CLINICAL HANDBOOK OF SCHIZOPHRENIA

402 VI. SPECIAL POPULATIONS AND PROBLEMSAssessing Substance Use IssuesSubstance use has been linked consistently with the occurrence of violence within theschizophrenia population, so it should be assessed thoroughly. Even if the individual livesin a facility with little or no access to drugs, illicit substances may still play a part in thelikelihood of future violence. Many people who may have become violent only when underthe influence of substances may believe that simply avoiding substances is the key tonot being violent in the future. Although this may be true, not assessing problems relatedto violence may discount such problems until there is a greater likelihood that the personwill use substances. However, if the individual is motivated, he or she may engage in agreat deal of useful relapse prevention work in relation to substances. As previously discussed,the type of intervention that might be necessary depends on the individual’s attitudetoward substance use and his or her motivation to change, as indicated in the engagementprocess described earlier.Assessing Medical and Biochemical NeedsIn treating people with complex presentations, it is important to review physical healthneeds and to ensure that there are no medical causes for any changes in presentation orincreased aggression or violence. This review includes the following:1. A full physical examination and follow-up on any abnormalities detected.2. A review of routine blood tests to establish whether any further tests are indicated(e.g., thyroid function tests, HIV status).3. A review of previous electroencephalography, computed tomography, and magneticresonance imaging scans to consider whether there are clinical indications torepeat them.People presenting with such complex needs have often been subjected previously tovarious types of intervention. Medication may have been altered frequently, at times as aknee-jerk response to violence, and many clients may have been subjected to injections ofantipsychotic medication against their will. It is important to perform a full assessment ofprevious and current pharmacological interventions. This entails a detailed analysis of thecase notes and drug sheets that document the effect of changes in medication on symptomsand presentation. It is only by conducting this somewhat laborious exercise thatclear patterns of improvement or deterioration emerge and inform future directions forpharmacological treatments.Similarly, medication side effects and clients’ attitudes toward medication should beassessed using standardized instruments such as the Liverpool University Side Effect RatingScale and the Drug Attitude Inventory (Day, Wood, Dewey, & Bentall, 1995). Clientswho have experienced significant side effects may be reluctant to engage in further pharmacologicaltreatment. Education about medication and motivational approaches thatmay increase willingness to consider medication help clients to make informed choicesabout medication and encourage adherence.Assessing the Role of Environmental Factors in the Occurrence of ViolenceThe context in which an act of aggression or violence takes place is extremely importantand should form a major part of the assessment process. The clinician gains a good understandingof the client by examining the circumstances under which previous aggressiveor violent acts took place (e.g., did they tend to occur in certain places, around certain