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CONTENTS
PREFACE xvii
ABOUT THE AUTHOR xxv
CHAPTER 1 An Introduction to the Competency-Based Assessment Model 1

Introduction 1
The DSM-5: Approaches to the Assessment 4
The DSM-5 Definition of Mental Illness 6
How the DSM-5 Is Organized 7
A Closer Look at Section II 8
Using the DSM-5 9
Refining the Diagnosis 10
The Competency-Based Assessment Model 12
The Biopsychosocial Framework 12
The Ecological Perspective 19
The Strengths Perspective 20
Systems Theory 21
Understanding the Client 24
Summary 28
Competency Notes 30
CHAPTER 2 Neurodevelopmental Disorders 33

Introduction 33
Intellectual Disability (Intellectual Developmental Disorder) 34
Prevailing Pattern 35
Differential Assessment 35
Other Related Disorders 39
Autism Spectrum Disorder 40
Attention-Deficit/Hyperactivity Disorder 48
Other Neurodevelopmental Disorders 54
Communication Disorders 55
v
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vi CONTENTS
Motor Disorders 60
Summary 61
Practitioner s Reflections 62
Activities 62
Competency Notes 63
CHAPTER 3 Schizophrenia Spectrum and Other Psychotic Disorders 66

Introduction 66
Schizophrenia 70
The Role of Dopamine 73
Key Features Defining the Schizophrenia Spectrum 74
Cultural Considerations 78
Catatonia as a Specifier and as a Disorder 89
The Impact of Schizophrenia: Suicide, Depression, and Substance Use 91
Delusional Disorder 92
Brief Psychotic Disorder 96
Schizophreniform Disorder 97
Schizoaffective Disorder 100
Other Disorders of Diagnostic Importance 104
Substance/Medication-Induced Psychotic Disorder 104
Psychotic Disorder Due to Another Medical Condition 104
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 104
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 105
Summary 105
Activities 106
Competency Notes 107
CHAPTER 4 Bipolar and Related Disorders 111

Introduction 111
Bipolar Disorders 112
Variations of Bipolar Disorder 114
Bipolar Disorder Specifiers 115
CONTENTS vii
Cyclothymic Disorder 121

Other Bipolar and Related Disorders 123
Substance/Medication-Induced Bipolar and Related Disorder 123
Bipolar and Related Disorder Due to Another Medical Condition 124
Other Specified Bipolar and Related Disorder 124
Unspecified Bipolar and Related Disorder 124
Summary 124
Activities 126
CHAPTER 5 Depressive Disorders 129

Introduction 129
Disruptive Mood Dysregulation Disorder 129
Major Depressive Disorder 133
Persistent Depressive Disorder (Dysthymia) 144
The Minor Depressive Disorders 148
Premenstrual Dysphoric Disorder 148
Substance/Medication-Induced Depressive Disorder 149
Depressive Disorder Due to Another Medical Condition 149
Other Specified and Unspecified Depressive Disorders 150
Complications Associated with Major Depressive Disorders 150
Medications Commonly Associated with the Depressive Disorders 154
Summary 156
Activities 157
CHAPTER 6 Anxiety Disorders 161

Introduction 161
Separation Anxiety Disorder 162
Selective Mutism 166
viii CONTENTS
Specific Phobia 167

Social Anxiety Disorder (Social Phobia) 170
Panic Disorder 173
Agoraphobia 179
Generalized Anxiety Disorder 182
Other Anxiety Disorders 185
Summary 187
Activities 188
CHAPTER 7 Obsessive-Compulsive and Related Disorders 191

Introduction 191
Obsessive-compulsive Disorder 192
Body Dysmorphic Disorder 199
Hoarding Disorder 204
Other Obsessive-compulsive and Related Disorders 207
Summary 209
Activities 210
CHAPTER 8 Trauma- and Stressor-Related Disorders 214

Introduction 214
Reactive Attachment Disorder 215
CONTENTS ix
Disinhibited Social Engagement Disorder 218

Posttraumatic Stress Disorder 221
Acute Stress Disorder 231
Adjustment Disorders 236
Summary 239
Activities 240
CHAPTER 9 Dissociative Disorders 244

Introduction 244
Cultural Perspectives and the Dissociation Experience 248
Dissociative Identity Disorder 251
Dissociative Amnesia 258
Dissociative Amnesia with Dissociative Fugue 262
Depersonalization/Derealization Disorder 263
Summary 266
Activities 267
CHAPTER 10 Somatic Symptom and Related Disorders 270

Introduction 270
Somatic Symptom Disorder 272
Illness Anxiety Disorder 277
x CONTENTS
Conversion Disorder (Functional Neurological Symptom Disorder) 283

Psychological Factors Affecting Other Medical Conditions 287
Factitious Disorder 290
Closing Observations About Nan Finkelhorn 292
Summary 293
Activities 294
CHAPTER 11 Feeding and Eating Disorders 297

Introduction 297
Pica 299
Rumination Disorder 304
Avoidant/Restrictive Food Intake Disorder 308
Anorexia Nervosa 311
Bulimia Nervosa 319
Binge-Eating Disorder 325
Other Feeding or Eating Disorders 331
Other Specified Eating or Feeding Disorder 331
Unspecified Feeding or Eating Disorder 332
The Role of Obesity 332
Summary 333
Activities 335
CONTENTS xi
CHAPTER 12 Elimination Disorders 341

Introduction 341
Enuresis 342
Encopresis 346
Other Related Disorders 349
Summary 349
Activities 350
CHAPTER 13 Disruptive, Impulse-Control, and Conduct Disorders 353

Introduction 353
Cultural Perspectives 354
Oppositional Defiant Disorder 356
Intermittent Explosive Disorder 360
Conduct Disorder 363
Pyromania and Kleptomania: An Overview 368
Pyromania 368
Kleptomania 369
Summary 369
Activities 370
CHAPTER 14 Substance-Related and Addictive Disorders 373

Introduction 373
The Essential Features of the Substance-Related and Addictive Disorders 379
Substance Use Disorder 380
Severity, Specifiers, and Recording 381
Substance-Induced Disorders 382
Substance Intoxication 382
Substance Withdrawal 382
Substance/Medication-Induced Mental Disorders 384
xii CONTENTS
Other Diagnostic Considerations 386

Alcohol-Related Disorders 387
Alcohol Use Disorder 388
Alcohol Intoxication 389
Alcohol Withdrawal 390
Long-Term Effects of Alcohol Use 395
Caffeine-Related Disorders 396
Caffeine Intoxication 397
Caffeine Withdrawal 397
Cannabis-Related Disorders 398
Cannabis Use Disorder 399
Cannabis Intoxication 400
Cannabis Withdrawal 401
Hallucinogen-Related Disorders 401
The Phencyclidines 401
Phencyclidine Use Disorder 402
Phencyclidine Intoxication 404
The Other Hallucinogens 404
Other Hallucinogen Use Disorder 405
Hallucinogen Intoxication 405
Hallucinogen Persisting Perception Disorder 406
Inhalant-Related Disorders 406
Inhalant Use Disorder 407
Inhalant Intoxication 408
Opioid-Related Disorders 408
Opioid Use Disorder 409
Opioid Intoxication 411
Opioid Withdrawal 411
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders 412
CONTENTS xiii
Sedative, Hypnotic, or Anxiolytic Use Disorders 412

Sedative, Hypnotic, or Anxiolytic Intoxication 414
Sedative, Hypnotic, or Anxiolytic Withdrawal 415
Stimulant-Related Disorders 415
Stimulant Use Disorder 417
Stimulant Intoxication 419
Stimulant Withdrawal 419
Tobacco-Related Disorders 420
Tobacco Use Disorder 422
Tobacco Withdrawal 424
Other (or Unknown) Substance-Related Disorders 424
Other (or Unknown) Substance Use Disorder 425
Other (or Unknown) Substance Intoxication 425
Other (or Unknown) Substance Withdrawal 425
Unspecified Other (or Unknown) Substance-Related Disorder 425
Concluding Case Review 425
Gambling Disorder 430
Summary 434
Activities 435
CHAPTER 15 The Neurocognitive Disorders 443

Introduction 443
Delirium 446
The Neurocognitive Disorders 450
Mild Neurocognitive Disorder (Mild NCD) 456
Major Neurocognitive Disorder 456
Neurocognitive Disorder Due to Alzheimer s Disease 457
Vascular Disease 465
Neurocognitive Disorders Other than Alzheimer s and Vascular Disease 465
Frontotemporal Neurocognitive Disorder 465
Neurocognitive Disorder with Lewy Bodies 466
xiv CONTENTS
Neurocognitive Disorder due to Traumatic Brain Injury 466

Substance/Medication-Induced Neurocognitive Disorder 467
Neurocognitive Disorder Due to HIV Infection 467
Prion Disease 468
Neurocognitive Disorder Due to Parkinson s Disease 468
Neurocognitive Disorder Due to Huntington s Disease 469
Additional Neurocognitive Diseases 469
Summary 469
Activities 471
CHAPTER 16 The Personality Disorders 475

Introduction 475
Cluster A: Odd and Eccentric Personality Disorders 481
Paranoid Personality Disorder 481
Schizoid Personality Disorder 486
Schizotypal Personality Disorder 490
Cluster B: Emotional, Dramatic, or Erratic 496
Antisocial Personality Disorder 496
Borderline Personality Disorder 501
Histrionic Personality Disorder 508
Narcissistic Personality Disorder 512
Cluster C: Anxious, Fearful 517
Avoidant Personality Disorder 518
Dependent Personality Disorder 522
CONTENTS xv
Obsessive-Compulsive Personality Disorder 527

