Psychiatric Interviewing The Art of Understanding A Practical Guide For Ebook PDF Version
Psychiatric Interviewing The Art of Understanding A Practical Guide For Ebook PDF Version
Psychiatric Interviewing The Art of Understanding A Practical Guide For Ebook PDF Version
Chapter 15 Understanding and Effectively Engaging People With Difficult Personality Disorders
Introduction to Object Relations and Self Psychology
The Four Developmental Stages of the Self and Their Clinical Applications
References
References
Section 1: Risk Factors, Warning Signs, and Protective Factors: Their Role in the Clinical Formulation of Risk
Concluding Comments
References
Conclusion
References
To the Reader
References
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Chapter 20 Culturally Adaptive Interviewing
Introduction: A Reason to Be
Part 3: Developing and Utilizing Cultural Literacy to Engage Patients and to Better Understand the Complexity of Their
Problems
Part 4: Cultural Disconnects – How to Prevent Them Before They Occur, Recognize Them as They Occur, and Transform
Them Once They Occur
Part 5: Practical Tips for Exploring Religion, Spirituality, and Framework for Meaning
References
References
Motivational Interviewing
References
Part 5: Practical Interviewing Techniques and Strategies for Enhancing Medication Interest and Use
References
Appendix I An Introduction to the Facilic Schematic System – A Shorthand for Supervisors and
Supervisees (Interactive Computer Module)
Background and Foundation
Interactive Exercises for Consolidating the Understanding and Use of Facilic Shorthand
References
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Appendix III The Written Document/Electronic Health Record (EHR): Effective Strategies
Appendix IIIA Practical Tips for Creating a Good EHR/EMR Document
Appendix IIIB Prompts and Quality Assurance Guidelines for the Written Document
Index
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Praise for Psychiatric Interviewing, 3rd Edition
“Readers of this book, whether beginning students or wizened clinicians with decades of
experience, will find much that is innovative. . . . . I had the pleasure of running across Shea's
interviewing strategy for uncovering suicidal ideation, behaviors, and intent (the Chronological
Assessment of Suicide Events – CASE Approach) years ago. . . . . In this book readers will find a
remarkably compelling and practical introduction to the effective use of the CASE Approach. Shea's
subsequent video demonstrations of the CASE Approach are, in my opinion, unparalleled in the
history of mental health training. I have never seen such great teaching videos on eliciting suicidal
ideation. They are a treasure, and I believe that many lives will be saved by those lucky enough to
view them.”
“Dr. Shea has done the impossible – written a text that works for bachelors, masters, and doctoral
level social workers. Throughout the text, Shea integrates cultural humility, the client perspective,
clinical wisdom, and the best that research has to offer. His writing is authoritative yet accessible.
The accompanying videos are the most amazing instructional videos I've ever seen – they include
mini-lectures, video of an actual client interview, and wondrously realistic role-plays (which invite
you into the mind of a master) and speak directly to the content in the text. Instructors will treasure
the text because it covers everything that needs to be covered and is presented in a way that
inspires the reader to learn the material. I hate to say it, but a medical doctor has written the best
social work interviewing text on the market. I hope this text gets adopted in every school of social
work.”
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cultural principles for students – while modeling numerous immediately useful questions and
strategies – he provides examples of clinician/client dialogue in which the student can actually see
the interviewer gracefully transforming awkward cultural disconnects. I've never seen anything quite
like it in the clinical literature. Simply superb! PS: Year after year my master level counseling
students have raved – and I mean raved – about Shea's textbook, and this Third Edition looks to be
even better! I know of no book that better prepares a student for actual clinical practice.”
Former Director of Student Affairs for the Clinical Mental Health Counseling
Program at Antioch University New England
“In this highly readable and engaging book, psychiatric nursing students learn the principles and
techniques of conducting fluid and individualized assessments. We have been using the second
edition of this book for over a decade at our school, and it has been an indispensable resource for
both our faculty and our students. This 3rd Edition has been revised and expanded including
fascinating new chapters on topics such as wellness, motivational interviewing, cultural diversity and
how to collaboratively talk with patients about their medications. Many of the chapters are enriched
with engrossing video demonstrations (be sure to watch the video on eliciting suicidal ideation, it
brings the practical art of suicide assessment alive). I can't recommend this book enough. It will
infuse passion and curiosity in your students. It will be a resource they will return to for learning for
years to come.”
“Both of the previous editions of Dr. Shea's book have anchored Bryn Mawr's advanced clinical
social work practice curriculum for a generation of our master's degree students. This third edition is
a masterful integration of text and video instruction. Indeed, it represents a pedagogical leap, in
which Dr. Shea brings the beginning and advanced student into the mysteries of the first encounter
with his characteristic warmth, compassion, and wisdom that has so enthralled our students over
the years. Only now, we can see it, not only in engaging text, but in amazingly effective video
instruction and interview demonstrations, that bring to life the clinical encounter. Shea models for
students the core interviewing skills, the advanced practice competencies, and the guiding ethical
behaviors that are the foundations of all helping professions. With the publication of this book, I
personally believe that Dr. Shea has cemented his standing as one of the most influential mental
health educators of the 21st Century.”
