Tak sedikit yang mencebik tika saya mulakan perjalanan ini sepuluh tahun yang lalu, sekarang ini dah lebih separuh berjalan, syukur dengan izin Allah, berserta perancangan yang baik, sokongan keluarga dan teman-teman, ianya sebuah perjalanan yang nak kata sunyi tak juga, nak kata susah, sampai berguling nak bunuh diri atau bunuh-bunuh orang, wish-wish orang, "sila meninggal" tu memang tak ada pernah rasa,lah. Kira ok la, bolehlah. Alhamdullillah.
My experience in Managing Risk of Getting Schizophrenia Relapse while Completing Post-graduate Courses
Upon accepting an offer to further education at master level in an establish university in Malaysia I am clueless about risk and risk management process, somehow instinct tells me to layout some plan and precaution as a safeguard from getting mental illness. I am suffering schizophrenia remission and I am afraid that I suffer relapses, which often lead to hospitalisation that unable me to complete my study. I have discussed the possibility of relapses with my medical doctor and he told me the chances is small provided I strictly adhere to recovery programme prescribed and quickly consulted him if I have suffer symptom of relapses. For heathy candidate, I believe students are not aware of challenges such as pressure and deadline, lead to mental health problem. However, studies conduct locally and abroad shows that mental problem such as loneliness, neurosis, depression, suicidal ideation does happen among university students.
In Denmark, a study conducted on 26,000 students from 70 colleges and university shows 6% of undergraduates and 4% of graduate students had seriously considered suicidal ideations and especially the male graduates were at high risk to commit suicide (Drum, et. al 2009). Even though suicidal ideation is not critical level among local student based on study conduct by Mustafa et al (2013), tendency to think toward it, referring to the scores on respondent’s answers, intervention measures to prevent it from getting worst and eventually translated in suicidal action should be given an appropriate attention. Apart from that, study by Nordin et al (2009) which conducted among 1,468 undergraduate student from five university in Malaysia, revealed that a total of 65.6% of them are mentally healthy and 34.4% experiencing mental health problems such as loneliness, neuroticism and extraversion personality. This indicate every students with or without mental history are exposed to risk of mental illness while pursuing a scholarly journey even though the percentage is small. Besides, according to (Azizan, Razali, Pillai, 2013) mental health is common and can affect anyone.
There are so many types of mental illness but this essay will focus on relapses. It is defined as a worsening of psychopathological symptom or re hospitalization in years after hospital discharge (Almond et al 2004). Relapses is often fear by schizophrenia patient and their family even while on treatment because according to Piggot et al (2003) it may result hospitalisation, treatment resistance, cognitive impairment due to progressive structural brain damage, personal distress, incarceration and interference with rehabilitation efforts. This essay will focus on risk, peril and hazard of relapse and cost associated to it. It also touch on effect on inducement in risk minimisation and risk management policy. Lastly, this essay will illustrate Grid-group Cultural Theory in examining my attitude toward risk. How I view and think of the world, and how I think those differ from me, face the world.
2.0 Risk, Peril, hazard and Cost of Relapse
Discussion on risk, peril and hazard factor only focus on relapses. Relapses statistic among schizophrenia patient is high. According to Zubin et al., (1992) only about 22% of those who experienced one psychotic episode and improved, did show positive sign, while the rest continued to experience recurrent relapse of the psychotic episodes with different degrees of impairment in between. Kaplan et al., (1994) supports more than 50% of the patients with schizophrenia have poor outcome. This include repeated hospitalizations and symptom exacerbation.
With the above not so welcoming statistic, the adverse outcome of my decision in enrolling for post-graduate studies is so apparent. Instead of a getting a scroll for master degree, I may end-up being hospitalised. (Vaughan and Vaughan 2014) define risk as a condition in which there is a possibility of an adverse deviation from a desired outcome that is expected or hoped for. Therefore, rehospitalisation because of losing the sanity of mind is my risk of continue study at master level.
· Peril and hazard
Now let us look at peril and hazard. Vaughn, (1997) stated that both terms are often used interchangeably with each other in risk discussion. According to him, peril is a cause of loss, and hazard is a condition that may create or increase the chance of loss arising from the peril.
In most of relapse cases, peril is discontinue of treatment because the patient believe that they have cured or may be due to forgetfulness. They purposely discontinue the ongoing assessment, not attending the psychiatric unit for follow up visits. Relapse may be caused by stress full life event. University life is very stress full with exams, test and back to back assignment due date. Apart from that opting to study in part times basis, causing me to juggle between work and studies add on stress to life. Poor result in a test or assessment also making life as student becoming more stressful.
