fermented juice
of the sugar-cane, and four hideous heads of Guinans entirely
disfigured,—these were the trophies of the victory. When all the
assistants had taken their places, a champion of Laganguilan y
Madalag, took one of the heads and presented it to the chiefs of the
town, who showed it to all the assistants, making a long speech
comprehending many praises for the conquerors. This discourse
being over, the warrior took the head, divided it with strokes of his
hatchet, and took out the brains. During this operation so unpleasant
to witness, another champion got a second head and handed it to
the chiefs; the same speech was delivered, then he broke the skull
to pieces in like manner and took out the brains. The same was done
with the four remaining skulls of the subdued enemies. When the
brains were taken out, the young girls pounded them with their
hands into the vases containing the liquor of the fermented sugar-
cane; they stirred the mixture round, and then the vases were taken
to the chiefs, who dipped in their small osier goblets through the
fissures of which the liquid part ran out, and the solid part that
remained at the bottom they drank with ecstatic sensuality. I felt quite
sick at this scene so entirely new to me. After the chieftains’ turn
came the turn of the champions. The vases were presented to them
and each one sipped with delight this frightful drink, to the noise of
wild songs. There was really something infernal in this sacrifice to
victory.
“We sat in a circle, and these vases were carried round. I well
understood that we were about undergoing a disgusting test. Alas! I
had not long to wait for it. The warriors planted themselves before
me and presented me with the basi and the frightful cup. All eyes
were fixed upon me. The invitation was so direct that to refuse it
would perhaps be exposing myself to death. It is impossible to
describe the interior conflict that passed within me. I would rather
have preferred the carbine of a bandit five paces from my chest, or
await, as I had already done, the impetuous attack of the wild
buffalo. I shall never forget that awful moment; it struck me with
terror and disgust; however, I constrained myself, nothing betraying
my emotion. I imitated the savages, and dipping the osier goblet into
the drink, I approached it to my lips and passed it to the unfortunate
Alila (Gironiere’s servant and companion), who could not avoid this
infernal beverage. The sacrifice was complete, the libations were
over, but not the songs. The basi is a very spirituous and inebriating
liquor, and the assistants who had partaken rather too freely of it
sang louder to the noise of the tom-tom and the gong, while the
champions divided the human skulls into small pieces destined to be
sent as presents to all their friends. The distribution was made during
the sitting, after which the chiefs declared the ceremony over. They
then danced. The savages divided themselves into two lines, and
howling as if they were furious madmen, or terribly provoked, they
jumped about, laying their right hand upon the shoulder of their
partners and changing places with them. These dances continued all
day; at last night came on, each inhabitant repaired with his family
and some few guests to his abode, and soon afterwards tranquillity
was restored.”
In defending the system of warfare practised by the Dayaks,
Rajah Brooke specially instances the thirst for blood and general
cruelty evinced by the savage Indian warrior of North America. Like
other barbarians the North-American Indian has his European and
American champions—Catlin among the latter—who profess to see
in this savage nothing vile or mean or cruel, but, on the contrary, all
that is brave, generous, and hospitable. The said champions,
however, overlook the fact that bravery and generosity as exhibited
amongst one’s friends are but insignificant virtues as compared with
what they are when displayed towards an enemy; indeed, in the
former case they may scarcely be reckoned virtues at all, but merely
social amenities, lacking which, man ceases to be companionable.
As enemies, how do North-American savages treat each other? Let
what has already been said on this subject in these pages, as well
as what here follows, furnish an answer to the question.
 CHAPTER XXII.

Wooing a war dream—Companions in arms—The squaw of sacrifice

—On the march—Bragging warriors—Deeds of Indian men of war
—Swallowing an Indian’s horse—The belle of the party—An
instance of Indian heroism—How to serve an enemy—Savage
Duelists—A story of a precious scalp—The Indian warrior’s
confidence in dreams—Concerning Indian canoes—A boat made
up with stitches—Women boat-builders—Samoan warfare—The
Samoans’ war tools and symbols—A narrow escape—“Perhaps
upward the face!”—A massacre of Christians—Treachery of the
Pine Islanders—The fate of “The Sisters”—The scoundrelly
Norfolk Island men—A little story told by Mr. Coulter—The useful
carronades—The “one unnecessary shot”—How it might have
been.
r. Kohl informs us that, when a chief of the North-
American Indians is meditating a war expedition, it is
of the first importance that he should “dream” about it.