The Proposed Alternative DSM-5 Model for Diagnosing the Personality
Disorders 531
Summary 534
Activities 534
APPENDIX 541
GLOSSARY 562
NAME INDEX 573
SUBJECT INDEX 580
PREFACE
INTRODUCTION
All of us engage in behaviors that we usually do not think a lot about from eating,
to talking, feeling, thinking, remembering, playing, buying things, or even going to
the bathroom, to list a few. However, these behaviors can potentially have a mal-
adaptive component that can be diagnosed as a mental disorder. These dysfunctions
are a source of substantial concern to many different mental health professions
whose members hold differing opinions regarding the etiology, pathology, and
treatment of these disorders. Professionals think in terms of their language, and
in order to be able to meaningfully communicate with one another, it is important
to share a common vocabulary. The Diagnostic and Statistical Manual of Mental
Disorders (DSM) published by the American Psychiatric Association (APA, 2013)
offers an official diagnostic nomenclature, making it a powerful document. It plays
a significant role in how practitioners, their agencies, funding sources, social pro-
grams, and the general public conceptualize and respond to problematic and mal-
adaptive behaviors (Schwartz & Wiggins, 2002).
Among the 500,000 mental health professionals in the United States who use the
DSM-5, the largest group is social workers (U.S. Department of Labor, Bureau of
Labor Statistics, 2010) followed by mental health counselors (American Counseling
Association, 2011), psychologists (American Psychological Association, 2012), and
psychiatrists (APA, 2011). Moreover, social work practice specific to the field of
mental health is the largest subspecialty within the profession (Whitaker, Weismiller,
Clark, & Wilson, 2006). Historically, the use of the psychiatric nomenclature in
social work practice has been controversial and has generated considerable discussion
within the profession (Washburn, 2013). To some extent, mental disorders are the
constructions of practitioners and researchers rather than proven diseases and ill-
nesses (Maddux, Gosselin, & Weinstead, 2008). On the other hand, the diagnoses
found in the DSM are not necessarily lacking credibility or empirical support.
THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

DISORDERS AND ITS FIFTH EDITION
The publication of the DSM-5 in 2013 is the fifth edition of the DSM, representing
the first major revision to the manual in more than 30 years (APA, 2013). The
DSM has a profound influence on all mental health professions. Certainly there
xvii
xviii PREFACE
have been numerous controversies surrounding the DSM-5 including the overall
reliability of the system, poor research for field trials, its seeming slant toward a
biological approach, the relative lack of participation of professional groups other
than psychiatry, and the inclusion and definition of particular mental disorders
most notably the autism spectrum (First, 2010; Frances, 2012, 2013; Friedman,
2012; Jones, 2012; Pomeroy & Anderson, 2013). Admittedly, the DSM-5 may con-
tain flaws, but for the most part it describes what is reasonably understood by most
practitioners and researchers to be the predominant forms of psychopathology. The
psychiatric diagnosis is primarily a way of communicating and the categories of the
different disorders can be useful without necessarily being the final word about
how people function. The DSM-5 may be imperfect and sometimes biased, but no
one has questioned whether the manual should be used at all or suggested that
there is an alternative way to move forward. Regardless of the criticisms, the reality
is that the DSM remains as the primary classification system across the counseling
professions for diagnosis and reimbursement purposes (Washburn, 2013). If we are
to provide our clients with the best possible services, then the ability to make an
accurate diagnosis is an important step in that direction. Regardless of where you
stand, it is essential to become familiar with the changes in the DSM-5 and its
potential impact on clients. In fact, using the DSM-5 is unavoidable for many clinical
social workers. For instance, the Association of Social Work Boards (ASWB)
includes questions specific to the DSM on its licensing exams, which are required
by almost every state (Frazer, Westhuis, Daley, & Phillips, 2009). Beginning in
July 2015, the licensure test questions shifted to testing knowledge of the DSM-5.
Revising the DSM has been an enormous undertaking and no diagnostic pro-
cess is perfect. Keep in mind that a work of this magnitude will have some errors.
The APA has made every effort to keep up with the listing of errata, and you are
encouraged to check the association s website (http://www.dsm5.org), which posts
corrections to the manual. It is anticipated that minor text edits will be corrected
in later publications.
In the prior edition of this book I shared the experience of one of my students on a
field trip we took to an agency that works with the severely and persistently mentally ill
organized around the clubhouse model. Essentially this student had reservations
around working with those people until she met a real client and had the chance to
get to know him a little better as he proudly showed us around the agency. I still
remember this client s greeting as we approached the front door of the agency. He
had a big smile and proudly announced, Hi, I m Danny and I have schizophrenia.
Welcome to our clubhouse. I can t wait to show you around. I remembered thinking,
who knows more about mental illness than someone who lives with a disorder on a
daily basis? Danny s symptoms may wax and wane, but ultimately they do not go
away. The competency-based approach to the assessment process takes into account a
client s lived experiences with a diagnosis. From this perspective, Danny s diagnosis
becomes but a part of his identity and does not define him. The intent of the compe-
tency-based model is to advance the assessment process to one that recognizes each
person s uniqueness rather than to focus solely on a diagnostic label.
Lacasse and Gomory (2003) analyzed a sample of psychopathology syllabi from
top graduate schools of social work around the country and found that the most fre-
quently required texts were authored by psychiatrists. No course had a stand-alone
PREFACE xix
text authored by a social worker. As social workers, we are familiar with working
from a strengths perspective with our clients, and this orientation somehow becomes
lost in books from other disciplines. This book is written by a social worker for social
workers. Learning about psychopathology and related diagnoses is like learning a
new language. Best to learn this language with a social work accent!
THE BOOK S ORGANIZATION

The changes in the DSM-5 will require practitioners to relearn how to classify and
conceptualize some mental disorders. The aim of this book s fourth edition is to
help readers understand the new features of the DSM-5 to the extent that you can
take this information and, by incorporating the competency-based assessment
model, apply diagnoses correctly. As with prior editions, case studies are provided
to highlight diagnostic criteria and to differentiate among the different diagnoses.
Stigma and misunderstanding of mental illness is pervasive, and many still con-
sider mental health problems to be the result of personal shortcomings. The book is
organized around the competency-based model, which highlights the biological
(including neurological), psychological, and social aspects of a person s life as a part
of the diagnostic process. In this way, understanding psychopathology will not focus
on character flaws or personal weakness but include a strengths-based orientation to
the assessment, which looks to how someone like Danny copes with and rebounds
from the challenges of living with a mental disorder. The diagnosis understands the
individual s biopsychosocial makeup, cultural and political influences, coping meth-
ods, and factors that are a basis for strengths, resiliency, and resources. This orienta-
tion balances psychopathology with a parallel appreciation of factors related to
strengths and resiliency. It goes without saying that using the DSM requires skill in
order to be able to distinguish the client s symptom picture. The competency-based
assessment extends this understanding and looks beyond a review of the client s
symptoms to consider how a disorder is experienced, how it is expressed, and how
symptoms are interpreted by the person and those close to him or her.
INTRODUCTION TO ENHANCED CONTENT

You will find a number of changes in each of the chapters. The DSM-5 definition of
mental illness takes into account the neurological features of mental disorders. In
order to familiarize the social work practitioner with the neurological contributions
to psychopathology, Chapter 1 expands the review of the biopsychosocial frame-
work supporting the competency-based assessment by including content on the
role of the brain and related systems in psychopathology. Subsequent chapters
include a discussion of these influences around particular disorders. A review of
changes to the reorganization of the DSM are also included.
The DSM-5 classification system cuts across all developmental stages, thus elimi-
nating the need for a separate chapter on the disorders of infancy, childhood, and
adolescence as seen in the DSM-IV-TR. From a life-span perspective, disorders spe-
cific to early development are placed in the second chapter on neurodevelopmental
disorders, and a later chapter on neurocognitive disorders addresses late life
xx PREFACE
developments. This approach to DSM reorganization also attempts to better reflect the
relative strength of relationships among disorder groups. For example, although there is
an overlap of symptoms among the anxiety disorders, obsessive-compulsive disorder,
posttraumatic stress disorder, and acute stress disorder, each has a different clinical pre-
sentation and are now included in separate chapters on the basis of overt symptoms in
the DSM-5. However, clients with any one of these closely related disorders can show
comorbid disorders from among this spectrum (Bienvenu et al., 2011).
Consistent with this approach to the DSM classification system, new chapters
have been added; for example, obsessive-compulsive and related disorders, and
trauma- and stressor-related disorders, to list a few. To remain consistent with prior
editions, all of the chapters from 2 through 16 in the book have been ordered around
how they appear in the DSM. You will find a review of the specific disorders fol-
lowed by an updated discussion of prevailing patterns, and the differential diagnosis.
Case vignettes are presented followed by a diagnosis and the competency-based
assessment. An assessment summary reviews possible alternative diagnoses so that
readers can become familiar with the process of distinguishing symptoms and client
competencies in reality-based situations. In this way, readers may learn to take the
client s whole person into account when making a diagnosis of mental illness.
Not every disorder addressed in the DSM-5 appears in the book. The intent is to pro-
vide a more in-depth review of those syndromes social workers will more than likely
encounter in their everyday practice. As before, each chapter is designed to stand
alone. This feature was kept in order to facilitate individual instructor preference
around sequencing the teaching of content about a particular disorder. In addition,
it is easier for readers who might want to re-review a diagnosis.
New case stories have been added throughout the book to illustrate the new
diagnoses included in the DSM-5. For example, you will notice the case of John
Laughlin highlighting disruptive mood dysregulation disorder in the depressive disor-
ders chapter, and Larry Dalton s experiences with gambling disorder in the sub-
stance-related and addictive disorders chapter. There are numerous familiar case
studies from prior editions, but the diagnosis has been updated to reflect the DSM-5
diagnostic criteria. For example, Rudy Rosen still struggles with schizophrenia, but
the way it has been diagnosed is different. To add context to the diagnostic shifts,
each chapter ends with a summary of the changes from the DSM-IV-TR to the
DSM-5. Sometimes a diagnosis that the practitioner will more than likely not see in
the average practice situation was reviewed, and this was done to expand the overall
understanding of the diagnostic categories in the DSM-5. For instance, you will find
Patty Nemeth s story about separation anxiety in the chapter featuring the anxiety
disorders, and Mary Ellen Creamer s struggles with pica in the feeding and eating dis-
orders chapter. The DSM-5 has moved away from a categorical approach to the
diagnosis that is, either you meet criteria for a diagnosis or not and more toward
a dimensional perspective. Reflective of this shift, you will find more listings of diag-
nostic specifiers and severity ratings for each of the diagnoses.
The fourth edition of the book remains a part of the Cengage Learning
Empowerment Series and continues to integrate the Council on Social Work Educa-
tion (CSWE) Educational Policy and Accreditation Standards (EPAS). However, in
March 2015, CSWE approved a new set of standards, referred to as practice com-
petencies. This newly revised set of practice behaviors has been integrated into each
PREFACE xxi
chapter, thus further supporting the book s emphasis on a performance-based ori-