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Here is a book I would enthusiastically recommend to all graduate students in psychology on the art
of clinical interviewing and to all faculty who teach such courses. Shea's book provides a highly
satisfying introduction to the core principles of clinical interviewing but much more. It also, with a
refreshingly informal writing style, provides a sophisticated journey into advanced interviewing
techniques and strategies as needed in the real world of clinical practice. Even the most
experienced clinician will enjoy and learn much from this text. I don't believe I've ever seen an
author capture the pain of patients dealing with serious disorders such as major depression,
schizophrenia, and bipolar disorder with such sensitivity and compassion, while transforming this
understanding into easily learned questions and techniques for use in actual practice. Combine this
sensitive and comprehensive approach with Shea's skillful use of advanced technology (over 7
hours of streaming video modules and interviewing demonstrations) and you have a book, whose
shelf-life will be measured not in years, but decades.”
and Communities
Principle Investigator: Use of iPad Assisted Learning for Autism
Interviewing skills are not only indispensable, they are the rate-limiting factor in providing quality
care. In the 3rd Edition of Dr. Shea's classic text, we now have an indispensable book to match the
training needs of our psychiatric residents (indeed, of our trainees in any mental health discipline).
As a forensic specialist, let me focus on Shea's chapters devoted to exploring suicidal ideation and
violent ideation. Using Shea's interviewing principles, especially the Chronological Assessment of
Suicide Events (CASE Approach), clinicians will be able to render the best possible care, often
exceeding the standard of care. The skills delineated within these chapters should, in my opinion,
be taught in all psychiatric residency programs. Every resident should buy and read this entire book
before taking his or her first night of call. Every resident. In fact, I recommend reading it twice. I
almost forgot to mention, Shea's extraordinary streaming videos will thrust this book to the forefront
of web-based learning. Trust me on this point. They're fabulous.
Professor of Psychiatry
“While reading the pages of this wonderful book, I kept wishing I could have held this book in my
hands when I was a psychiatric resident. Dr. Shea's stand-out chapters on personality dysfunction
(from DSM-5 differential diagnosis to the effective application of object relations and self
psychology) are suffused with an understanding of the pain experienced by patients with personality
disorders, and the confusion and intensity they can stir-up in the interviewer. Using Shea's
techniques, clinicians will feel competent at steering through the most turbulent and treacherous of
interpersonal eddies in order to connect with and help these patients. Readers of this highly
engaging, ground-breaking book, and viewers of its over 7 hours of stunning videos, will be able to
become the clinicians their patients deserve, the ones they were meant to be.”
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Laura Miller, M.D.
“This book is a gift – an extraordinary gift – to the field of clinical social work. Its sophisticated yet
delightfully readable text and its brilliantly conceived and executed streaming video, combine to
create the single most practical and enjoyable clinical textbook that I've ever read. Unlike other
books that focus only on what needs to be addressed, Dr. Shea teaches the how and he does so
with unmatched insight, clarifying intensity, a self-effacing humor, a contagious warmth, and a
genuine sense of mission. The wealth of comprehensive topics explored, ranging from DSM-5
differential diagnosis to uncovering domestic violence and suicide, sensitively exploring psychotic
process, and advanced diversity counseling, make this more than a book or a course – it is a virtual
traineeship. It provides social workers and other mental health professional with an opportunity to
learn from one of the greatest innovators in the history of clinical interviewing. You'll never have a
book that you highlight more. In fact, it's probably simpler to highlight what you don't want to
emphasize. You'll save ink.”
“Using a rich palette of information from various fields, including psychoanalysis, behavioral
psychology, and sociology, the author writes about the entire interview, and reveals the rich
interaction that begins even before the first words are spoken. . . . . It is no surprise that this book
has been well received by major psychiatric journals. However, it is always a pleasant surprise to
find an engaging book that is both theoretically sound and clinically indispensable.”
Doody's Book Reviewer
“This is a book I wish I could have written. . . . . can be read with interest by expert and novice
alike.”
“Rich in information, wisdom, humor, and charm, this book teaches not only interviewing skills but
also the attitudes and behaviors that underpin the therapeutic personality and process.”
American Journal of Psychiatry
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“Intensely practical, with a riveting chapter on the assessment of risk for suicide and homicide. . . . .
Reviewers have a way of telling you that a good book is essential for every psychiatric library. This
time it really is true.”
Canadian Journal of Psychiatry
“Shea's book, which is now in its second edition, is a valuable counter-weight to the ‘one size fits all’
approach to interviewing and eliciting data. It is an invaluable book for those training in psychiatry or
other mental health professions and indeed for practicing clinicians.”
Australian and New Zealand Journal of Psychiatry
“Rich with sensitive observations and practical suggestions and enlivened by frequent examples of
diagnostic interviewing.”
Transactional Analysis Journal
“A marvelous text on an aspect of psychiatry that often does not receive as much attention as it
deserves.”
Hospital and Community Psychiatry
“Year in and year out, one of the most popular, if not most popular, required textbooks for our
master level students in counseling. Superbly practical yet filled with a sense of compassion.”
“For mental health professionals this book is a must read. The writing style is fluid, fast paced, and
stimulating. I recommend it without hesitation to all nurses and nursing students.”
“Practical, sensitive, and comprehensive. . . . . The chapter on handling resistance and awkward
questions provides a wealth of practical suggestions for students in mental health from social work
to psychiatry.”