He does not, however, choose to wait for his dream in
the ordinary manner, but seats himself for the express purpose,
concentrates his every thought on the subject, and seeks to gain
good dreams for it before he proceeds to carry his war project into
execution.
He keeps apart from his family, and, like a hermit, retires to a
solitary lodge built expressly for the purpose. There he sits whole
evenings on a mat, beating the drum and muttering gloomy magic
songs, which he will break off to sigh and lament. He has all sorts of
apparitions while lying in his bed; the spirits of his relatives murdered
by the enemy visit him, and incite him to revenge. Other spirits come
and show him the way into the enemy’s camp, promise him victory,
tell him at times accurately where and how he will meet the foe and
how many of them he will kill. If his drum and song are heard
frequently in the evenings, a friend will come to him, and sitting down
on the mat by his side will say: “What is the matter with thee, Black
Cloud? Why dreamest thou? What grief is oppressing thee?” The
Black Cloud then opens his heart, tells him how his father’s brother
was scalped three years back by their hereditary enemies, the Sioux,
his cousin last year, and so on, and how thoughts of his forefathers
has now come to him. They have often appeared to him in his
dreams and allowed him no rest with their entreaties for vengeance.
He will tell him, too, a portion of the auguries and signs he has
received in his dream about a brilliant victory he is destined to gain
and of the ways and means that will conduct him to it. Still only a
portion, for he generally keeps the main point to himself. It is his
secret, just as among us the plan of the campaign is the
commander-in-chief’s secret.
The friend, after listening to all this, if the affair seems promising,
will take to the drum in his turn, and aid his friend with his dreams.
The latter, if placing full confidence in him, appoints him his
associate or adjutant, and both place themselves at the head of the
undertaking. They always consider it better that there should be two
leaders, in order that if the dreams of one have not strength enough
the other may help him out.
These two chefs-de-guerre now sit together the whole winter
through, smoke countless pipes, beat the drum in turn, mutter magic
songs the whole night, consult over the plan of operations, and send
tobacco to their friends as an invitation to them to take part in the
campaign. The winter is the season of consultation, for war is rarely
carried on then, partly because the canoe could not be employed on
the frozen lakes, and partly because the snow would betray their trail
and the direction of their march too easily.
If the two are agreed on all points, if they have assembled a
sufficient number of recruits and allies, and have also settled the
time of the foray—for instance, arranged that the affair shall begin
when the leaves are of such a size, or when such a tree is in
blossom, and this time has at length arrived, they first arrange a
universal war dance with their relatives and friends, at which the
women are present, painted black like the men. The squaws appear
at it with dishevelled hair, and with the down of the wild duck strewn
over their heads. A similar war dance is also performed in the lodges
of all the warriors who intend to take part in the expedition.
 If the undertaking and the band of braves be at all important, it is
usually accompanied by a maiden, whom they call “the squaw of
sacrifice.” She is ordinarily dressed in white: among the Sioux, for
instance, in a white tanned deer or buffalo robe, and a red cloth is
wrapped round her head. Among several prairie tribes, as the Black-
feet, this festally adorned sacrifice squaw leads a horse by the bridle,
which carries a large medicine-bag, and a gaily decorated pipe.
Among the Ojibbeways, who have no horses, and usually make their
expeditions by water, this maiden is seated in a separate canoe.
When all have taken their places in full war-paint, they begin their
melancholy death-song and push off.
If the expedition is really important—if the leader of the band is
very influential—he will have sent tobacco to other chiefs among his
friends; and if they accept it, and divide it among many of their
partisans, other war bands will have started simultaneously from the
villages, and come together at the place of assembly already
arranged.