Whereby hazard, is factors that may create or increase the chance of relapse. Adding more stress to life, such lack of planning, high expectation, unable to control emotion is hazardous act when decide to enrol in post-graduate study. Extra stress can come from lack of planning include lack of discipline in completing the task and assignment according to schedule, last minutes revision and postponing doing assignment to the end of due date. Apart from that, putting high expectation in exam result also add in more stress to life if the result is not par to the expectation. Lastly, poor emotional management also causes stress to be pile-up. Example, getting jealous when other student get good mark then us, easily upset when other people ignore us or don’t listen to us or when people critic or give negative comment on us. Another example, thinking too much about others may think about us also cause to emotional imbalance.
When a patient experience relapse, they incurred medical cost in term of hospitalisation and if the patient has to be hospitalised for a long time, the do not able to go to work. I have suffer one relapse episode in my medical history, but I did not count the loss in monetary value that I have incurred.
Luckily as a civil servant I am entitle for 180 day medical leave and I was only be hospitalised for 2 weeks and was not able to go to work for a month. If the hospitalisation took longer than 180 days, my employer can put me into medical board and lose my job if the board report I cannot work anymore. Luckily, that does not happened during my relapse experience in 2003.
I hope I do not suffer any relapse again. I have identify several inducement factor in helping me reduce the chances getting relapse not only during the completion of master degree, but for the rest of my life. The next point will discuss the effect on this inducement on reducing the risk of getting relapse.
3.0 Effect of Inducement in reducing risk
In order to avoid relapses from happening, I list down here several inducement factor, which help me from avoiding getting relapse not only during my study but also for a lifetime I divide it personal inducement and environmental inducement.
· Personal Inducement
An inducement factor, which make it, lessen the probability of relapse from happening. It include factor like adherence to recovery programme, religious ritual & Hobbies and employment. Firstly, adherence to programme such as counselling, psychotherapy or antipsychotic medication is important role in relapses prevention. Most of relapse cases is due to withdrawal from the programme prescribe to patient. Strictly adhere to the program is one of the key success in a journey to recovery.
Secondly, religious ritual and hobbies help improve the condition. Religion is also about positive value, love and avoiding prejudices. Apart from that religious ritual like reciting Quran, help to feel me, not matter how hard life is, God is always there for each one of us. For hobbies, I keep a journal as I like writing; I took up painting to keep me busy if I do not have anything to do.
Lastly, having a job boost self-esteem. If I am not earning for my living I feel guilty for not able to help my family to find extra income. Instead, they have to support me. This make me feel stressful and feeling bad about myself. By being employed and able to fund for my education and provide little cash to my family make me happy less stress full and improve my mental health condition. It also good to see that we are able to go on family trip and the fact that I contribute in funding the trip make me happy and feel more confident in taking care of my family rather then they have to watch me all the time. I am also very lucky because as an auditor I am assigned in a small group. I do not have to be secretive about my illness because one of the senior suffer anxiety. He lead a normal life, so when I told them I am with schizophrenia, they are indifferent toward me and show no sign of stigmatization. I believe they already have successes story of the anxiety patient, therefor having a schizo who currently read master degree in forensic accounting, is not a big deal to them.
· Environment Inducement
Environment inducement are factor that are within my surrounding that making it less likely for relapse to occur. There several factor in the environment that protect me from relapse, which include family and peer support, and mental health services.
Support from family are the most important thing in avoiding relapse. Family especially my mother show support and not only give advice and encouragement. My mother will stay with me to help me tend my need like making daily chore such as cook for me, and clean the house for me if I am too busy preparing for my exam. She will be with me for during my exam week look after me, watch out if I am too stress out, ensures I study, sleep and eat well.
Apart from that, peer support also help me a lot. I have friend to support and comfort me. They wish me good luck when never I have exams or test. Sometimes if I perform well in my test or exam, friend will give a treat like buying me kueh or having coffee. Sometimes, we went out for lunch and talk about studies, people that have hurt us, gossiping about local artist and talk about hobbies. The indiscrimination shows by my friend make feel happy and more confident in finishing my studies with have to suffer any difficulties in my mental health condition.
Lastly, mental health services available here in Putrajaya is the best. They give me counselling and advice to reduce stress, how to take care for me. They give advice especially to my mom and family how to watch out for relapse symptom to enable them supervising me better. It include in reading material and face-to-face consultation. Apart from that, they also monitor my physical heath. Once a year I have to undergone full medical assessment to ensure my physical wellbeing.
4.0 Risk Management Policy
Nowadays, most well establish organisation have consider risk management fundamental to be incorporated in their corporate governance. This is because effective risk management will provide an essential contribution towards achieving organisation strategic and operational objective and goal. Risk Management policy is formulated so that better-informed decision and operational & strategic objectives can be achieved. The policy sets out organisation’s approach to risk and its management together with the means for identifying, analysing and managing risk in order to minimise its frequency and impact.