“This beautiful and immensely useful book is a great gift. It should stand as the best starting clinical
text for all mental health professionals. . . . . I predict that beginning clinicians, and many
experienced ones, too, will return to this book the way people return to the books they find deepest
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and most evocative, reading a few pages at a time, to be savored and enjoyed, so its wisdom enters
our bones.”
“A highly crafted book on interviewing which impressed me with the remarkable ways in which it is
truly comprehensive. The chapter on personality assessment is a rich blend of gathering valid
diagnostic data while simultaneously attending to the patient's feelings and needs. It is a remarkable
introduction to the assessment and diagnosis of personality disorders.”
“Dr. Shea deserves congratulations for writing an engaging book on a fascinating, but difficult
subject. The text demonstrates the creativity and flexibility Dr. Shea values as integral to the
process of interviewing. There is much here for the beginning clinician from a variety of disciplines,
but the rewards for the more experienced interviewer are equally apparent. This book is not just
informative, it challenges the reader to reflect on his or her own interviewing style and technique.”
“This book is rich with case presentations, vivid clinical dialogues, theoretical eclecticism, personal
wit, clinical acumen, and undeniable readability. I can't think of any other book that my graduate
students enjoy as much, or talk about with more enthusiasm. In my view Psychiatric Interviewing:
the Art of Understanding, 2nd Edition is unequivocally the best beginning text for mental health
professionals, no matter what their discipline.”
“The mental health counselor rarely finds psychiatric literature that bridges the traditional differences
of theoretical orientation and practice. Dr. Shea has carefully and sensitively responded to the
needs of all mental health professionals, providing careful examination of psychopathology,
diagnosis and resistance that is refreshing for the non-psychiatrically trained mental health
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counselor.”
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Copyright
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher's permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
ISBN: 978-1-4377-1698-6
E-ISBN: 978-1-4377-3782-0
Inkling ISBN: 978-0-323-32901-9
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
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19
Dedication
to open it,
and
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Foreword
It has been my privilege to train and supervise young mental health professionals from many
disciplines for over 50 years. I can say that doing so has been one of the great joys of my life. I can
also safely say that you are holding in your hands one of the most remarkable books I have had the
pleasure to read in all of those years. Enormously practical, elegant in execution and delightfully
fun to read, every page holds clinical wisdom.
Shea has an almost uncanny ability to genuinely perceive the complexities of clinical
interviewing, while creating frameworks that illuminate, clarify, and simplify those complexities so
that young clinicians can actually apply them. And he accomplishes this challenging task with a
self-effacing humor and a refreshing sense of compassion that combine to shed a vibrant brilliance
on our art. I can think of no better first book for any trainee in mental health, for it is not only, in my
opinion, an unsurpassed book about how to interview, it is a book about why we interview. It is a
book that captures the wonderment of our work and the soul of our mission.
It is also my opinion, that you are holding in your hands the textbook of tomorrow, today. Shea's
graceful integration of over 7.5 hours of streaming video throughout the text provides every
psychiatric resident and graduate student the chance to see a truly talented interviewer at work
undertaking tasks as complex as exploring sensitive and taboo topics to uncovering suicidal
ideation and intent. If this were not enough, the viewer also gets the chance to watch and hear Shea,
one of the most dynamic speakers in our field today, discuss these interview excerpts, powerfully
consolidating what the student has just read in the text while providing new nuances and insights
not even mentioned in the text. It is a stunning wedding of innovative educational theory with
today's revolutionary technology. As the student enters their clinical rotations, and ultimately, as
they leave their residency and graduate programs to secure their first jobs, they can return to these
videos, stream them on their laptops, tablets, and smart phones, wherever they are and whenever
they choose. The video illustrations of the book will always be available to them in the palm of their
hands.
Readers of this book, whether beginning students or wizened clinicians with decades of
experience, will find much that is innovative. Indeed, Shea's innovations, in my opinion, have been
pivotal in shaping how interviewing is both done and taught across disciplines. I had the pleasure
of running across Shea's interviewing strategy for uncovering suicidal ideation, behaviors, and
intent (the Chronological Assessment of Suicide Events – CASE Approach) years ago and promptly
invited him to write an article about it in the Psychiatric Annals.
As the years have passed, the CASE Approach has become one of the most respected approaches
for eliciting suicidal ideation in the world, as reflected by its being chosen as a recommended
strategy by the Zero Suicide Initiative and its selection for the Best Practices Registry from the
Suicide Prevention and Resource Center (SPRC). In this book readers will find a remarkably
compelling and practical introduction to the effective use of the CASE Approach. Shea's subsequent
video demonstrations of the CASE Approach are, in my opinion, unparalleled in the history of
mental health training. I have never seen such great teaching videos on eliciting suicidal ideation.
They are a treasure, and I believe that many lives will be saved by those lucky enough to view
them.