entation to learning that links theory and action; that is, using real-life case exam-
ples to highlight the assessment process. Competency notes are provided at the end
of each chapter that describe each competence and its relationship to chapter con-
tent. The Appendix contains test questions for each chapter, and they have been
expanded to reflect the revisions to this edition.
While the book targets social workers, it can be used by all mental health profes-
sionals taking courses in psychopathology, human behavior, or direct practice. It is
also a good reference for practitioners who want to review the basics of psychopa-
thology or to prepare for a licensure exam. Supervisors will find it a useful reference
for psychiatric diagnoses. The case studies are drawn from real-life practice experi-
ences, and I hope readers will find the diversity reflective of contemporary practice.
All case stories have been changed to protect anonymity, and some represent a com-
pendium of different client experiences. Any resemblance to a real-life client is acci-
dental and not intentional. The cases can be used by both instructors and
supervisors as a part of a homework assignment, to supplement lectures, or adapted
to provide evidence of students understanding of the assessment process in practice.
INSTRUCTOR SUPPLEMENTS
For this edition of the textbook, the author has crafted a detailed Instructor s Man-
ual to support your use of the new edition. The manual includes chapter summa-
ries, practitioner reflections that can be used as student exercises, suggestions for
further study, and additional online and print resources. There is also a detailed
test bank and a set of classroom PowerPoint slides that accompany the text.
This material can be found at http://www.cengagebrain.com.
ACKNOWLEDGEMENTS
The DSM-5 created the opportunity for making significant changes in the book. It
did not take very long for me to realize that an undertaking like this could be
accomplished only with a lot of help and support. I would especially like to
acknowledge all of the helping hands behind the scenes who worked diligently to
make this edition of the book a reality. Looking back, I find it hard to believe that
15 years have passed since the first edition was published. Back then I could not
have predicted that the competency-based assessment would make such an enduring
contribution to the mental health field. I am always collecting case stories from
my own practice, students, supervisees, and colleagues and continue to be
impressed by the strength and resilience of those who struggle with a mental disor-
der. Thank you to all who have shared their stories with me.
Diagnosing clients is not an easy task. The DSM-5 provided an exciting oppor-
tunity to look at this process through the lens of the values of our profession and
then applying those values in contemporary practice. Over and over again, readers
have shared that this textbook, with its real-life case stories, has helped them to
learn psychopathology in a way that keeps in mind the uniqueness of each person
who struggles with the challenges associated with living with a mental disorder.
xxii PREFACE
Thank you for encouraging me to continue this work. When each client s diagnosis is
individualized through the competency-based assessment, we move in the direction of
a societal culture that encourages a change in the negative perceptions of mental ill-
ness and the stigma that surrounds those who seek help for these challenges.
I would like to thank Gordon Lee, Product Manager Anthropology and Social
Work, who was involved at the outset, and Julie Martinez, Product Manager
Counseling, Human Services, and Social Work, who saw this edition through to its
successful completion. I would also like to acknowledge those who assisted with the
production phase of the book, including Tanya Nigh, Senior Content Project Man-
ager, Jeffrey Hahn, J. L. Hahn Consulting Group, and Valarmathy Munuswamy,
Associate Program Manager, Lumina Datamatics, Inc. I know there are many others
on the Cengage team and I do want to acknowledge their contributions.
As a last step, I wish to thank my husband, Kenneth, whose support has made
all of this possible. As with his experiences with my work on prior editions, there
were many times we would miss meals, eat take out, or have lunch at 3:00 or 4:00
p.m. because I was on the computer and, just need another minute to finish this
thought. He claims not to know anything about social work but somehow man-
ages to provide the right words of encouragement at the right time. His faith in
me is something special!
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American Counseling Association. (2011). 2011 statis- on May 1, 2015 from: http://www.psychology
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VA: Author. guide-not-bible-ignore-its-ten-worst-changes
American Psychiatric Association. (2011). American Frances, A. J. (2013). Two fatal technical flaws in the
Psychiatric Association. Retrieved on May 1, DSM-5 definition of autism. Huffington Post.
2015 from: http://www.psychiatry.org/ Retrieved on May 1, 2015 from: http://www.huf
American Psychiatric Association (APA). (2013). fingtonpost.com/allen-frances/two-fatal-technical-
Diagnostic and Statistical Manual of Mental Dis- flaws_b_3337009.html
orders (5th ed.). Arlington, VA: Author. Frazer, P., Westhuis, D., Daley, J., & Phillips, I.
American Psychological Association. (2012). Support (2009). How clinical social workers are suing
Center: How many practicing psychologists are the DSM: A national study. Social Work in Mental
there in the United States? Retrieved on May 1, Health, 7, 325 339.
2015 from: http://www.apa.org/support/practice. Friedman, R. A. (2012). Grief, depression, and the
aspx DSM-5. New England Journal of Medicine.
Bienvenu, O. J., Samuels, F. J., Wuyek, A., Liang, Retrieved on May 2, 2015 from: http://www
K-Y., Wang, Y., Grados, M. A., Nestadt, G. .nejm.org/doi/full/10.1056/NEJMp1201794?
(2011). Is obsessive-compulsive disorder an anxi- query=TOC
ety disorder and what, if any, are spectrum con- Jones, K. D. (2012). A critique of the DSM-5 field
ditions? A family study perspective. Psychological trials. Journal of Nervous and Mental Disease,
Medicine, 41(1), 33 40. 200, 517 519.
First, M. B. (2010). Clinical utility in the revision of Lacasse, J. R., & Gomory, T, (2003). Is graduate
the Diagnostic and Statistical Manual of Mental social work education promoting a critical
Disorders (DSM). Professional Psychology: approach to mental health? Journal of Social
Research and Practice, 41, 465 473. Work Education, 39, 383 408.
Frances, A. J. (2012). DSM-5 is guide not bible ignore Pomeroy, E. C., & Anderson, K. (2013). The DSM-5
its ten worst changes. Psychology Today. Retrieved has arrived. Social Work, 58(3), 197 200.
PREFACE xxiii
Schwartz. M. A., & Wiggins, O. P. (2002). The hege- workers. Retrieved on May 1, 2015 from: http://
mony of the DSMs. In J. Sadler (Ed.), Descrip- www.bls.gov/ooh/Community-and-Social-Service/
tions and prescriptions: Values, mental disorders Social-Workers.htm
and the DSM (pp. 199 209). Baltimore, MD: Washburn, M. (2013). Five things social workers
Johns Hopkins University Press. should know about the DSM-5. Social Work,
Maddux, J. E., Gosselin, J. T., & Weinstead, B. A. (2008). 58(5), 373 376.
Conceptions of psychopathology: A social construc- Whitaker, T., Weismiller, T., Clark, E., & Wilson,
tionist perspective. In J. E. Maddux & B. A. M. (2006). Assuring the sufficiency of a front-
Weinstead (Eds.), Psychopathology: Foundations for line workforce: A national study of licensed
a contemporary understanding (2nd ed., pp. 3 18). social workers. Special report: Social work ser-
New York: Routledge/Taylor & Francis Group. vices in behavioral health care settings.
U.S. Department of Labor, Bureau of Labor Statistics. Washington DC: National Association of Social
(2010). Occupational outlook handbook: Social Workers.
ABOUT THE AUTHOR
Susan W. Gray is Professor Emerita at Barry University s Ellen

Whiteside McDonnell School of Social Work in Miami Shores,
Florida. She received her PhD in social work from Barry University
with a specialization in licensure and professional regulation, her
EdD concentrating on adult education from Nova Southeastern
University, her MBA from Barry University, and her MSW in
clinical practice from Rutgers the State University. She is a member
Photography by Mazrk Safra
of the National Association of Social Workers, the Academy