They naturally take with them as little as possible, and are mostly
half naked in order to march easily. They do not even burden
themselves with much food, for they starve and fast along the road,
not through any pressure of circumstances, but because this fasting
is more or less a religious war custom.
They also observe all sorts of things along the road, which are in
part most useful, precautionary measures, in part superstitious
customs. Thus, they will never sit down in the shade of a tree, or
scratch their heads, at least not with their fingers. The warriors,
however, are permitted to scratch themselves with a piece of wood
or a comb.
The young men who go on the war trail for the first time, have, like
the women, a cloth or species of cap on the head, and usually walk
with drooping head, speak little, or not at all, and are not allowed to
join in the dead or war songs. Lastly, they are not permitted to suck
the marrow from the bone of any game that is caught and eaten
during the march. There are also numerous matters to be observed
in stepping in and out of the canoes on the war trail. Thus, the foot
must not on any condition be wetted.
The only things they carry with them, besides their arms and
pipes, are their medicine-bags. These they inspect before starting,
as carefully as our soldiers do their cartridge-boxes, and place in
them all the best and most powerful medicines, and all their relics,
magic spells, pieces of paper, etc., in order that the aid of all the
guardian spirits may be ensured them.
The same authority gives us a sample of Indian war dances and
speeches:
“By the afternoon all were ready, and the grand pipe of peace,
they intended to hand to the great father, was properly adorned with
red feathers, blue drawings, strings of wampum, etc.
“It occurred to me that although it was after all but a ceremony, the
Indians regarded the matter very solemnly and earnestly. According
to traditional custom the pipe of peace passed from tent to tent and
from mouth to mouth among the warriors. When each had smoked,
the procession started and marched with drums beating, fluttering
feather-flags and flying-otter, fox, and skunk tails through the village,
to the open space before the old fort of the North West Company.
Here they put up a wooden post, and close to it their war flag, after
which the dances, speeches, and songs began.
“A circle of brown skinned dancers was formed, with the
musicians and singers in the centre. The musicians, a few young
fellows, cowered down on the ground, beat a drum, and shook a
calabash, and some other instruments, which were very primitive.
One had only a board, which he hammered with a big knife, while
holding his hollow hand beneath it as a species of sounding board.
The principal singers were half a dozen women wrapped up in dark
cloaks, who uttered a monotonous and melancholy chant, while
keeping their eyes stedfastly fixed on the ground. The singing
resembled the sound of a storm growling in the distance. To the
music the warriors hopped round in a circle, shaking the otter, fox,
and beaver tails attached to their arms, feet, and heads.
 “At times, the singing and dancing were interrupted; adorned with
flying hair and skins, a warrior walked into the circle, raised his
tomahawk, and struck the post a smart blow, as a signal that he was
going to describe his hero deeds. Then he began to narrate in a loud
voice, and very fluently, some horrible story in which he had played
the chief part. He swung the tomahawk, and pointed to the scars and
wounds on his naked body in confirmation of his story, giving the
post a heavy blow now and then. Many had painted their scars a
blood-red colour, and their gesticulations were most striking when
they described the glorious moment of scalping. Although
surrounded by many kind interpreters, who translated all that was
said at once into English or French, I fear it would lead me too far
were I to write down all that was said. Here is a specimen, however:
—
“Many speeches were begun in a humorous fashion. One little
fellow bounded into the circle, and after striking the post, went on,
‘My friends, that I am little you can all see, and I require no witnesses
to that. But to believe that I, little as I am, once killed a giant of a
Sioux, you will need witnesses.’ And then he plucked two witnesses
out of the circle. ‘You and you were present;’ and then he told the
story just as it had occurred. Another with a long rattlesnake’s skin
round his head, and leaning on his lance, told his story objectively,
just as a picture would be described:
“‘Once we Ojibbeways set out against the Sioux. We were one
hundred. One of ours, a courageous man, a man of the right stamp,
impatient for distinction, separated from the others, and crept onward
into the enemy’s country. The man discovered a party of the foe, two
men, two women, and three children. He crept round them like a
wolf, he crawled up to them like a snake, he fell upon them like
lightning, cut down the two men and scalped them. The screaming
women and children he seized by the arm and threw them as
prisoners to his friends who had hastened up at his war yell; and this
lightning, this snake, this wolf, this man, my friends, that was I. I
have spoken.’
