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Kaugmaon ug Paglaum: A case study on the Person with Schizophrenia

Preprint · May 2018

DOI: 10.13140/RG.2.2.32292.78724

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 Pamoso
Abstract: Community mental
health in the Philippines has a long
way of development in order to be
felt by every Filipinos. Recently, the
Philippines already passed its
Mental Health Bill and just one
step away from becoming a law. In
contrast, there is a prevalent
scarcity on the implementation of
mental health and mental health
practitioners in the country.
In this paper, in the local
community, a client with
Schizophrenia was assessed
through the use of an in-depth
interview with the client’s
caregivers, and with the use of
selected clinical assessment tools.
The researcher postulated that
natural catastrophic events and
socio-economic factors may cause
psychological trauma which may
lead to the exacerbation of the
condition of the client. Moreover,
psychosocial support was seen as a
factor that alleviates the current
condition of the client.

Kaugmaon ug
Paglaum:
A Case Study on
the Person with
Schizophrenia
Keywords: Schizophrenia, mental disorder,
case study, community psychology, mental
health, clinical psychology
Aron Harold G. Pamoso, RPm
University of San Carlos

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 Pamoso

VIGNETTE

Problems are inevitable. Each person has its own issues. Different levels of
issues and problems may occur depending on the experience and age of a person. In
another perspective, problems may be categorized differently. It can be that a
problem is within the person, within other person or with nature, or perhaps in
another dimension. Causes of problems are unlimited. To quote from a famous line,
“sky is the limit!”

As a graduate student in Clinical Psychology, it helped me broaden my mind

to problems. Before, my mindset in terms with problems is that “I don’t have
enough money; I need to find a job; I need to be successful, I need to be like this and
that.” Name it, and probably, I have those woes in life. Yet, I realized that these
problems of mine were too ego-centered. Just about the satisfaction of myself and
it’s too shallow to call it a LIFE.

When I realized a different realm of looking at problems, I realized many

things. First, all of us has our problems. No one is excused from it. Second, there is
more to life than just thinking about my own problems. My problems may or may
not be as more problematic to other people. That is why I tend not to judge
immediately in people’s attitudes since almost all of us has our own struggles. Third
and final, life can be more satisfying and meaningful. If I start to reach out to
others and lend my hand to them. It is my dream to help people. But how can I help
them? That is now my dilemma…

The moment I moved from our previous home around 2008, everything was
new. New home, new environment and people. Everything was normal except for a
guy who is also our neighbor. Every time I went to school, I saw him walking on the
pavement. He was talking to someone else yet there is no other person. I tried to
check if he is using some gadget, but he did not. Then when I asked my neighbors
about him, they mentioned, “Ahhh, Buang mana siya, naa mana siyay gamay”
(Ahh, He is crazy.) And from that moment, I just ignored him. As time passed by,
when I reached college, I still saw him, walking and talking to his self as if he had a
conversation with a person.

When I reached graduate school, I realized that the neighbor whom I see
every day needs medical attention. I assume before that he is receiving treatment.
But based on my observation, he did not.

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I can say that writing this empirical paper is a blessing in disguise. It will
help me achieve my goal (to pass this course) and to help our neighbor who has been
suffering the disorder for quite long time.

INTRODUCTION

Schizophrenia

Schizophrenia may be defined in different perspectives. But authors and

scholars have a common ground line in defining the disorder. Kring, Johnson,
Davinson, Neale in 2014, contended that Schizophrenia is a confusion described by
unsettling influences in thought, feeling, and conduct—scattered reasoning, in
which thoughts are not consistently related; defective observation and
consideration; an absence of enthusiastic expressiveness or, now and again,
unseemly articulations; and aggravations in development and conduct, for example,
a tousled appearance. On the other hand, Barlow and Durand in 2015, mentioned
that Schizophrenia is the startling disorder characterized by a broad spectrum of
cognitive and emotional dysfunctions including delusions and hallucinations,
disorganized speech and behavior, and inappropriate emotions. In the latest
statistics of the World Health Organization, the said disorder is a severe mental
disorder that globally affects more than 21 million people. The illness is
characterized by alterations in thinking, perception, emotions, language, sense of
self and behavior and the most common experiences include hearing voices and
delusions (Chattu, 2017). All of these characteristics can be summarized on the
definition of Schizophrenia by the American Psychiatric Association in 2012. They
are defined by abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal
motor behavior (including catatonia), and negative symptoms.

How this disorder affects us? The world and the economy? Several studies
have found out that Schizophrenia had many implications for the economy and to
the countries. In 2o13, the Schizophrenia Research Institute found out that it is one
of the top ten causes of disability developed countries worldwide (Gibson, 2013). In
the United States of America, Norquist & Regier in 1996, mentioned that 1.1% of
the population has schizophrenic disorders (Gibson, 2013).