However, as an individual, even though I do not set proper written policy in regard of managing the risk in my daily life, as a human I believe each of us have spontaneous way of dealing with risk according to our attitude, culture background and upbringing. The following part of the essay will discuss further on attitude toward risk based on Grid-Group Cultural theory model.
In this essay, Grid-Group Cultural is used model helps to understand other people, which may be different, form me. Understanding of others do minimises conflict from time to time and less conflict can reduce stress significantly and beneficial for mental health wellbeing. This model also help in looking at different perspective of different type of individual see the world.
Grid-group cultural theory cultural model developed by anthropologists Mary Douglas, Michael Thompson, and Steve Rayner. Also by political scientists Aaron Wildavsky and Richard Ellis, and others also contribute to these theory. At first, history of grid and group cultural theory, written by Mary Douglas grid look like follows when she inserted the three Cultural Heroes drawn by Christian Brunner:-
Douglas refer them as “[A] the stern bureaucrat with his briefcase, [B] The smug pioneer with his pickaxe and [C] the holy man with his halo. According to Douglas, they exemplify Max Weber’s three types of rationality: bureaucracy, market, and religious charisma. Douglas start with top right quadrant when society becoming more complex, peoples who live in a social environment where they are equally free of group pressure and of structural constraints. Everything has to be negotiated ad hoc becoming to regulation that is more comprehensive the groups, they becoming more hierarchical in nature. With roles and regulation are ascribed, behaviour governed by positional rules, forming constituent groups contained within a comprehensive larger group. Its cultural bias supports tradition and order. Roles are ascribed according to birth, gender, or family, and ranked according to function and tradition. We originally called this sector “hierarchy” in the sense of a rational system.
The left and the bottom right are the opposite of the top grids. Douglas explain the bottom right hand side, is a kind of community that also features a strongly bounded group with no ranking or grading rules for the relations between its members unlike in the top right grid. They surmised that it would be suitable for a community of dissidents. Leaders of a sect support group boundaries by declaring all outsiders evil. Dealing with internal dissent is difficult for them: withdrawn from and outside the main society. They cannot invoke the law to punish their offenders. Their only penalty for disaffection is expulsion but they do not want to use it. The danger of defection is why sectarian groups tend to have a black-and-white vision of the world. The enclave community tends to be egalitarian because it repudiates the inequalities of the rejected outside world.
Douglas continue to explain on extreme individualism, of bottom left, in the quadrant which are both weak in group controls and in grid controls whereby the main form of control that is available here is by competition based on merit. They only concerned with private benefit. It has a principle an egalitarian society, but as it defers to wealth and power, it fails to realise its egalitarian ideals. Lastly Douglas left quadrant one open to discussions. She describe it as strong grid control without any group membership. It could be a slave, soldier, the very poor people or the Queen of England herself. In addition, some individuals who avoids responsibility and pressure such hermit or the monk may fit into this culture. They are free and isolated because they are alone, attract no attention, no one asks for their opinion or takes them seriously in argument because of their reputation for apathy. Over the time, the quadrant changes and we have following grid:-
The above quadrant was designed in order to show how native rituals and practices were relevant to modern society. This model has two dimensions, measuring the degree to which individuals in a population tend to associate in social groups and form cooperative societies. It is dived into Group and Grid
The group dimension describes how strongly people are bonded together. The left end there shows distinct separated individuals. Even though they have common reason to be together, but they have less sense of unity and connection. At the right end, people are connected in term of identity related more deeply and personally together. They have stable relationships and the also spend more time together. As such, they form a group and imposed or formulate laws, rule, regulation and policy. Strong bonding allows for central control where high group managing the resources.
The grid dimension describes how different people are in the group and how they take on different roles. At one end of this spectrum, people are relatively homogeneous in their abilities, work and activity and can easily interchange roles. This makes them less dependent on one another. At the other end, there are distinct roles and positions within the group with specialization and different accountability. There are also different degrees of entitlement, depending on position and there may well be a different balance of exchange between and across individuals. This makes it advantageous to share and organize together.
· The model
The model is a two-by-two table forming four quadrant. From the quadrant, Michael Thompson add the “hermit” as 'fifth' non-chart ritual and practices. The pattern then identified as follows:-
· The diagonal of affirmation: Individualists and Hierarchies
- The diagonal of withdrawal: Fatalists and Egalitarianisms
- Social democracy: Hierarchists and Egalitarianism.
- American individualism: Individualists and Egalitarianism.
- State capitalism: Individualists and Hierarchists.
- Totalitarianism: Fatalists and Hierarchists.