of Certified Social Workers, and the Council on Social Work
Education. She has been a member of the faculty since 1980,
teaching a variety of courses across the curriculum, including founda-
tion and advanced clinical social work practice courses specializing in
working with individuals, families and groups, an elective course
in crisis intervention, and a doctoral course in social work education. Among her
accomplishments, Dr. Gray directed the Doctoral Program and spearheaded an
extensive revision of its curriculum.
Dr. Gray is a Licensed Clinical Social Worker and registered clinical supervisor
in Florida, where she also serves as a member of the Probable Cause Panel for the
state licensure board. Dr. Gray holds a wide range of experience in direct clinical
practice with individuals, families, and groups, having worked in a variety of clinical
and community settings, including a half-way house for pregnant adolescents, family
and children outpatient counseling centers, acute care medical settings, inpatient
psychiatric units, and private practice. She also served as a member of the Florida
Board of Clinical Social Work, Mental Health Counseling, and Marriage and Family
Therapy.
Her practice interests include her work in supervision, professional regulation
and licensure, rural practice, bereavement groups, intergenerational family assessment
tools, the brief solution-focused model of practice, methods of classroom teaching,
and aspects of cultural diversity. Dr. Gray s current research interests are in mental
health assessment and practice. She has authored numerous publications, given pre-
sentations at local, state, national, and international social work conferences, and is
also the author of Competency-based Assessments in Mental Health Practice: Cases
and Practical Applications. Dr. Gray is known to be an informative and engaging
speaker and has received numerous awards; most notably, she was honored as a
mentor by the Council on Social Work Education s Council on the Role and Status
of Women in Social Work Education and received the lifetime achievement award
xxv
xxvi ABOUT THE AUTHOR
from the Florida Miami Dade National Association of Social Workers. Dr. Gray s
decision to become a teacher was based on her wish to continue to serve and to pay
forward all of the mentoring and support she received throughout her professional
career. Looking to the new generation of graduating social workers and experienced
practicing social workers, she hopes that this book will set the stage for readers to
find their way to positively influence the profession beginning each client, and one
case at a time.
1
An Introduction to the
Competency-Based
Assessment Model
INTRODUCTION
The now century-old tradition of psychiatric social work was one of several specia-
lizations, including medical social work and child welfare, that emerged during the
early part of the twentieth century. While the field of psychiatric social work grew
during the 1900s, social workers struggled when seeking employment because of
negative professional attitudes directed toward them. French (1940) identified
some of the problems associated with early psychiatric social work positions such
as large caseloads, low pay, and in some cases requirements to live on the institu-
tion s premises and perform nonprofessional duties within the institution.
The profession changed over time, and in the last part of the twentieth century,
social workers could be found serving all areas of the public and private mental
health sectors. During the past five decades, social workers have had considerable
flexibility in assessing clients, with the choice of using diagnostic categories found
in various editions of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) (5th ed., APA, 2013 [DSM-5]) or other psychosocial or behavioral criteria.
Looking at practice in the twenty-first century, some of the ways social workers
have historically assessed clients is in jeopardy, especially regarding specific diag-
nostic descriptions and interventions based on presenting symptoms. In an effort
to make the profession a convincing competitor in the marketplace, accountability
is one of the central themes for present-day contemporary social work practice. The
DSM classification system is often used to meet these accountability requirements
and for third-party payments. As a consequence, social workers are called upon to
2 CHAPTER 1
balance the profession s traditional focus on client strengths and resilience with the
symptom-based orientation organizing the DSM.
Looking to the future, changes in the service delivery structure of agencies, sig-
nificant cost containment efforts, and the federal health care reforms enacted in
2010 have moved the profession toward a further reevaluation of the assessment
process in clinical social work practice. The push toward reform of the private
health insurance market, and to provide better coverage for those with preexisting
conditions has set the stage for questions about spiraling medical expenses emerging
in the form of increased costs for employee insurance coverage, as well as care for
the poor and uninsured who currently seek medical treatment at emergency rooms
and public clinics. The full extent of the repercussions of the overhaul of the
American health care system are yet to be determined. Nonetheless, the implications
of these initiatives are the merging of public and private services; the shifting of
financial risk to service providers; the development of community-based service
alternatives; and an increased emphasis on client strengths and social supports.
Organized around theoretical underpinnings familiar to our profession, this book
is about a competency-based assessment model that keeps sight of the complexities
of life in vulnerable populations such as the mentally ill while formulating a differ-
ential diagnosis using the classification system found in the DSM.
Mental disorders are common, and in any given year, about 26.2 percent of
American adults over age 18 suffer from a mental disorder (National Institute of
Mental Health [NIMH], 2010). Looking to the rates of mental illness in children,
approximately 7 percent of a preschool pediatric sample were given a psychiatric
diagnosis in one study and approximately 10 percent of 1- and 2-year-olds receiving
developmental screening were assessed as having significant emotional/behavioral
problems (Carter, Briggs-Gowan, & Davis, 2004). Despite one s career direction
within the field of social work, practitioners in today s practice arena are more than
likely to encounter clients with mental illness. Those who work with individuals con-
sidered mentally ill recognize the need to learn how to decipher the DSM format. Part
of the problem in using the manual is that one might come away from it questioning
how the diagnostic criteria presented translate to the real-life clients and their strug-
gles seen in practice. Social workers must know not only how to assess individuals
effectively but also how to develop an appropriate intervention plan that addresses
clients needs.
The DSM format is not for amateurs and should not be considered a substitute
for professional training in assessment or the other skills needed to work with cli-
ents. For example, tasks such as performing mental status exams and monitoring of
medication (historically the sole domain of psychiatrists) are now routinely handled
by social workers. It is important to recognize that using a classification system can
never replace an assessment that considers the basic fact that people are quintes-
sentially social beings, existing with each other in symbiotic as well as parasitic rela-
tionships (Gitterman & Germain, 2008a, p. 41). That is, the person is much more
than his or her diagnosis. There have been a number of long-standing criticisms of the
DSM (see e.g., Dumont, 1987; Kirk & Kutchins, 1994; Kirk, Siporin, & Kutchins,
1989; Kutchins & Kirk, 1987). Being a social work practitioner as well as an
educator, my primary reason for writing this book is to help make the DSM
format more understandable and accessible to other social workers. This book
AN INTRODUCTION TO THE COMPETENCY-BASED ASSESSMENT MODEL 3
does not take a linear or traditional psychiatric approach; rather, it incorporates a

competency-based assessment as a vehicle to support the profession s historical ori-
entation to practice.
Developing a working knowledge of psychopathology is similar to mastering a
foreign language; at first everything seems confusing, but gradually the language
becomes understandable. Similarly, beginning social work students are often anxious
when asked to formulate an initial diagnosis, feeling they are somehow perpetuating
the tendency to pigeonhole, stereotype, or label people. The process is complicated
because most textbooks about mental disorders are written by psychiatrists or psy-
chologists and tend to be biased toward their authors own professional alliances. I
recognize that using the DSM-5 format has been a controversial topic within social
work practice (e.g., see Frances, 2012; Frances, 2013; Friedman, 2012). Since the
first introduction of the manual in the early 1950s, it has been used to describe and
classify mental disorders. Admittedly, the DSM is an imperfect system, and it has the
potential to stigmatize clients through labeling. However, despite its drawbacks, the
DSM continues to serve as the standard for evaluation and diagnosis. The aim in
writing this book is not to reinvent the proverbial wheel by creating a wannabe
mini-DSM. Rather, my concern for social work practitioners is the emphasis that
the DSM places on disease and illness obscures our profession s orientation,
which centers on client strengths. While practicing from a strengths perspective, the
social work practitioner does not ignore the hardships people living with a particular
diagnosis must face. Schizophrenia, for example, presents some very real challenges.
However, the competency-based assessment model expands the focus of the
evaluation to include looking at a person s abilities, talents, possibilities, hopes, and
competencies. Saleebey (2012) points out that people learn something valuable about
themselves when they struggle with difficulty as they move through life. Although this
book is organized around the DSM, I hope to simplify the language of psychopathol-
ogy in a way that will help to influence the kinds of information gathered, how it is
organized, and how it is interpreted. This interpretation includes looking at those
strengths that would be useful to the person who struggles with mental illness and
helps the social worker focus on the resourcefulness of a person, which is a beginning
step in restoring hope. In essence, the social worker looks at how people survive and
cope with a diagnosis of mental illness (Gitterman, 2014). A person s resourcefulness,
strengths, and coping become a part of the assessment process, ensuring that the
diagnosis does not become the center of his or her identity. The whole story of a
person must include the parts of his or her struggle that have been useful to them and
the positive information they have yielded.
The competency-based assessment includes the ability to differentially apply
knowledge of human behavior (specifically bio-psycho-social-spiritual theories) to
better understand the client s current functioning. Familiarity with the DSM diag-
nostic classification system is considered to be a part of this comprehensive
Competency
7b
approach to the assessment process. Competency-based practice emphasizes the
importance of identifying client competencies, and it focuses on assets instead of
deficits. More precisely, it strives to build and enhance the client s own skills as
they attempt to deal with life conditions.
The mental disorders found in the DSM will be presented here from a social
work perspective. Sometimes interesting historical information will be included; at
4 CHAPTER 1
other times editorial asides about exploration and assessment will be offered.
In most cases, a clinical case vignette is presented to help the reader keep in mind
the major features of assessment. Above all, the intent is to provide what social
workers need in a format that will prove clinically relevant, understandable, and
practitioner-friendly.
This book is not intended to address all of the specific DSM classifications, nor
does it include all specific disorders. It is anticipated that assessment criteria will be
advanced from a social work perspective while balancing the tensions inherent in
the medical model. The competency-based assessment encompasses an ecological
approach, the strengths perspective, and systems theory to determine what biopsy-
chosocial factors contribute to the client s problems, as well as factors that may be
useful in intervention planning. The struggle is to shift the lens away from defining
pathology and toward focusing on internal processes in which all of the social
and environmental factors that influence functioning are considered. Many current
textbooks are starting to move away from terminology describing those considered
mentally ill as patients. The DSM format has also moved away from such
negative descriptions. The ultimate challenge is to know how and when the DSM
Competency is effective and useful and how and when to keep its classification system in
7b perspective.
We now turn to a review of the DSM-5. This discussion is intended to update,
and in some cases reintroduce the reader to the core concepts of the diagnostic
assessment using the DSM-5.
THE DSM-5: APPROACHES TO THE ASSESSMENT

In December 2012, the American Psychiatric Association (APA) Board of Trustees
voted to approve the new DSM-5. This much-anticipated revision has been received
with both excitement and uncertainty. The manual was introduced at the APA s
national conference in May 2013, and copies were made available to the public
shortly thereafter. This latest version of the DSM represents the first major revision
in nearly 20 years since the initial publication of the fourth edition (DSM-IV) in
1994. Unlike earlier editions, there was an unprecedented openness and transpar-
ency never before seen in the manual s revision process. Specifically, the APA pub-
lished three separate drafts of the manual during 2012 on their website asking for
feedback. This resulted in approximately 13,000 comments and thousands of
emails and letters. National Institute of Mental Health (NIMH) director Thomas
R. Insel, MD, wrote in an April 29, 2013, blog post (Insel, 2013): The goal of
this new manual, as with all previous editions, is to provide a common language
for describing pathology. While DSM has been described as a Bible for the field,
it is, at best, a dictionary, creating a set of labels and defining each. The strength of
each of the editions of DSM has been reliability each edition has ensured that
clinicians use the same terms in the same ways.
Why has the DSM taken on such a large role in mental health practice? It may
be related to the reality that the prevalence of mental disorders touches most peo-
ple s lives or someone we know. Mental disorders are common in the United States.
The Centers for Disease Control and Prevention (CDC) report, Mental Illness
AN INTRODUCTION TO THE COMPETENCY-BASED ASSESSMENT MODEL 5
Surveillance among Adults in the United States, released on September 2, 2011,