I was pleased to see that Shea's numerous other innovations are equally expertly reviewed and
updated in this edition. His internationally respected supervision system for helping trainees to
create fluid and naturalistic interviews, known in the clinical interviewing literature as the study of
facilics, is beautifully updated in this edition, including an interactive web program. An entire
chapter has been dedicated to the topic of “validity techniques,” a field of study first delineated by
Shea years ago for helping patients to share sensitive and taboo material such as incest, domestic
violence, and substance abuse. And, as a bonus, for any clinicians who prescribe medications, there
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is a chapter on Shea's Medication Interest Model (MIM) as the model is applied to psychiatric
medications. If not familiar with the MIM, it is a collaborative model of talking with patients about
their medications. In this chapter, the reader will find over 40 specific interviewing techniques that
help patients make wise decisions about whether or not medications are a good choice for them and
can help clinicians to effectively motivate patient interest in using those medications once chosen. I
have been intimately involved in the study and use of medications for decades, and I was fascinated
by the principles and techniques delineated in this chapter. I have a feeling that the MIM will
someday be as important in the field of improving medication adherence as the CASE Approach
has become to uncovering suicidal ideation.
On a final note, Shea is not only a great innovator – he is a wonderful explicator of the ideas and
concepts of others. In short, he is a natural born teacher. His eloquent mastery of language and his
well-timed wit brings the work of others to life for readers. Two examples will demonstrate my
point. Shea has had nothing to do with the development of motivational interviewing (Chapter 22),
yet his chapter on motivational interviewing is a remarkably succinct and penetrating introduction
to its use. I would recommend it to anyone as a first introduction to the subject. Likewise, Shea's
introduction to object relations and self psychology (Chapter 15) is a wonderful monograph on the
topic. He brings to life some of the traditionally most difficult concepts in the field of
psychodynamic therapy. I feel quite confident that his chapter will delight and fascinate new
trainees, who I find have a genuine hunger for learning more about psychodynamic thought. Such
students will be hard pressed to find a more practical and compelling introduction to the topic.
In closing, I have always been a believer that every minute counts in this life. I believe that if one
values every moment, one essentially stretches life. I close with this thought because I realize that
time is at a great premium in our contemporary lives. I just want to reassure any faculty that require
this book, and any students that read it, that every minute spent in its pages will be worth it. Every
minute will count. And every minute will not only benefit you but all the future patients that your
caring will touch.
Jan Fawcett M.D.
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Foreword to the 2nd Edition
This beautiful and immensely useful book is a great gift. It should stand as the best starting clinical
text for all mental health professionals, because the ultimate success of our clinical interventions is
determined directly by the information we must sensitively garner from the interview. Einstein
remarked that in early sciences, examples serve better than concepts; indeed, they form the earliest
concepts. Shea introduces the beginning clinician to the work by means of concrete situations and
particular examples of actual clinical dialogue. There could be no sounder starting point. Later, I
predict, beginning clinicians, and many experienced ones, too, will return to this book the way
people return to the books that they find deepest and most evocative, reading a few pages at a time,
to be savored and enjoyed, so its wisdom enters their bones.
The book starts where all interviewers start, in the dark, knowing that they must gently feel their
way. This is a necessity not only because valid psychological data are extremely difficult to secure
but also because our first job is to establish an effective relationship to carry on the work. In other
words, Shea takes the interview with deep seriousness, which is the same as taking the relationship
seriously and the importance of uncovering valid findings.
On the other hand, in a particularly refreshing light, Shea does not take himself too seriously. He
draws our attention to his own mistakes, reflecting on them with a gentle humor, demonstrating
directly what can be learned from them. No better model for learning could be demonstrated for the
beginning, and often frightened student, allowing the student immediately to feel more at home
both with himself or herself and with the author. Moreover, Shea knows that an interview and a
relationship can be at cross purposes, so he doesn't want patients to feel that they are “being
interviewed,” but rather that they are “talking with someone.” He states his goal early, “to gather
the necessary clinical information efficiently while powerfully engaging the patient.”
The focus is on assessment, not ongoing psychotherapy, but there is much here for all
psychotherapists. For instance, throughout the book Shea emphasizes the point that a well-crafted
initial interview, although it is not psychotherapy, is always therapeutic. He proceeds to
demonstrate with practical illustrations, including an entire transcript of one of his own interviews,
exactly how to accomplish this complex task.
With “facilics,” his innovative set of principles for studying and understanding the methods by
which clinicians structure interviews and manage their time, he provides a wonderfully practical
method for gracefully navigating the tight time constraints of modern clinical practice. He manages
to artfully wed the process of data gathering with compassionate listening. He furthers this
integrative task by highlighting the many practical interviewing techniques that other authors have
developed from a myriad of disciplines, including analytic, interpersonal, self-psychological,
cognitive–behavioral, and existential schools of thought. In short, this is a sophisticated, deeply
informed work, the hands-on emphasis of which does not belie a profound understanding.
Too often, clinical discussions have a pretentious, high theoretical cast, whether of putative brain
processes or unconscious ones. In our mission to help others, unlike theoretical physicists, it is not
our main goal to penetrate the secrets of nature and society. Rather, in clinical care, we are more like
engineers whose task is to construct the practical bridges and strong foundations that foster the
healing process. We need to get from A to B, from meeting to connecting, from guessing to
surmising, from sensing to feeling deeply. Shea breaks down the steps, makes the distinctions, and
lets us build our own working methods from the various examples he provides. We are to practice
techniques and create new ones, until a wide range of possible actions becomes second nature to us
all.
This is where clinical work must begin. We could not be in better hands.
Leston Havens M.D.
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24
Preface
The purpose of life is to serve and to show compassion and the will to help others. Only then have
we ourselves become true human beings.