Chattu in 2017 had a comprehensive statistics on Schizophrenia. He

mentioned that in developed countries, with well-organized healthcare systems,
between 44% and 70 % of patients with mental disorders do not receive treatment

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whereas in developing countries the treatment gap close to 90%. Also, he noted that
the said disorder is a severe mental disorder which affects more than 21 million
people worldwide. He added that person with Schizophrenia is 2-2.5 times more
likely to die early than the general population often due to physical illnesses, such
as cardiovascular, metabolic and infectious diseases. Uncommon to the public, it
commonly starts earlier among men and it is found to be more common among
males (12 million) than females (9 million).

Outlooks

Interestingly, Schizophrenia can be seen in different perspectives. On the

study of de Haan and Fuchs in 2010, they have found out that concepts for the
understanding of Schizophrenia have a bodily dimension. Researchers can discern
three different strands. Each takes a different level to be primary. The meta
representationalist approach considers metarepresentational deficiencies as the
main problem, i.e. schizophrenic symptoms such as thought insertion and
experiences of alien control arising out of a failure of the patients to correctly
attribute their own experiences to themselves (Frith, C.D., Blakemore, S., Wolpert,
D.M., 2000).

In another perspective, De Haan and Fuchs in 2010, mentioned that

Schizophrenia in terms of so-called basic symptoms; in this view, metacognitive
impairments are the result of an accumulation of more basic neurological defects
(Gross, G., Huber, G., Klosterkotter, J., 1987). "In between is the phenomenological
perspective, whose proponents argue that we can best understand Schizophrenia as
a disturbance of the basic embodied self. The basic pre-reflective sense of self is
weakened, which in turn shows in lower-order neurological deficits and also
influences higher-order cognitive functioning (Fuch, T., 2005; Gallager, S., 2004;
Sass, L.A.,2003)."

In other words, Schizophrenia has different perspectives, depending on the

inclination of the clinician. One clinician may adopt a view on the disorder in the
biological perspective, others may see it in a socio-cultural perspective. The
important point here is to give the most effective treatment to our clients.

Implications of Schizophrenia

Health. On the perspective of the health of the client with Schizophrenia, there
were a lot of concerns. Chattu in 2017, found out that people with Schizophrenia are

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likely to seek care than the general population. He also found out that more than
50% of people with Schizophrenia are not receiving appropriate care

How is a person with Schizophrenia treated? Treatment with medicines and

psychosocial support is effective. However, the majority of people with chronic
Schizophrenia lack access to treatment (Chattu, 2017). Moreover, Chattu in 2017
quoted that "provision of antipsychotic medication alone is inadequate to address
the complex social, economic and health needs of those affected by a chronic and
highly disabling illness such as Schizophrenia."

In a similar manner in the different types of classifying the disorder, the

treatment plan shares the same thought. Treating the disorder really depends on
the clinician’s inclination, available resources and most importantly, client’s fitting
approach.

Self. Unknowingly to the public, people with Schizophrenia also means loss
of understanding of their selves. In the study of Estroff in 1989, he noted that Loss
of self is, arguably, at the core of the psychopathology in people suffering from
psychosis. People diagnosed with Schizophrenia are observed as suffering from a
profound sense of being cut-off from themselves and the outside world, with the
disorder having been defined as an “I am an illness – one that may overtake and
redefine the identity of the person” (Bargenquast, Schweitzer, Drake, 2015).
Gallagher and Zahavi in 2008 also agreed to the claim of Estroff, 1989. They
mentioned that "Different authors have suggested that Schizophrenia is a problem
at the level of the so-called minimal or basic self – as opposed to the extended,
autobiographical or narrative self " (de Haan, Fuchs, 2010).

Several scholars also noted in the relationship of Schizophrenia and

metacognitive capacity of the person with the disorder. In the study of Buck, Taylor
and Rose, 2008, as cited by Bargenquast et. al in 2015, found out that recent
advances in the field have linked disturbed self-experience in people diagnosed with
Schizophrenia with impaired metacognitive capacity, that is, the ability to think
meaningfully about one’s own thoughts and feelings and the thoughts and feelings
of others. In connection, Semesari et al., 2003, found out that recent research has
suggested that we may conceive of metacognitive capacity in terms of 1)
Understanding one’s own mind, which is the capacity to recognize, distinguish, and
integrate one’s own mental states; 2) Understanding others’ minds, which is the
capacity to understand others’ mental states and form integrated representations of
other people; 3) Decentration, which is the capacity to recognize that one is not at
the center of others’ lives; and 4) Mastery, which is the capacity to use

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metacognitive knowledge to cope with psychological problems (Bargenquast, et. al,

2015).

