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
1.0 INTRODUCTION
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[1],
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.
·
Risk
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.
·
Cost
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
·
Group
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.
·
Grid
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.
7.0 Conclusion
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.
[1]
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
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