Albert Schweitzer
It is with great pleasure and excitement that I sit down to write the preface for the 3rd edition of this
book. Much has changed in our field since the publication of the 2nd edition 18 years ago – some
good, some not so good. My pleasure arises, to a great extent, from the fact that the cornerstone
principles of the first two editions – sensitivity and compassion – still resonate in our field today;
indeed, in the age of managed care, increasing time pressures, and the advent of the electronic
health record, they may play an even more important role as guideposts than ever before. Put more
bluntly, many extraneous factors have been introduced into the environment of everyday clinical
care that, in my opinion, make it harder to be a sensitive listener today than has been the case in all
previous generations.
In this regard, the one over-arching goal of this textbook is to prepare the trainee to function effectively, and
with compassion, in the hectic worlds of community mental health centers, inpatient units, emergency rooms,
university counseling centers, and private practices. To accomplish this task, today's students require
the acquisition of a series of advancing interviewing skills that must be developed sequentially
throughout the years of their residency and graduate training (indeed, as an ongoing education
throughout the rest of their careers). In these pages I have made my best effort to address these
progressive steps in a fashion that makes their acquisition both more pleasant and more effective. I
have tried to create a book that, in essence, grows with the trainee through the years of their
residency or graduate program and beyond.
Moreover, in an exciting fashion, the field of clinical interviewing has exploded with innovations
since the 2nd edition of this book, from the widespread acceptance of motivational interviewing to
the numerous advances made with regard to culturally adaptive interviewing and the increased
emphasis on wellness interviewing. Towards capturing this excitement, I have tried to keep intact
whatever elements of the 2nd edition reader feedback has suggested were most effective, while
approaching the topics of each chapter with the same informal writing style that readers seemed to
enjoy so much in the previous editions. As they say, don't fix what isn't broken. In addition, as with
the 2nd edition, I have given careful attention to presenting the complexities and nuances of each
topic with the in-depth sophistication they warrant when training psychiatric residents and
graduate students in clinical psychology, psychiatric social work, psychiatric nursing, and
counseling.
Concerning the sequential skills that new trainees must master, first and foremost, trainees – no
matter what their disciplines – must, in their initial course on clinical interviewing, acquire a set of
core interviewing skills of a surprisingly complex nature. More specifically, the trainees must
acquire and practice skills ranging from topics as diverse as conveying empathy, nurturing
engagement, and sensitively structuring interviews, to effectively uncovering client wellness and
strengths, as well as delicately uncovering the truth about sensitive and taboo topics. All of these
skills must be learned while simultaneously addressing the interplay between these skills and the
complex context of cultural diversity, nonverbal communication, and the interface between the
interview and collaborative treatment planning. No small task for an introductory course! Part I of
this text – “Clinical Interviewing: the Principles Behind the Art” – was designed to meet this
daunting task head-on with individual chapters addressing all of these topics.
And, here is where things get really exciting. As I mentioned earlier, many things have changed
since the 2nd edition of this book. A truly great advance has been the ability to stream video through
the web. This has revolutionized how we can go about the process of training clinicians in
interviewing (as well as psychotherapy). Throughout Part I (as well as Parts II and III) more than 7.5
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hours of streaming video have been integrated directly into the text of the book. Now readers become
viewers. After learning about specific techniques, with the mere click of a link, the reader of the
accompanying e-book can view streaming video in which I am not only consolidating and
elaborating on what was just read, but I am demonstrating the exact same interviewing techniques
with annotated video. Moreover, as Jan Fawcett noted in his Foreword to the 3rd edition: “As the
student enters their clinical rotations, and ultimately, as they leave their residency and graduate
programs to secure their first jobs, they can return to these videos, stream them on their laptops,
tablets, and smart phones wherever they are and whenever they choose. The video illustrations of
the book will always be available to them in the palm of their hands.”
In Step 2 of their maturation as clinical interviewers, after acquiring their core interviewing skills,
the trainee will encounter a new, and particularly challenging set of skills to master. Specifically the
graduate student or psychiatric resident must learn how to adapt their newly acquired core
interviewing skills for use in the real world of community mental health centers, inpatient units,
college counseling centers, private practices, and emergency departments. In these settings, the
trainees, during their clinical rotations and internships (and subsequently in their years of
employment) will encounter patients suffering from a variety of painful disorders ranging from
major depressive disorders, substance use disorders, post-traumatic stress disorder (PTSD), and
obsessive–compulsive disorder, to bipolar disorder and schizophrenia.
This requires that a clinical interviewer understand the phenomenology and exquisite pain with
which these psychopathological symptoms present themselves to each unique patient (as well as
the pain of the family members who love the patient). Moreover, it is not enough to have an
introduction to this phenomenology. One must understand, in a particularly sophisticated fashion,
the person beneath these symptoms and be able to sensitively explore the experience and meaning
of these symptoms, for they are manifested uniquely by each person and the cultural context that
shapes that person.
Part II of this textbook – “The Interview and Psychopathology: From Differential Diagnosis to
Understanding” – attempts to address these critical concerns. The major diagnostic categories are
approached with chapters dedicated not only to sensitively performing a differential diagnosis (in
which I provide numerous sample questions and illustrative interview excerpts) but with separate
chapters that illustrate various questions and strategies that will take the reader into an even deeper
understanding of the pain and symptoms of the person before them. You will note that careful
attention is given to cultural and familial factors so that clinicians – who are interviewing a patient
who comes from a different culture than the interviewer's culture – will not mistake cultural
differences as psychopathology or, on the other side of the coin, miss disorders that are unique to
the patient's cultural heritage.