Across studies, the self is one of the big factors in the disorder. “Individuals
with Schizophrenia may pull back from other individuals and from ordinary reality,
frequently into an existence of odd convictions (daydreams) and visualizations"
(Kring, Johnson, Davinson, Neale, 2014). The said guarantee was approved by Van
Putten, Crumpton, and Yale in 1976. They argue that "Individuals with this
condition have a delusion of health and wish to keep the status quo" (Gibson, 2016).
Moreover, the said disorder can cause significant harm to a person’s life (Birks,
2013; Gibson, 2016). And lastly, Chattu in 2017, conclude that lack of good
judgment and absence of rationality are hallmarks of Schizophrenia.

Family. Having a person with Schizophrenia in the family is challenging. In

Ethiopia, Fekadu , Medhin , Kebede , Alem , Cleare, Prince, Hanlon , Shibre, in
2015, found out that the often severe and chronic nature of Schizophrenia means it
can have a catastrophic impact on individuals and their families, expressed in high
levels of mortality (over three times that of the general population in Ethiopia
(Asher, Fekadu, Teferra, De Silva, 2017).

Family played a factor in the development of the disorder. In the study of

Pedersen and Mortensen in 2001, "family history of schizophrenia is the strongest
determinant of Schizophrenia risk at the individual level” (Ran, Xiao, Zhao, Chan,
2018). In the study of Ran, et al. in 2018, they found out that "Individuals with a
positive family history of schizophrenia had a significantly younger age of the first
onset than those with a negative family history of schizophrenia in 1994 and 2004.
Compared with individuals with a negative family history of schizophrenia, those
with a positive family history of schizophrenia had a significantly higher rate of
homelessness and a lower rate of death due to other reasons in 10-year (2004) and
14-year follow-up. The positive family history of schizophrenia is strongly related to
younger age of onset, and may predict a poorer long-term outcome (e.g., a higher
rate of homelessness) in persons with schizophrenia in the rural community" (Ran,
et. al, 2018).

Many scholars agreed that family history is a key to the development of the
disorder. Agerbo et al., 2015; Kendler et al., 1997; Malaspina et al., 1998, claimed
that several studies have suggested that a positive family history is associated with
the risk of schizophrenia and related clinical outcomes. Ran et. al, 2018, noted that
"family history of psychosis is considered to be the strongest risk factor of
schizophrenia, and has been a marker for etiologic subtypes that vary on clinical

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characteristics, social functioning, and other outcomes (Cannon and Jones, 1996;
Esterberg et al., 2010)." Anglin et al., 2009; Esteberg et al., 2010 concluded that "the
potential link between and outcomes of people with Schizophrenia could be
explained by both genetics and environment, while heterogeneity is still observed in
clinical, cognitive, and social functioning (Ran, et. al, 2018).

Ran et. al, in 2018 had created comparisons from different scholars in terms
of family history of Schizophrenia. According to them, "Compared to people without
family history of psychosis (FH-), (FH+) with family history of Schizophrenia
patients have an earlier age of first onset of psychosis (Albus and Maier, 1995; Alda
et al., 1996; Ritsner et al., 2007; Wickhama et al., 2002), increased suicide risk (Qin
et al., 2002), higher rates of homelessness (Ran et al., 2006), more severe negative
(Borkowska and Rybakowski, 2002; Malaspina et al., 2000; Martin-Reyes et al.,
2011; Ritsner et al., 2005) and positive symptoms (Arajarvi et al., 2006), and poorer
social functioning (Arajarvi et al., 2006; Käkelä et al., 2014; McGlashan, 1986)."

Community and Stigma. Whenever a person will be diagnosed with

Schizophrenia, it has already given that the person can’t avoid prejudice and
discrimination. World Health Organization in 2016 for example, noted that people
affected by Schizophrenia often face difficulty in obtaining or retaining normal
employment or housing opportunities. According to Chattu in 2017, there is a
greater mark of stigma and discrimination involved to this and destruction of
human rights of people with Schizophrenia are very common. Sahu and Mukherjee,
2018, claimed that "Although numerous studies documented perceive or
experienced stigma of the person with Schizophrenia (PWS), comparatively little
research has been done to explore how courtesy stigma limits the social support and
social opportunities available to family members of stigmatized individuals; which
has significant implication on management of Schizophrenia." Moreover, they added
that family members of a person with Schizophrenia experienced a great degree of
stigma which was higher when their knowledge about Schizophrenia was poor. To
solve the existing issue, Chatto, 2017 suggested that a key recommendation of the
action plan is to shift services from institutions to the community.