indicates that nearly 50 percent of U.S. adults will develop at least one mental ill-
ness during their lifetime (CDC, 2011). Fortunately, only about 5.8 percent of the
U.S. population, or 1 in 17 adults, struggles with a severe mental disorder (NIMH,
2010). Considered as the gold standard, the DSM establishes the almost univer-
sal measure by which medical professionals diagnose and ultimately treat mental
disorders, making it an essential part of the field of psychiatry. In addition, the
DSM is used by clinicians in the field of mental health, and also by researchers
and health insurance companies. As well, the DSM s criteria for specific disorders
is used to determine insurance coverage, grant funding, and new mental health
policies. Even so, the final published edition of the DSM-5 was welcomed with
both praise and challenge from mental health professionals.
As a response to criticism of the DSM-5, the DSM-5 task force chair, David
Kupfer, MD, identified the conceptual framework that guided the development of
the manual (Kupfer, 2013):
Chapters of the specific disorders have been revised to signal how disorders
may relate to each other based on underlying vulnerabilities or symptom
characteristics.
The specific disorders are framed in the context of age, gender, and cultural
explanations in addition to being organized along a developmental life span
within each chapter.
Key disorders were combined (or reorganized) because the relationships among
the different categories placed them along a single continuum, such as (the
newly introduced) substance use disorder and autism spectrum disorder.
A new section of the manual introduces emerging measures, models, and cul-
tural guidance to help clinicians in their evaluation of patients. For the first
time, self-assessment tools are included in the manual with the intent to directly
include patients in their diagnosis and care.
There is also a greater alignment with the ICD-11. The number 11 represents
the most recent version of the International Classification of Diseases (ICD), which
is a coding system used to classify morbidity data from inpatient and outpatient
records, physician offices, and most National Center for Health Statistics (NCHS)
surveys. The NCHS serves as the World Health Organization (WHO) Collaborat-
ing Center for the Family of International Classifications for North America. In this
capacity, the center is responsible for coordination of all official disease classifica-
tion activities in the United States relating to the ICD and its use. The manual
attempts to harmonize with the ICD-11, which is expected to be released sometime
in 2015. The DSM-5 also places a greater reliance on the genetic and neurobiologi-
cal research that support a biologic etiology of many psychiatric disorders; for
example, schizophrenia, autism spectrum, or depressive disorders. The biological
aspects are a good fit with the competency-based assessment, which looks at the
range of factors affecting a client, including biological influences.
Consistent with previous editions of the manual, using the revised DSM under-
scores the need for clinical training and practice experience in order to accurately
distinguish between normal reactions to things that can happen in a person s life
and those responses that can be diagnosed as a mental disorder. Many of the
6 CHAPTER 1
changes in the DSM-5 will now require even experienced practitioners to relearn
how to classify and conceptualize a number of disorders. These revisions support
the focus of this edition of the book, which is intended to demystify what can be a
complex and intimidating process to diagnose clients. You will notice a number of
additional cases, which are intended to feature the diagnoses that are new to the
DSM-5. Cases in the earlier editions of our book have been slightly modified to
highlight the revised diagnostic process.
We now turn to the DSM-5 definition of a mental illness to set the stage for a
more detailed review of how to use the DSM-5.
THE DSM-5 DEFINITION OF MENTAL ILLNESS

A long-standing challenge in the field of mental health practice has been making the dis-
tinction between what is a mental disorder and what can be regarded as a normal
behavior. The DSM-5 proposed some changes to the definition of mental illness in an
attempt to provide a more scientifically valid and clinically useful definition (Stein et al.,
2010). According to the DSM-5 (APA, 2013, p. 20), the following elements are
required in order to diagnose mental illness:
A mental disorder is a syndrome characterized by clinically significant distur-
bance in an individual s cognition, emotion regulation, or behavior that reflects
a dysfunction in the psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are usually associated with
significant distress or disability in social, occupational, or other important
activities. An expectable or culturally approved response to a common stressor
or loss, such as the death of a loved one, is not a mental disorder. Socially
deviant behavior (e.g., political, religious, or sexual) and conflicts that are
primarily between the individual and society are not mental disorders unless
the deviance or conflict results from a dysfunction in the individual, as
described above.
Using this definition, the practitioner approaches the assessment by looking for a
behavioral or psychological syndrome or pattern that reflects an underlying psycho-
biological dysfunction. Mental illness is considered when the consequences of these
conditions cause the person clinically significant distress or disability that is not an
expectable response to common stressors and losses, a culturally sanctioned response
to a particular event, or a result of social deviance or conflicts with society. Disorders
are seen as a spectrum that can be scored in terms of severity rather than discrete
categories. The rationale for moving in this direction is based on research that sug-
gests the underlying biology of mental disorders is more dimensional than categorical
(Kupfer & Regier, 2011). The guiding principles organizing the DSM-5 take into
account the neurological and dimensional features of mental disorders.
Earlier versions of the DSM were organized around a categorical approach. For
instance, if someone had four of nine symptoms of major depression, they did not
meet the threshold for a diagnosis. In contrast, if five of nine symptoms were
evident, then the person met criteria for a diagnosis of major depression. For all
intents and purposes, the categorical approach is seen as an all-or-nothing approach
to making a diagnosis. While a person must still meet criteria for a particular
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year to be good in, as little Christian says, a new year to live and learn in. It
is true that, perhaps, you may not see its end; but, nevertheless, it is the
beginning of a new year with many opportunities, both of doing and
receiving good, and therefore we should be glad, and we should ask God to
make us His faithful servants, loving Him and keeping His commandments
all through this year, and if God does that you may be sure this will be a
very happy new year to us all. Well, Halbert,” he continued, turning to his
son, who was back again by Aunt Christian’s side, “has little Christian
satisfied you?”
Halbert’s face and conscience were both quite cleared; it was right to be
glad on a new year’s day, and he got a promise that that night he should
hear some of the many things which had happened on former new years’
days, and had made that day a special anniversary in the family; and
besides, the relation of these things was to be committed to Aunt Christian,
therefore Halbert was quite satisfied. And then the seniors closed round the
fireside, and all the children—with the exception of Halbert Melville and
Mary Hamilton, the eldest of the two families, who hang by Aunt Christian
still—sought more active amusement in the farther corners of the room, and
recollections of those bygone years became the long lingered on subject
with Halbert, Charles, Christian, and the two Marys; and they looked back
with half-wondering gaze upon the past, as men look through the wondrous
glass of science on the clear outline of some far distant shore, of which the
human dwellers, the fears and hopes, the loves and sorrows, which people
the farther sides of the blue slopes that yet linger in their view, have all
faded from their retiring vision.
But then comes a distant shout from the lobby into which some of the
children have strayed in their play, of “Uncle James! Uncle James!” and
here he is. Older, of course, yet looking much as he looked in the old times;
though we must whisper that the bridegroom whom we saw some fourteen
or fifteen years ago at the commencement of this story, has now, at its
conclusion, become a portly gentleman; in good sooth, most
unsentimentally stout, and with a look of comfort and competence about
him, which speaks in tones most audibly, of worldly success and prosperity.
A good man, too, and a pleasant, he is, with the milk of human kindness
abounding in his heart; as such Mr. James Melville is universally
considered and honoured, though with scarcely so large a heart as his
brother the minister, nor so well mated. It is true, Mrs. James, since she
found out who her friend of ten years ago was; and Mary’s reasons for
rejecting what seemed so good a match, and the failure, the utter failure of
her party on that new year’s night in consequence; has grown wonderfully
careful, and begins to discover that there are pleasanter things in life, than
the collecting together a dozen or two of people to be entertained or wearied
according to their respective inclinations, and her fireside has grown a
much more cheerful one always, though for a few nights in the year less
brilliant than heretofore; and her husband’s quotations of “Christian” have
grown less disagreeable to her ears, though still she sometimes resents the
superiority which everybody accords to her. James is always welcomed in
his brother Halbert’s house, and never more warmly than on New Year’s
night; for Elizabeth does not accompany him on these annual occasions;
and even that loving circle feel relieved by her absence at such a time, for
the conversation generally runs upon certain remembrances which she
would not like to hear; and which none of them would like to mention in
her presence. So James sits down and joins them for awhile in their
recalling of the past; and little Halbert Melville gazes at his father in open-
mouthed astonishment, as he hears him speak of being the cause of
unhappiness and sorrow to Aunt Christian and Aunt Mary, and to Uncles
James and Robert, and his grave old grandfather who died two years ago.
His father—and Halbert would have defied anybody but that father’s self.
Yes! even Aunt Christian, if she had said such words as these—his father
cause unhappiness and sorrow to anybody!—his father, whom old Ailie,
still a hale and vigorous old woman, and chief of Christian’s household, and
prima donna in Mary Melville’s nursery, had told him was always as kind
and good to everybody all through his life as he was now! Halbert could not
believe it possible. And little Mary Hamilton’s eyes waxed larger and
larger, in amazement, as Aunt Christian spoke of her mother—her mother
whom she had never seen without a smile on her face, being at that
infinitely remote period before any of them were born, most unhappy
herself; yes, very unhappy! Mary would have denied it aloud, but that she
had too much faith in Aunt Christian’s infallibility, to doubt for an instant
even her word. This night was a night of wonders to these two listening
children.
But the time passed on, and Uncle James—while yet the other little ones
were engaged in a merry game, chasing each other throughout all the house,
from the glowing kitchen, clean and bright, up to the nursery where old
Ailie presided in full state and glory—must go. Elizabeth was unwell; and
he felt it was not seemly to be from home, loth and reluctant as he was to
leave that fireside and its loving circle. So Uncle James prepared to go
home; and down rushed again the whole merry band, deserted Ailie, even in
the midst of one of her old-world stories, to bid him good-night; and thus
environed by the little host with shouts as loud as had welcomed his arrival,
Uncle James went away home.
CHAPTER II.
Men rail upon the Change!