Note that the 3rd edition of this book is specifically designed to allow faculty to literally create the
textbook that he or she feels is best suited for the course being taught. Thus some faculty will feel
that there is time within their trainees' first course – on core interviewing skills – to assign these
chapters on the interface between the clinical interview and psychopathology. Other faculty may
decide these chapters are best suited for a separate course on psychopathology. Still others may
decide that one or two of the chapters are invaluable in the first course on clinical interviewing so as
to ensure that the students immediately understand that their core interviewing skill will be
implemented with patients in great pain and with varying disorders.
The third graduated step in the trainee's development of interviewing skills is challenging,
indeed, sometimes legitimately intimidating. The student must learn how to sensitively elicit
suicidal ideation and intent as well as violent ideation and intent. Many trainees also find the
mental status to be confusing and awkward to implement gracefully. These specific tasks are of
such importance that separate chapters are dedicated to each of them in Part III of the book –
“Mastering Complex Interviewing Tasks Demanded in Everyday Practice.”
The expanded chapter on suicide assessment in this 3rd edition includes some of my very favorite
pages in the book, which I hope you will enjoy as well. It is an introduction to the interviewing
strategy for uncovering suicidal ideation, planning, intent, and actions known in the clinical
literature as the Chronological Assessment of Suicide Events (the CASE Approach). It has been one
of my greatest satisfactions to see the interest and adoption – both nationally and internationally –
of the CASE Approach, which was first delineated in the 2nd edition of the book. In this expanded
26
chapter, I have an opportunity to not only describe the updated version of the CASE Approach (for
we are always improving it) but to demonstrate, via streaming video, the interview strategy in its
entirety, dissecting its nuanced variations as the clinical risk of suicide presents in varying degrees
of severity.
Finally, in a trainee's fourth evolution in clinical interviewing skills, during his or her graduate
program or psychiatric residency, the trainee will need to learn advanced skill sets, which are
addressed in Part IV, “Advanced Interviewing and Specialized Topics.” As noted earlier in this
Preface, I have tried to create a book that will grow with the psychiatric resident or graduate
student as they progress through their training, while providing a reference that they will pull off
the shelf in their subsequent careers as a mental health professional.
The bonus chapters in Part IV are essentially designed as independent monographs regarding
each of these topics. I would like to draw the reader's attention to two of these advanced chapters
that I think, paradoxically, despite their advanced nature in the sense of requiring a pretty good
observing ego to employ their techniques, faculty might find very enticing to include as closing
bonus chapters in an introductory course on clinical interviewing. Students really appreciate the
usefulness of the topics.
The chapter, “Transforming Anger, Confrontation, and Other Points of Disengagement” covers
all of the types of awkward moments that beginning clinicians dread such as patients confronting
them on their inexperience, asking personal questions such as, “Do you believe in God?” or “Have
you ever had an affair?”, or a delusional patient asking, “Do you believe me?” I tried to provide an
easily understood framework for handling such questions as well as providing the beginning
student with possible answers and illustrative dialogue of clinicians responding gracefully to such
moments.
I also think that faculty may find that some of their beginning students will be ready to enjoy the
sophisticated introduction to culturally adaptive interviewing to be seen in the chapter, “Culturally
Adaptive Interviewing: The Challenging Art of Exploring Culture, Worldview, and Spirituality.” I
have attempted to create a comprehensive “monograph” that will allow a student – through the
reading of a single chapter – to come away with a sound introduction to this fascinating, and
critically important, area. I have tried to not only describe what needs to be done during culturally
competent interviewing, but I have also tried to give compelling examples of dialogue that
demonstrate culturally adaptive interviewing.
Two truly advanced topics, dear to my heart and closely related to each other, also appear as
bonus chapters. In this 3rd edition, I finally had a chance to do something that I have wanted to do
for years – attempt to provide, in a single chapter, a reasonably sound introduction to the highly
innovative work of Miller and Rollnick – Motivational Interviewing (MI). As one would expect in
this book, I focus on how the principles of MI can be employed in the initial interview.
It was also a pleasure to be able to introduce to all mental health providers, especially all those
who prescribe medications (from psychiatrists to psychiatric nurse clinicians, psychiatric physician
assistants, and psychiatric clinical pharmacists) the collaborative and motivational model known as
the Medication Interest Model (MIM), which addresses how we can go about the complex process
of talking with our patients about the possible use of medications in a truly collaborative fashion.
The MIM was first introduced for use in general medicine in my book Improving Medication
Adherence: How to Talk with Patients About Their Medications as applied to medications being used to
treat all disease states from diabetes, hypertension, and congestive heart failure to depression and
PTSD. In our bonus chapter in Part IV of this book, I have been able to create a fast-reading
monograph on how the collaborative interviewing principles and techniques of the MIM can be
specifically applied with patients considering psychiatric medications. I hope this monograph on
the psychiatric application of the MIM will help many clinicians to help many patients for many
decades to come.