The attitude toward risk are as follows:-
· Fatalism: view risk as danger which give no gain to them
· Hierarchy: they will managed the risk
· Individualism: see risk as an opportunity
· Egalitarian: will tried to balance the risk delicately
Whereas, hermit is an individual who retreat from whatever culture exist. They will interact with other when necessary.
6.0 Different perspective in facing the world and Attitude toward risk
To understand my own attitude toward risk, I asked good friend to look at the grid and group Model and asked a question “which quadrant I belong to?” He told me that I am an egalitarian. My dear friend look at me as an egalitarian because he say I like to help people. I do not like protocol. Sometimes voice-up my opinion critically on post-modern Malay lifestyle and government policy. Post-modern life is my own term for Malay that either too hooked-up with hedonist lifestyle from western culture or those who are so engross with Arabian culture that they see those who do not look like them, will go straight to hell. However, I always think I am a fatalist or more of a hermit, but with recovery programme that I have gone through, I see myself fit in hierarchy quadrant.
Personally, I believe that I am a risk adverse person. If I would, I will avoid taking risk. However, with the help of family, friend and programme that I follow, I am I willing to take some risk. Good people that around me teach and guide me how to managed risk. Sometime I totally avoid risk; sometime I do take risk, as I understand high risk associated with high return and we have to accept that the moment we step out of the door of our home risk is waiting for us. We can stay indoor all the time, with the care and support of family, but my mother want me to stay out the home, make some friends, get a job and make a living. Besides living as a hermit sometimes dull and boring.
Sometime I wish that I could be a hermit, where all my need is attend by the loves one, but sadly to say in my case I have to make a living on my own, facing unknown adverse outcome that I do not wish to happen. Some people say no man is an island and my mother teach me good Malay girl is the one who are friendly and know how to respect other people and know how to mix around. Even though I am already 44 years old, my mother never tired “to teach” me how to be courteous, how be more helpful and respectful to other, especially to older people and children. However, I found mixing around is very stressful. I always wish can be like a monk, stay at the top of the hill, but as I am not coming from a rich family I have to go to work and make a living. As a hermit or fatalist, how do I think of the world, the answers always, “WHY BOTHER”? Everything is predetermined. I am not here to change the world, but I may tell those who are close to me, “not too worrying too much about what had happened and what is going to happen in the world”. All we have to do is concentrate on our health and wellbeing. If we think, too much about others, we end up heaving so little time improving ourselves.
As on how others see the world, and how they face the world, I have very little idea on it, and I took what Mary Douglas et.al write-up as mention in previous point as a reference. According to them, people divide into 5 group, which are hermit, fatalist, hierarchy, individualist, and egalitarian. Different group of people face the world differently.
Firstly, a hermit do not really care about other people, they are a loner and they withdrew themselves form the society, and risk adverse. Secondly, a fatalist feels everything is predetermined. No matter what he or she does, or does not do, the outcome is the same. They are sometimes do not show any emotion even toward frightening circumstances. They think risk is harmful and stay away from it.
Third, the hierarchy culture, people are strongly connected yet are very different. Due to bondage, they developed institutions, hierarchies and laws in regulating individual action and provide for weaker social members. Hierarchies look at risk as something that need to be managed. They formulate policy and process in dealing with risk.
Fourth, an individualist. People are relatively similar yet have little obligation to one another. People enjoy their differences more than their similarities and seek to avoid central authority they are self-regulate individual, they do not follows norm and the see risk as opportunity to expend or be more successful.
Lastly, egalitarian. There are less central rule compare to hierarchy in this culture. However, they requires individuals to help others voluntarily. The rule is thus less about law and more about values. Similarity in individuals are essential as similarity that leads people to agree and adopt similar values. Those who do not agree with the value will ejected out. Thus egalitarian can be said as ideal utopia, can only survive in smaller groups, and very rare. Their view about risk is trying to balance it out risk delicately.
Decision to enrol in post-graduate studies is never easy. It require a lot of commitment. It come with big risk and big reward as well because risk have direct relationship with reward. Careful consideration should be given when risk come to the picture. A number of student facing mental problem in the university even though is small is worth taking into consideration when decide to enrol to the courses. In this essay, I have put forward a risk of getting relapse while completing my master degree. It discuss on risk, peril and hazard, cost of getting relapse, inducement, my attitude toward risk and how I view the world and how those who are different from me view the world. No one could predict what is going to happened during their studies in the university, but learning more about risk, able to put thing into different perspective make me becoming more confident in the decision that I have made.
 Symptom of mental illness worsen which often lead to hospitalisation and other serious consequences – Understand Mental Relapse http://www.choicesinrecovery.com/strategies-for-success/mental-health-relapse.html