* * * * *
But think they as they speak?
Thou softener of earth’s pain,
Oh Change! sweet gift of the Infinite to the weak,
We hail alike thy sunshine and thy rain;
Awe dwells supreme in yon eternal light,
Horror in misery’s doom;
But frail humanity dares breathe, when bright
Thy tremulous radiance mingles with the gloom.—Y.S.P.
NCLE JAMES has just gone, and the group of elders in the
parlour are just drawing their chairs closer together to fill up the
gap which his departure has made, when they hear a hasty knock
at the door; a hasty, imperative summons, as if from urgent need
that would not be denied access, and a dripping messenger stands on the
threshold—for the cold rain of winter falls heavily without—begging that
Mr. Melville would go with him to see a dying man, a stranger who has
taken up his residence for the last few weeks at a small inn in the
neighbourhood, and was now, apparently, on the very brink of death, and in
a dreadful state of mind. The calls of the sick and dying were as God’s
special commands to Halbert; and he rose at once to accompany the
messenger, though the faces of his wife and sisters twain, darkened with
care as he did so. It was very hard that he should be called away from them
on this especial night; and when he firmly declared he would go, Mary
whispered to Charles to go with him, and to bring him soon back. The two
brothers went away through the storm, and the sisters drew closer to each
other round the fire, as the gentlemen left them; then Mrs. Melville told the
others how anxious she always was when her husband was called out in this
way; how he might be exposed to infection in his visiting of the sick so
assiduously as he did; and how, for his health’s sake, she could almost wish
he were less faithful and steady in the discharge of these his duties: and
Mary looked at her in alarm as she spoke, and turned pale, and half
upbraided herself for having unnecessarily exposed Charles, though a more
generous feeling speedily suppressed her momentary selfishness. But
Christian was by, and when was selfishness of thought, or an unbelieving
fear harboured in Christian’s gentle presence?
“Mary! Mary!” she exclaimed, as she turned from one to the other, “are
you afraid to trust them in the hands of your Father? They are but doing
what is their duty, and He will shield His own from all evil. Would you
have your husband, Mary Melville, like these ministers whose whole work
is their sermons—alas! there are many such—and who never try, whether
visiting the sick and dying, or the vicious and criminal, would not advance
their Master’s cause as well—would you that, rather than Halbert’s going
forth as he has done to-night?”
“No, no; but it is terrible for me to think that he is exposed to all kinds of
contagion; that he must go to fevers, and plagues, and diseases that I cannot
name nor number, and run continually such fearful risks,” said Mary,
energetically.
“Our Father who is in Heaven, will protect him,” said Christian,
solemnly. “I have heard of a minister in London, who never for years ever
thinks of seeing after his own people in their own homes; it is too much
labour, forsooth, he is only their preacher, not their pastor; and though he
sends—Reverend Doctor that he is—his deacons and such like to visit; it’s
seldom that himself ever goes to a poor sick bed, and as to his trying to
reclaim the vicious, there is not on his individual part the least attempt or
effort. Now, Mary, would you have Halbert such a man as that?”
“I would rather see him lying under the direfullest contagion. I would
rather that he was stricken by the Lord’s own hand, than that it should be
said of Halbert Melville that he flinched in the least degree from the work
which the Lord has laid upon him,” returned Mary, proudly elevating her
matronly form to its full height, with a dignity that gladdened Christian’s
heart.
“Yet that man in London will be well spoken of,” said Mary Hamilton,
“and our Halbert unknown. No matter: the time will come when Halbert
will be acknowledged openly; and now, Christian, I feel assured and
pleased that Charles went out with Halbert.”
“And you may, when they went on such an errand,” said Christian;
“but”—and she continued briskly, as if to dispel the little gloom which had
fallen upon them, and resuming the conversation, which had been broken
off on the departure of the gentlemen—“but Robert writes me, that he is
very comfortably settled, and likes his new residence well.”
“I am sorry,” said Mrs. Melville, after a pause, during which her
agitation had gradually subsided, “I am sorry that I saw so little of Robert.
He and I are almost strangers to each other.”
“Not strangers, Mary, while so nearly connected,” said Christian, kindly.
“Moreover, Robert gives me several very intelligible hints about a young
lady in your uncle’s family to whom you introduced him.”
“Indeed!” exclaimed Mrs. Melville, “no doubt he means my cousin
Helen. Oh, I am very glad of that. Your brothers are too good, Christian, to
be thrown away on cold-hearted, calculating people, who only look at
money and money’s worth——” and as the words fell from her lips, she
stopped and blushed, and hesitated, for Mrs. James flashed upon her mind,
and the comparison seemed invidious.
“You are quite right, Mary,” said the other Mary, smiling; “and if Robert
be as fortunate as Halbert has been, we shall be a happy family indeed.”
Did Christian’s brow grow dark with selfish sorrow, as she listened to
these mutual congratulations? Nay, that had been a strange mood of
Christian’s mind in which self was uppermost, or indeed near the surface at
all; and her whole soul rejoiced within her in sympathetic gladness. Nor,
though they were happy in the full realisation of their early expectations,
did she hold herself less blessed; for Christian bore about with her, in her
heart of hearts, the holy memory of the dead, and in her hours of stillest
solitude felt not herself alone. An angel voice breathed about her in
whispering tenderness when she turned over the hallowed leaves of yon old
Bible; and when the glorious light of sunset fell on her treasured picture, it
seemed, in her glistening eyes, to light it up with smiles and gladness; and
the time is gliding on gently and silently, day upon day falling like leaves in
autumn, till the gates of yon far celestial city, gleaming through the mists of
imperfect mortal vision, shall open to her humble footsteps, and the beloved
of old welcome her to that everlasting reunion; and therefore can Christian
rejoice, as well on her own account, as in ready sympathy with the joyful
spirits round about her.
But the present evening wore gradually away, and the children became
heavy, weary, and sleepy, and the youngest of all fairly fell asleep; and Mrs.
Melville looked at her watch anxiously, and Mary said she could not wait
for Charles, but must go home; but here again Christian interposed. The
little Melvilles and Hamiltons had slept under the same roof before now,
and being too far gone in weariness to have joined in their domestic
worship, even had the elders been ready to engage in it, were taken off by
twos and threes indiscriminately to their respective chambers; and the three
sisters are left alone once more, maintaining, by fits and starts, a
conversation that showed how their thoughts wandered; and, in this dreary
interval of waiting for the home-coming of Halbert and Charles, listening to
the doleful dropping of the slow rain without, until the long-continued
suspense became intolerably painful. At length footsteps paused at the door;
there was a knock, and some one entered, and each drew a long breath as if
suddenly relieved, though Mrs. Melville started again, and became deadly
pale, when Charles Hamilton entered the room alone. He seemed much
agitated and distressed.
“Where is Halbert?” Mrs. Melville exclaimed; and her cry was echoed
by the others at the fireside. “Has anything happened to Halbert?”
“Nothing—nothing: Halbert is quite well,” said Charles, sitting down
and wiping the perspiration from his forehead, while Halbert’s wife clasped
her hands in thankfulness. “He will be here soon; but I come from a most
distressing scene—a deathbed—and that the deathbed of one who has spent
his life as an infidel.”
“A stranger, Charles?” asked Mary.
“A stranger, and yet no stranger to us,” was Charles’s answer; and he
pressed his hands on his eyes, as though to shut out the remembrance of
what he had so lately witnessed. As he spoke, the servants entered the room
for the usual evening worship, under the impression that the master had
returned; and Charles Hamilton took Halbert’s place; and wife, and
Christian, and the other Mary, marvelled when Charles’s voice arose in
prayer, at the earnest fervent tone of supplication with which he pleaded for
that dying stranger, that the sins of his bygone life might not be
remembered against him; and that the blood of atonement, shed for the
vilest, might cleanse and purify that polluted soul, even in the departing
hour; and to these listeners there seemed a something in Charles’s prayer, as
if the dying man and the sins of his fast fading life were thoroughly familiar
to him and them.
A dreary journey it was for Halbert and Charles Hamilton as they left the
warm social hearth and threaded the narrow streets in silence, following the
sick man’s messenger. It was a boisterous night, whose windy gusts whirled
the heavy clouds along in quick succession, scattering them across the dark
bosom of the sky, and anon embattling them in ponderous masses that
lowered in apparent wrath over the gloomy world below. A strange contrast
to the blithe house they had left was the clamour and rudeness of the
obscure inn they entered now, and an unwonted visitor was a clergyman
there; but up the narrow staircase were they led, and pausing for an instant
on the landing-place, they listened for a moment to the deep groans and
wild exclamations of impatient agony, as the sufferer tossed about on his
uneasy bed.
“Ay, sir,” said a servant, who came out of the room with a scared and
terrified expression upon her face, in answer to Halbert’s inquiry; “ay, sir,
he’s very bad; but the worst of it is not in his body, neither!” and she shook
her head mysteriously; “for sure he’s been a bad man, and he’s a deal on his
mind.”
She held open the door as she said so, and the visitors entered. The
scanty hangings of his bed hid them from the miserable man who lay
writhing and struggling there, and the brothers started in utter amazement as
they looked upon the wasted and dying occupant of that poor room; the
brilliant, the fashionable, the rich, the talented Forsyth—where were all
these vain distinctions now?—lay before them, labouring in the last great
conflict; poor, deserted, forlorn, and helpless, without a friend, without a
hope, with scarce sufficient wealth to buy the cold civility of the terrified
nurse who tended him with mercenary carelessness; pressing fast into the
wide gloom of eternity, without one feeble ray of life or hope to guide him
on that fearful passage, or assuage the burning misery of his soul ere it set
out. Halbert Melville, deceived by that poor sufferer of old, bent down his
face on his clasped hands, speechless, as the well-known name trembled on
his companion’s tongue,—
“Forsyth!”
“Who calls me?” said the dying man, raising himself fearfully on his
skeleton arm, and gazing with his fiery sunken eyes through the small
apartment. “Who spoke to me? Hence!” he exclaimed, wildly sitting up
erect and strong in delirious fury. “Hence, ye vile spirits! Do I not come to
your place of misery? Why will ye torment me before my time?”
His trembling attendant tried to calm him: “A minister,” she said, “had
come to see him.” He said: “He allow a minister to come and speak with
him?”
A wild laugh was the response. “To speak with me, me that am already
in torment! Well, let him come,” he said, sinking back with a half-idiotic
smile, “let him come”—— and he muttered the conclusion of the sentence
to himself.
“Will you come forward, sir?” said the nurse, respectfully addressing
Halbert. “He is composed now.”
Trembling with agitation, Halbert drew nearer the bedside, but when
those burning eyes, wandering hither and thither about the room, rested on
him, a maniac scream rang through the narrow walls, and the gaunt form sat
erect again for a moment, with its long arms lifted above its head, and then
fell back in a faint, and Halbert Melville hung over his ancient deceiver as
anxiously as though he had been, or deserved in all respects to be, his best
beloved; and when the miserable man awoke to consciousness again, the
first object his eye fell upon, was Halbert kneeling by his bedside, chafing
in his own the cold damp hand of Forsyth, with kindest pity pictured on his
face. Had Halbert disdained him, had he shunned or reproached him, poor
Forsyth, in the delirious strength of his disease, would have given him back
scorn for scorn, reproach for reproach. But, lo! the face of this man, whom
he had wounded so bitterly, was beaming on him now in compassion’s
gentlest guise; and the fierce despairing spirit melted like a child’s, and the
dying sinner wept.
“Keep back, Charles!” whispered Halbert, as he rose from the bedside;
“the sight of you might awaken darker feelings, and he seems subdued and
softened now. There may yet be hope.”
Hope!—the echo of that blessed word has surely reached the quick ear
of the sufferer; and it draws from him a painful moan and bitter repetition as
he turns his weary form on his couch again: “Hope! who speaks of hope to
me?”
“I do,” said Halbert Melville, mildly looking upon the ghastly face
whose eyes of supernatural brightness were again fixed upon him. “I do,
Forsyth; I, who have sinned as deeply, and in some degree after the same
fashion as you. I am commissioned to speak of hope to all—of hope, even
on the brink of the grave—of hope to the chief of sinners. Yes, I am sent to
speak of hope,” he continued, growing more and more fervent, while the
sick man’s fascinated attention and glowing eyes followed each word he
uttered and each motion of his lifted hand. “Yes, of hope a thousand times
higher in its faintest aspirations than the loftiest ambition of the world.”
“Ay, Melville,” he murmured, feebly overcome by his weakness and
emotion. “Ay, but not for me, not for one like me. Why do you come here to
mock me?” he added fiercely, after a momentary pause; “why do you come
here to insult me with your offers of hope? I am beyond its reach. Let me
alone; there is no hope, no help for me!” and again his voice sunk into
feebleness, as he murmured over and over these despairing words, like,
Charles Hamilton said afterwards, the prolonged wail of a lost soul.
“Listen to me, Forsyth,” said Halbert, seating himself by the bedside,
and bending over the sufferer. “Listen to me! You remember how I denied
my God and glorified in the denial when last I saw you. You remember how
I renounced my faith and hope,” and Halbert, pale with sudden recollection,
wiped the cold perspiration from his forehead. “You know, likewise, how I
left my home in despair—such despair as you experience now. Listen to
me, Forsyth, while I tell you how I regained hope.”
Forsyth groaned and hid his face in his hands, for Halbert had touched a
chord in his heart, and a flood of memories rushed back to daunt and
confound him, if that were possible, still more and more; and then, for there
seemed something in Halbert’s face that fascinated his burning eyes, he
turned round again to listen, while Halbert began the fearful story of his
own despair—terrible to hear of—terrible to tell; but, oh! how much more
terrible to remember, as what oneself has passed through. With increasing
earnestness as he went on, the poor sufferer gazed and listened, and at every
pause a low moan, wrung from his very soul, attested the fearful
faithfulness of the portraiture, true in its minutest points. It was a sore task
for Halbert Melville to live over again, even in remembrance, those awful
years, and exhibit the bygone fever of his life for the healing of that
wounded soul; but bravely did he do it, sparing not the pain of his own
shrinking recollection, but unfolding bit by bit the agonies of his then
hopelessness, so fearfully reproduced before him now in this trembling
spirit, till Charles, sitting unseen in a corner of the small apartment, felt a
thrill of awe creep over him, as he listened and trembled in very sympathy;
but when Halbert’s voice, full of saddest solemnity, began to soften as he
spoke of hope, of that hope that came upon his seared heart like the sweet
drops of April rain, reviving what was desolate, of hope whose every smile
was full of truthfulness, and certainty, firmer than the foundations of the
earth, more enduring than the blue sky or the starry worlds above, built
upon the divine righteousness of Him who died for sinners;—the heart of
the despairing man grew sick within him, as though the momentary gleam
which irradiated his hollow eye was too precious, too joyful, to abide with
him in his misery—and, lo! the hardened, obdurate, and unbelieving spirit
was struck with the rod of One mightier than Moses, and hiding his pale
face on his tear-wet pillow, the penitent man was ready to sob with the
Prophet, “Oh! that mine head were waters, and mine eyes a fountain of
tears!”
A solemn stillness fell upon that sick-room when Halbert’s eloquent tale
was told; a stillness that thrilled them as though it betokened the presence of
a visitor more powerful than they. The solitary light by the bedside fell
upon the recumbent figure, with its thin arms stretched upon the pillow, and
its white and ghastly face hidden thereon—full upon the clasped hands of
God’s generous servant, wrestling in silent supplication for that poor
helpless one. It was a solemn moment, and who may prophesy the issue, the
end of all this? A little period passed away, and the fever of the sick man’s
despair was assuaged, and weariness stole over his weak frame, with which
his fiery rage of mind had hitherto done battle; and gentle sleep, such as had
never refreshed his feeble body since he lay down on this bed, closed those
poor eyelids now. Pleasant to look upon was that wasted face, in
comparison with what it was when Halbert Melville saw its haggard
features first of all this night. God grant a blessed awakening.
Softly Halbert stole across the room, and bade Charles go; as soon as he
could leave Forsyth he promised that he would return home, but it might be
long ere he could do that, and he called the nurse, who was waiting without
the door, to see how her patient slept. She looked at him in amazement. Nor
was the wonder less of the doctor, who came almost immediately after—he
could not have deemed such a thing possible, and if it continued long, it yet
might save his life, spent and wasted as he was; but he must still be kept in
perfect quietness. Halbert took his station at the bedside as the doctor and
nurse left the room, and shading Forsyth’s face with the thin curtain, he
leant back, and gave himself up for a time to the strange whirl of excited
feeling which followed. The memories so long buried, so suddenly and
powerfully awakened; the image of this man, as he once was, and what he
was now. Compassion, interest, hope, all circled about that slumbering
figure, till Halbert’s anxiety found vent in its accustomed channel, prayer.
The night wore slowly on, hour after hour pealed from neighbouring clocks
till the chill grey dawn of morn crept into the sick-room, making the
solitary watcher shiver with its breath of piercing cold; and not until the
morning was advanced, till smoke floated over every roof, and the bustle of
daily life had begun once more, did the poor slumberer awake.
Wonderingly, as he opened his eyes, did he gaze on Halbert: wonderingly
and wistfully, as the events of the past night came up before him in
confused recollections, and he perceived that Halbert, who bent over him
with enquiries, had watched by his side all night. Forsyth shaded his eyes
with his thin hand, and murmured a half weeping acknowledgment of
thankfulness, “This from you, Melville, this from you!”
CHAPTER III.
Hope the befriending,