For faculty readers some particularly rich new material has been added in the Appendices. In
Appendix IVB the reader will find four popular, unabridged articles from the Psychiatric Clinics of
North America describing innovative educational strategies and approaches. The articles examine
challenges such as designing effective interviewing training programs for psychiatric residents and
graduate students and teaching clinical interviewing skills using role-playing from conveying
empathy to eliciting suicidal ideation and intent. Separate articles describe, in detail, the real-world
27
application of educational advances such as macrotraining and scripted group role-playing (SGRP).
In addition, over the years I have been repeatedly asked by faculty and interviewing mentors
whether there was a readily available resource for quickly teaching both trainees and instructors the
schematics to be used in facilic supervision. With the production of this book, readers can now
enjoy an easy to use interactive computer module online to do so whenever they choose.
I hope that the reader enjoys this book as much as I enjoyed expanding, revising, and adding
video to it. In the final analysis, interviewing should be fun. I think it is important to emphasize that
this book does not pretend to show the “correct” way of interviewing, because there is no correct
way. Instead, I offer suggestions that will provide the reader with the principles to develop his or
her own creative style of interviewing, always flexibly matching the interview to the needs of the
patient, not to the dictates of a school of thought.
In closing, this is a book about knowledge – knowledge applied to the art of healing. In the last
analysis, as students of this art, it will always remain our great privilege to ensure that the
knowledge of our minds is guided by the compassion of our hearts and the wisdom of our souls. As
Albert Schweitzer so elegantly stated in our epigram, it is through this art and through our desire to
help others that we ultimately find ourselves.
Shawn Christopher Shea M.D.
28
A Few Stylistic Notes From the Author
Please note that the names of all the patients have been changed. In addition, at times,
distinguishing characteristics or facts have been altered to further protect their identity without
altering the clinical essence of our interaction.
Also note that, historically, various names have been used to refer to the people we are helping in
our therapeutic work including client, patient, consumer, and various other descriptors. To me
there are pros and cons to each of these, and I could genuinely make convincing arguments for the
use of any of them. I originally began the manuscript by randomly switching such descriptors, but I
found that readers then tried to ascribe reasons to why I used each in a particular passage (there
were no reasons for I was doing so randomly!).
It became evident that to avoid this type of misunderstanding and for the sake of consistency and
ease of reading, I should choose one of them. I chose to use the word “patient” for many readers –
at some point in their careers – will be working with people in settings such as hospital units or
emergency rooms where, indeed, the term “patient” is viewed as normative. This is not to suggest
that the word “patient” is superior or correct, it is merely a way of securing consistency in the text.
With regard to gender identifying words in the text, I also take that topic seriously, for I recognize
that language counts. For instance, some experts prefer the word Latino, others the word Latino/a,
and still others the word Latina/o (which is my personal preference). I can't pass judgment on any
of these descriptors as long as the writers are trying their best to be cognizant of the importance of
gender in their writing. I can't assure my readers that we will always agree on my choices, but I can
assure the reader that I made my choices with a genuine spirit of addressing gender fairly and in a
fashion consistent with the highest current values of our society.
29
Acknowledgments
I would like to begin by expressing my deep gratitude, once again, to all those who helped with the
first and second editions of this book.
With regards to the third edition, many colleagues, clinicians, and patients have coalesced over
the years into wonderfully evanescent teams of people whose knowledge, experiences, and bits of
self have found themselves into the pages of this book. I can't thank enough all of the clinicians –
whom I have had the pleasure to meet during my clinical interviewing workshops – who have
shared their interviewing tips with me and, oftentimes, subsequently made contributions to the
“Interviewing Tip of the Month” on our website for the Training Institute for Suicide Assessment
and Clinical Interviewing (www.sucideassessment.com). Your enthusiasm for clinical interviewing,
as well as your clinical wisdom, help to animate the pages of this book.
Regarding my years at Dartmouth spent developing the Dartmouth Interviewing Mentorship
Program for the Department of Psychiatry, a special thanks goes to the core members of the so-
called “Phantom Gate Club” – Ron Green, MD, Bruce Baker, PhD, Christine Barney, MD, Stephen
Cole, PhD and Mark Reed, MD. Your feedback, creative ideas, interviewing expertise, and
friendship are reflected throughout the chapters in this third edition.
A special thanks to three wonderful clinicians who provided outstanding input on the chapter
entitled, “Culturally Adaptive Interviewing: The Challenging Art of Exploring Culture, Worldview,
and Spirituality”. Dottie Morris, PhD provided a detailed review of the entire chapter, supplying
her insights from her years of work in the field of diversity and multiculturation. I would also like
to thank Edward Hamaty, DO for his sensitive review of the section exploring the needs of the
LGBT community as well as his cherished friendship since our meeting at Lee Hospital for a
summer work program way back in 1970. And thanks to Patsy “PJ” Taucer, M.Ed, a Certified
Medical Interpreter, for her hands-on input on the effective role of interpretation. Couldn't have
done it without you guys.
With regards to the ongoing development and support of the Chronological Assessment of
Suicide Events (CASE Approach) special thanks goes to the never-ending, always appreciated,
support of Skip Simpson, JD, as well as his deeply appreciated friendship. Thanks “Skipper”. More
than anyone, you have taught me the meaning of mission. In addition, both Tom Ellis, PhD and
David Jobes, PhD have been staunch advocates of the CASE Approach from its very inception. A
very special thanks goes to Donna Amundson, L.C.S.W., whose support, input on training
techniques, and unwavering efforts in training clinicians in the CASE Approach has undoubtedly
saved many lives. Her selfless efforts are a part of the soul of the CASE Approach and always will
be.