 North American Weapons.
“In most of the stories told us, however, I could trace very little that
was heroic. Many of them, in fact, appeared a description of the way
in which a cunning wolf attacked and murdered a lamb.
“One of the fellows, with one eye painted white, the other coal-
black, was not ashamed to tell loudly, and with a beaming face, how
he once fell upon a poor solitary Sioux girl and scalped her. He gave
us the minutest details of this atrocity, and yet at the end of his
harangue, he was applauded, or at least behowled, like the other
orators. All the Indians stamped and uttered their war yell as a sign
of applause, by holding their hands to their mouths trumpet fashion.
At the moment the man appeared to me little less ferocious than a
tiger, and yet when I formed his acquaintance at a latter date, he
talked most reasonably and calmly like an honest farmer’s lad. Such
are what are called the contradictions in human nature.
“Very remarkable in all these harangues, was the unconcealed
and vain self-laudation each employed about himself. Every speaker
considered his deed the best and most useful for the whole nation.
Each began by saying that what his predecessors had told them was
very fine, but a trifle when compared with what he had to say about
himself. It was his intention to astonish them once for all. His totem
was the first in the whole land, and the greatest deeds had always
been achieved by the spotted weasels (or as the case may be) and
so he, the younger weasel, not wishing to be the inferior to his
forefathers, had gone forth and performed deeds the description of
which would make their hair stand on end,” etc.
Among other tribes of North-American warriors, the braves were
armed with small tomahawks, or iron hatchets, which they carried
with the powder-horn in the belt on the right side, while the long
tobacco pouch of antelope skin hung by the left side. Over their
shoulders were leather targets, bows and arrows, and some few had
rifles—both weapons were defended from damp in deer-skin cases
—and quivers with the inevitable bead-work, and the fringes which
every savage seems to love.
Speaking of an army of Indian warriors “shifting camp,” Burton
says, in his curious book “The City of the Saints”:—“Their nags were
lean and ungroomed; they treat them as cruelly as do the Somal; yet
nothing short of whiskey can persuade the Indian warrior to part with
a favourite steed. It is his all in all,—his means of livelihood, his
profession, his pride. He is an excellent judge of horse-flesh, though
ignoring the mule and ass; and if he offers an animal for which he
has once refused to trade, it is for the reason that an Oriental takes
to market an adult slave—it has become useless. Like the Arab, he
considers it dishonourable to sell a horse: he gives it to you,
expecting a large present, and if disappointed he goes away
grumbling that you have swallowed his property.
“Behind the warriors and braves followed the baggage of the
village. The lodge-poles in bundles of four or five had been lashed to
pads or packsaddles girthed tight to the ponies’ backs, the other
ends being allowed to trail along the ground like the shafts of a truck.
The sign easily denotes the course of travel. The wolf-like dogs were
also harnessed in the same way; more lupine than canine, they are
ready when hungry to attack man or mule; and sharp-nosed and
prick-eared, they not a little resemble the Indian pariah dog. Their
equipments, however, were of course on a diminutive scale. A little
pad girthed round the barrel with a breastplate to keep it in place,
enabled them to drag two short light lodge-poles tied together at the
smaller extremity. One carried only a hawk on its back; yet falconry
has never, I believe, been practised by the Indian. Behind the ponies
the poles were connected by cross sticks upon which were lashed
the lodge-covers, the buffalo robes, and other bulkier articles. Some
had strong frames of withes or willow basket-work, two branches
being bent into an oval, garnished below with a network of hide-
thongs for a seat, covered with a light wicker canopy, and opening
like a cage only on one side; a blanket or a buffalo robe defends the
inmate from sun and rain. These are the litters for the squaws when
weary, the children and the puppies, which are part of the family till
used for beasts. It might be supposed to be a rough conveyance; the
elasticity of the poles, however, alleviates much of that
inconvenience. A very ancient man, wrinkled as a last year’s walnut,
and apparently crippled by old wounds, was carried probably by his
great-grandsons in a rude sedan. The vehicle was composed of two
pliable poles, about ten feet long, separated by three cross-bars
twenty inches or so apart. In this way the Indians often bear the
wounded back to their villages. Apparently they have never thought
of a horse litter, which might be made with equal facility, and would
certainly save work.