Does what she can, for she points evermore up to heaven, and faithful
Plunges her anchor’s peak in the depths of the grave, and beneath it
Paints a more beautiful world * * * *
* * * Then praise we our Father in Heaven,
Him, who has given us more; for to us has Hope been illumined;
Groping no longer in night; she is Faith, she is living assurance;
Faith is enlighten’d hope; she is light, is the eye of affection;
Dreams of the longing interprets, and carves their visions in marble;
Faith is the sun of life; and her countenance shines like the Prophet’s,
For she has look’d upon God.—Evangeline.
HERE were anxious enquiries mingling with the glad welcome

which Halbert Melville received as he entered his own house on
that clear cold winter’s morning,—for the evening’s rain had
passed away, and frost had set in once more—enquiries that
showed the interest which both his own Mary and Christian—for
Christian’s society, though she did not allow it to be monopolised by either,
was claimed in part by both the Marys, and her time divided between them
—felt in the unhappy sufferer.
“Does Mary know, Christian?” was one of Halbert’s first questions.
“Yes,” was the answer, “and much was she shocked and grieved, of
course; as was Charles also, but we were all rejoiced to hear from him that a
happy influence seemed at work before he left you. Has it gone on? Can he
see any light yet, Halbert?”
“I dare not answer you, Christian,” said her brother gravely. “I know too
well the nature of Forsyth’s feelings to expect that he should speedily have
entire rest; but God has different ways of working with different
individuals, and I have reason to give Him thanks for my own terrible
experience, as I believe my account of it was the means of softening the
heart of yon poor despairing man.”
“How wonderful, Halbert,” said Christian, laying her hand on his
shoulder; “how wonderful are the ways and workings of Providence. Who
could have imagined that you were to be the instrument, as I trust and pray
you may be, of turning your old tempter from the evil of his ways, and
leading him into the way of salvation!”
A month of the new year glided rapidly away, when one mild Sabbath
morning, a thin pale man, prematurely aged, entered Halbert Melville’s
church. The exertion of walking seemed very great and painful to him, and
he tottered, even though leaning on his staff, as he passed along to a seat. A
sickly hue was still upon his wasted features, and the hair that shaded his
high forehead was white, apparently more from sorrow than from years.
When he had seated himself, he cast around him a humble wistful glance, as
though he felt himself alone and begged for sympathy; and people of kindly
nature who took their places near him, felt themselves powerfully drawn to
the lonely stranger who looked so pale, and weak, and humble, and
wondered who he was; and many of them who watched him with
involuntary interest, noticed the quick flush that passed over his face as
Mary Hamilton entered, and how he gazed upon the other Mary, and
lingered with glistening eyes on every little one of the two smiling families,
as though their childish grace rejoiced his heart; but the observers wondered
still more when their minister had entered the pulpit to see the big round
tears which fell silently upon the stranger’s open Bible, and the expression
of almost womanly tenderness that shone in every line of his upturned face.
Mr. Melville, they said afterwards, was like a man inspired that day—so
clear, so full, so powerful was his sermon. His text was in one of Isaiah’s
sublime prophecies. “Look unto me and be ye saved, all the ends of the
earth, for I am God, and besides me there is none else.” And as he drew
with rapid pencil the glorious character of the divine speaker, in all the
majesty of the original Godhead, and also of his Mediatorial glory, his
hearers felt that he that day spoke like one inspired. Vividly he described
them lost in natural darkness, groping about the walls of their prison-house,
labouring to grasp the meteor light which flitted hither and thither about
each earthly boundary, hopeless and helpless, when this voice rang through
the gloom, “Look unto me and be ye saved.” Vividly he pictured the
entering light, which to the saved followed these words of mercy, steady,
unfailing, and eternal, that sprung from point to point of these desolate
spirit cells, illuminating the walls with heavenly radiance, and making them
prisons no longer, but changing them into temples dedicate to the worship
of the highest. “My brethren,” said the eloquent preacher, bending down in
his earnestness, as though he would speak to each individual ere he
concluded. “There are those among you who know the blessedness of being
thus plucked from the everlasting burnings—there are among you those
who have worn out years in a fiery struggle before they found rest;” and the
voice of the preacher trembled; “and there are those whose anguish has
been compressed into a little round of days; but I know also that there are
some here who can echo the words of one who knew in his own dread
experience the agony of despair:
“ ‘I was a stricken deer that left the herd