Moving on to production support, I want to give much deserved recognition and thanks to the
team at Elsevier. In all of my years, this team has been the most talented, professional, and mission-
oriented publication team that I have ever encountered. As our “little project” grew and grew, they
provided their unequivocal support and patience at every step. I can't thank my editor, Charlotta
Kryhl enough. Lotta's encouraging phone-calls with me and her work behind the scenes is the only
reason this book appears in its present innovative format and with its many hours of integrated
video. Thanks goes to Sharon Nash, content development specialist, who, with skill and savvy, has
steadfastly kept us all on track and schedule, no mean accomplishment with regards to myself I
might add. Thanks to Julie Taylor and her entire staff for the best production and “look” I have ever
had in a book. Finally, Marcela Holmes, my copyeditor. I may be biased, but she's got to be one of
the best in the business and has been a joy with whom to work. The book is a much better read for
her efforts. Hopefully I'll someday join you all for a round of bitters in a London pub – on me of
course.
I would also like to add something about the publisher itself, Elsevier. From the very start they
30
have been believers in the mission of this book. Their genuine belief in its mission was most
strikingly reflected in their choosing a remarkably low price for the book – without any hesitation
on their part – in an effort to make sure the book would get into the hands of the clinicians who can
transform its words into healing and hope. What an extraordinarily refreshing attitude in a world
so often consumed by greed and self-interest. Kudos to a great company. Many lives will be
changed because of your integrity.
As I come to the production team of our integrated video, I feel a sense of great gratitude and
warmth. Jeff Kolter of Jeff Kolter Productions is a remarkable human being, who put over 500 hours
into the project, a large amount of this time for gratis because of his belief in its mission. He is
responsible for all videography as well as all post-production and editing. My work with Jeff has
been some of the most enjoyable collaboration of my life. He brought the didactics and patient
interviews to life. And what a gorgeous green screen! Jeff, I'll always remember our times in your
studio and dinners at the Co-op. Many thanks to others involved in producing our integrated video
including Xavier Brown and Susan Shea for their creative input, support, and recommendations. A
special thanks also goes to both my wonderful role-players and, especially, to my patient for her
permission to use the video of her interview with myself.
Another artist warranting much thanks is Debi Stevens. Debi provided the lovely, and sometimes
haunting, artwork that forms the facing pages of the many new chapters that appeared in the third
edition. Debi, I'll fondly remember our hours at Brewbaker's Café brainstorming and reviewing
your remarkable creations.
A thanks goes to the delightful staff of the Susan Colgate Cleveland Library/Learning Center at
the Colby-Sawyer College in New London, New Hampshire for their support over the last three
years of the project. In particular, I would like to thank Noelle Bassi, Beth Krajewski, Erica Webb,
and Kelli Bogan for all of their support as I busily wrote and edited the last half of the book in your
beautiful library. You made “the trip” a fun one.
As my acknowledgments draw to a close, I have saved some of the most important for last. I
would like to thank Jan Fawcett, MD, for his supportive phone calls and his much appreciated
comments and suggestions for the mood disorder chapters in particular. But, most of all, I would
like to thank Jan for his truly lovely Foreword. It has been an honor to get to know you better. I
believe that anyone who has met you, comes to know that you are not only a gifted clinician and
innovator, but a truly good human being. The world is a softer place because you are in it. Many
thanks.
Finally, an enormous amount of gratitude to my wife and the Co-Director of the Training
Institute for Suicide Assessment and Clinical Interviewing (TISA). Susan, thanks so much for all of
your outstanding editorial suggestions on the text as well as the remarkable creative inputs you had
on this project. Moreover, for your support over the six years of this project - that required much
sacrifice on your part – I will forever be grateful. You are not only the love of my life, you are the
keeper of my soul.
Shawn Christopher Shea MD
31
Video Table of Contents
The Delicate Dance: Engagement and Empathy
32
Psychiatric Disorders such as Panic Disorder, Generalized
Anxiety Disorder, and Adult Attention-Deficit Disorder
Personality Disorders: How to Sensitively Arrive at a Differential Diagnosis
33
PA R T I
Clinical Interviewing: The Principles Behind the
Art
OUTLINE
Chapter 1 The Delicate Dance Engagement and Empathy
Chapter 2 Beyond Empathy Cornerstone Concepts and Techniques for Enhancing Engagement
Chapter 3 The Dynamic Structure of the Interview Core Tasks, Strategies, and the Continuum of
Open-Endedness
Chapter 4 Facilics The Art of Transforming Interviews into Conversations
Chapter 5 Validity Techniques for Exploring Sensitive Material and Uncovering the Truth
Chapter 6 Understanding the Person Beneath the Diagnosis The Search for Uniqueness,
Wellness, and Cultural Context
Chapter 7 Assessment Perspectives and the Human Matrix Bridges to Effective Treatment
Planning in the Initial Interview
Chapter 8 Nonverbal Behavior The Interview as Mime
34
CHAPTER 1
Carl G. Jung
In the following pages, we will begin a study of the interviewing process. We will be examining
35
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
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.