“Whilst the rich squaws rode, the poor followed their pack-horses
on foot, eyeing the more fortunate as the mercer’s wife regards what
she terms the carriage lady. The women’s dress not a little
resembles their lords’—the unaccustomed eye often hesitates
between the sexes. In the fair, however, the waistcoat is absent, the
wide-sleeved skirt extends below the knees, and the leggings are of
somewhat different cut; all wore coarse shawls, or white, blue, or
scarlet cloth-blankets around their bodies. Upon the upper platte, we
afterwards saw them dressed in cotton gowns after a semi-civilized
fashion, and with bowie knives by their sides. The grandmothers
were fearful to look upon; horrid excrescences of nature, teaching
proud man a lesson of humility. The middle aged matrons were
homely bodies, broad and squat like the African dame after she has
become mère de famille; their hands and feet are notably larger from
work than those of the men, and the burdens upon their back caused
them to stoop painfully. The young squaws—pity it is that all our
household Indian words, papoose for instance, tomahawk, wigwam,
and powwow, should have been naturalised out of the Abenaki and
other harsh dialects of New England—deserved a more euphonious
appellation. The belle savage of the party had large and languishing
eyes and teeth that glittered, with sleek long black hair like the ears
of a Blenheim spaniel, justifying a natural instinct to stroke or pat it,
drawn straight over a low broad quadroon-like brow. Her figure had
none of the fragility which distinguishes the higher race, who are
apparently too delicate for human nature’s daily food. Her ears and
neck were laden with tinsel ornaments, brass wire rings adorned her
wrists and fine arms, a bead-work sack encircled her waist, and
scarlet leggings fringed and tasselled, ended in equally costly
mocassins. When addressed by the driver in some terms to me
unintelligible, she replied with a soft clear laugh—the principal charm
of the Indian, as of the smooth-throated African woman—at the
same time showing him the palm of her right hand as though it had
been a looking-glass. The gesture I afterwards learned simply
conveys a refusal. The maidens of the tribe, or those under six, were
charming little creatures with the wildest and most piquant
expression, and the prettiest doll-like features imaginable; the young
coquettes already conferred their smiles as if they had been of any
earthly value. The boys had black beady eyes like snakes, and the
wide mouths of young caymans. Their only dress when they were
not in birthday suit was the Indian laguti. None of the braves carried
scalps, finger-bones, or notches on the lance, which serve like
certain marks on saw-handled pistols further east, nor had any man
lost a limb. They followed us for many a mile, peering into the hinder
part of our travelling wigwam, and ejaculating “How, How,” the
normal salutation.”
Here is an instance at once of Indian warrior heroism on the one
side and fiendish ferocity on the other that occurred at the late
engagement between a small war party of the Chippewas and a
greatly superior party of Sioux, near Cedar Island Lake. The
Chippewas, who were en route for a scalping foray upon the Sioux
villages on the Minnesota, here fell into an ambuscade, and the first
notice of danger which saluted their ears was a discharge of fire-
arms from a thicket. Four of their number fell dead in their tracks.
Another, named the War Cloud, a leading brave, had a leg broken by
a bullet. His comrades were loth to leave him, and, whilst their
assailants were reloading their guns, attempted to carry him along
with them to where they could gain the shelter of a thicket a short
distance to the rear. But he commanded them to leave him, telling
them that he would show his enemies how a Chippewa could die.