Long since, with many an arrow deep infixed
My panting sides were charged;’
and I rejoice to know that here there are those who can continue in the same
words—
“ ‘There ’twas I met One who had himself

Been hit by the archers, in his hands he bore
And in his pierced side, their cruel wounds;
With gentle force soliciting the darts,
He drew them out, and heal’d, and bade me live.’
and, oh, my brethren, did you but know the fearful suffering, the hopeless
anguish that follows a course of lost opportunities and despised mercies,
you would not need that I should bid you flee! escape for your lives, tarry
not in the cell, the plain fair and well watered, and like the garden of the
Lord though it seem; escape to the mountain lest ye be consumed. ‘Look
unto me and be ye saved, all the ends of the earth, for I am God, and
besides me there is none else.’ ”
The face of the lonely stranger is hidden, but those who sit near him are
turning round in wonder at the echoing sob which bore witness to the effect
of these thrilling words upon his mind; but when the minister had closed his
book, and the people united their voices in praise before the service ended,
the weak low accents of that humble man were heard mingling among
them, for he had found hope, even such hope and peace as the preacher of
this day had proclaimed in yonder dim sick-chamber to its dying occupant;
and this lowly man was he, raised as by a miracle at once from the gates of
hell, and from the brink of the grave. With gentle sympathy did Halbert
Melville, his work of mercy over, press the hand of that grateful man; with
kindly anticipation of his unexpressed wish did he bring the children one by
one before him, and they wondered in their happy youthfulness as the hand
of that slender stooping figure trembled on each graceful head; and when
the two little Marys hand in hand came smiling up Forsyth did not ask their
names. He discovered too clearly the resemblance shining in the daughter,
and scarce less distant in the niece of Mary Melville of old, and he
murmured blessings upon them. He feared to hear the name which brought
so many painful recollections in its sweet and pleasant sound.
But when a little time had passed away, Forsyth learned to love the very
shadow of Mary Melville’s eldest born, and cherished her as she sprang up
in graceful girlhood, as though she had been the child of his own old age,
the daughter of his heart. The solitary stranger was soon better known to the
hearers of the Rev. Halbert Melville, for he lingered about the place as
though its very stones were dear to him. Forsyth had made no friends in his
long season of sinful wealth and prosperity—gay acquaintances he had had
in plenty who joined his guiltiness, and called themselves friends, until the
new course of folly and excess on which he entered with headlong avidity
after Mary Melville rejected him, had dissipated his substance and made
him poor, and then the forlorn sufferer in his obscure apartment found out
the true value of these his heartless companions’ friendship. But now, a new
man among friends on whose unworldly sincerity he could rely without a
shadow of a doubt, his very worldly prospects brightened, and gathering the
remnants of his broken fortunes, he began now to use the remainder of
God’s once abundant gifts with a holy prudence, that made his small
substance more valuable a thousand fold, than the larger income that had
been so lavishly expended in the long years of his guilt and darkness; a
changed man was he in every particular, the talent which made him
foremost in the ranks of infidelity was laid upon God’s altar now, a
consecrated thing, and men who knew him first after his great changes,
marvelled at his strange humility, so unlike the world in its simple
lowliness. When he was told of the sinful and erring he bent his head and
blamed them not, for the remembrance of his own sins filled him with
gentlest charity, and when deed of mercy was to be done, that needed
earnest exertion and zealous heart, the mild and gentle Forsyth was ever
foremost delighting in the labour.
The threads of our tale have nearly run out; and we have but, as knitters
say, to take them up ere we finish. Our Halbert Melville is famed and
honoured; a wise and earnest minister, faithful and fervent in his pulpit,
unwearying in daily labour. His gentle Mary becomes the sweet dignity of
her matronhood well, rejoicing in the happy guardianship of these fair
children. Nor is the other Mary less blessed: the liberal heavens have rained
down gifts upon them all; seed-time and harvest, summer and winter, have
passed over their heads; but death and sorrow, making sad visits to many
homes around them, and leaving havoc and desolation in their train, have
never in their stern companionship come across these peaceful thresholds.
Now we must draw the veil, lest we should feel the hot breath of sickness in
these happy households, or see the approaching shadow of grief darkening
their pleasant doorways.
Our friend James grows rich apace; and were you to see his portly figure
and shining face “on Change,” where merchants most do congregate, you
would be at no loss to understand why his opinion is now so weighty and
influential. Messrs. Rutherford and Melville left a goodly beginning for
their more enterprising successor; and James is now a most prosperous,
because a most enterprising man. Robert, too, though at a distance in
another city, the resident partner of his brother’s great house, speeds well in
his vocation; and wedding one of his gentle sister-in-law’s kindred, has
made up our tale. The Melvilles are truly, as Mary said, a happy family.
But how shall we say farewell to our companion of so many days and
various vicissitudes—our generous single-minded Christian Melville; fain
would we linger over every incident of thy remaining story. Fain look upon
thee once more, dear Christian, in the sacred quietness of thine own
chamber, recalling the holy memories of the past. Fain go with thee through
thy round of duties, rejoicing in the love which meets thy gracious presence
everywhere. Fain would we add to our brief history another tale, recording
how the stubborn resolutions of a second Halbert would yield to no
persuasions less gentle than thine; and how the guileless hearts of the twain
Marys unfolded their most secret thinkings in sweetest confidence to only
thee; how thou wert cherished, and honoured, and beloved, dear Christian;
how willingly would we tell, how glad look forward through the dim future,
to prophesy thee years of happiness as bright and unclouded as this, and
testify to the truth of that old saying of Halbert’s, “that Christian would
never grow old.” But now we must bid thee farewell, knowing how “thy
soul, like a quiet palmer, travellest unto the land of heaven;” and believing
well that, Christian, whatever may happen to thee in thy forward journey,
however it may savour now, be it fresh trials or increased joys, will work
nothing but final good and pleasantness to thy subdued and heavenly spirit
—has not our Father said that all things shall work together for good to
them that love God as thou dost?—bringing but a more abundant entrance
at thy latter days into the high inheritance in thy Father’s Kingdom, which
waits for the ending of thy pilgrimage, dear Christian Melville.
THE END.
————
BILLING, PRINTER, GUILDFORD, SURREY.
*** END OF THE PROJECT GUTENBERG EBOOK CHRISTIAN
MELVILLE ***
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Empowerment Series: Direct Social Work Practice: Theory

Essentials of Testing and Assessment: A Practical Guide

CHAPTER 1 An Introduction to the Competency-Based Assessment Model 1

CHAPTER 2 Neurodevelopmental Disorders 33

CHAPTER 3 Schizophrenia Spectrum and Other Psychotic Disorders 66

CHAPTER 4 Bipolar and Related Disorders 111

Cyclothymic Disorder 121

CHAPTER 5 Depressive Disorders 129

CHAPTER 6 Anxiety Disorders 161

Specific Phobia 167

CHAPTER 7 Obsessive-Compulsive and Related Disorders 191

CHAPTER 8 Trauma- and Stressor-Related Disorders 214

Disinhibited Social Engagement Disorder 218

CHAPTER 9 Dissociative Disorders 244

CHAPTER 10 Somatic Symptom and Related Disorders 270

Conversion Disorder (Functional Neurological Symptom Disorder) 283

CHAPTER 11 Feeding and Eating Disorders 297

CHAPTER 12 Elimination Disorders 341

CHAPTER 13 Disruptive, Impulse-Control, and Conduct Disorders 353

CHAPTER 14 Substance-Related and Addictive Disorders 373

Other Diagnostic Considerations 386

Sedative, Hypnotic, or Anxiolytic Use Disorders 412

CHAPTER 15 The Neurocognitive Disorders 443

Neurocognitive Disorder due to Traumatic Brain Injury 466

CHAPTER 16 The Personality Disorders 475

Obsessive-Compulsive Personality Disorder 527

THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

THE BOOK S ORGANIZATION

INTRODUCTION TO ENHANCED CONTENT

chapter, thus further supporting the book s emphasis on a performance-based ori-

Susan W. Gray is Professor Emerita at Barry University s Ellen

of the National Association of Social Workers, the Academy

does not take a linear or traditional psychiatric approach; rather, it incorporates a

THE DSM-5: APPROACHES TO THE ASSESSMENT

Surveillance among Adults in the United States, released on September 2, 2011,

THE DSM-5 DEFINITION OF MENTAL ILLNESS

Men rail upon the Change!

Hope the befriending,

HERE were anxious enquiries mingling with the glad welcome

“ ‘I was a stricken deer that left the herd

“ ‘There ’twas I met One who had himself

Creating the works from print editions not protected by U.S.

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