Economy. The financial effects of psychological sickness influence individual

pay, the capacity of sick persons– and frequently their caregivers– to work,
profitability in the work environment and commitments to the national economy,
and additionally the use of treatment and bolster administrations (Chattu, 2017).
He additionally included that the World Monetary Discussion assessed that the
total worldwide effect of a mental issue as far as lost financial yield will add up to
US$ 16 trillion throughout the following 20 years, equal to over 1% of the worldwide
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total national output. The World Health Organization, 2013, noted that from a
recent study by the World Economic Forum estimated that the cumulative global
impact of mental disorders in terms of lost economic output will amount to US$ 16
trillion over the next 20 years. In the study of Lim, Jacobs, Ohinmaa, Schopflocher
and Dewa in 2008 found out that studies from specific countries provide similarly
sobering findings where the health care costs and lost earnings amount to at least
US$ 50 billion in Canada and US$ 75 billion in the United Kingdom both equivalent
to more than 2.5% of national GDP.6,7. The cost of mental health problems in
developed countries is estimated to be between 3% and 4% of GNP (Chattu, 2017).
Moreover, Chattu, 2017, argues that over 10% of the global burden of disease,
measured in terms of years of healthy life lost, can be attributed to this disorder.
For specific country statistics, in India for example in India, it was found
that half of the out-of-pocket expenditures made by households for psychiatric
disorders came from loans and a further 40% from household income or savings
(Patel, Chisholm, Kirkwood, Mabey, 2007).
Schizophrenia as a disorder not only affects the individual but also the
overall country. Chattu, 2017 fount that There is a strong international consensus
that the shortage of financial and human resources for mental health requires a
policy to integrate mental health care into general health care. Such integration
provides opportunities for reducing the stigma of mental health problems, which in
itself is a major barrier to accessing care. Similarly, World Health Organization
(WHO), 2013, claimed that globally, more than 25% of all years lived with disability
and over 10% of the total burden of disease is attributable to mental, neurological
and substance use disorders.

To alleviate the problem, WHO, 2013, created a mental health action plan
2013-2020, as endorsed by the World Health Assembly in 2013. The activity design
features the means required to give proper administrations to individuals with
mental disarranges including schizophrenia (Chattu, 2017).

Community and Support. Psychopharmacology alleviates the condition of a

person with Schizophrenia. But we can’t deny the efficacy of psychosocial support to
the healing of the said disorder. Asher and Patel, in 2017 suggested that there is
agreement that the treatment of Schizophrenia should join hostile to crazy
pharmaceutical and psychosocial intercessions with a specific end goal to address
complex social, monetary and wellbeing needs (Pattel, V., Chrisholm, D., Parikh, R.,
et. al., 2015; Patel, V., 2015; Fleischacker, W.W., Arango, C., et. al, 2014; WHO,
1996).They pointed out the family therapy or support; community-based

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rehabilitation; and/or self-help and support groups should be provided for people
with schizophrenia in low and middle-income countries."

Knowing the feasibility of the intervention, gather based psychosocial

intercessions should, consequently, be given in these settings as an adjuvant
organization despite office-based take care of people with Schizophrenia (Asher, L.,
Patel, V., S., M.J. 017). In a study in India by Sahu, Mukherjee, Sahu, in 2018, they
found out that families in India are involved in most aspects of care for a person
with several mental illnesses. Families not only provide practical help and personal
care but also provide emotional support to their relatives. This was validated by the
study of Ran, Xiao, Zhao, and Chan in 2018. They conclude that the findings on
their studies have implications for further studies on specific family-related
mechanisms on earlier intervention, clinical treatment, and rehabilitation, as well
as planning and delivering of community-based mental health services for people
with schizophrenia in China and elsewhere.

Although psychosocial intervention such as family support gained efficacy, it

still lacks results. Asher et al. argue that the effectiveness of community-based
psychosocial interventions in these settings is unclear.

As a general, treating the disorders may be varied, depending on the

orientation of the clinician. But what matters most if the treatment and
rehabilitation of the client.

What Is Next?

Mental Health. We are challenged with everyday problems. But seldom

people talk about mental health. I agree that mental health is still a woe in the
Philippines. Emotional well-being issues influence society in general, and not only
a little, disconnected section. They are hence a noteworthy test to worldwide
advancement (Chattu, 2017). In the discoveries of Chattu in 2017, no gathering is
insusceptible to mental scatters, yet the hazard is higher among poor people,
destitute, the jobless, people with low training, casualties of brutality, vagrants, and
displaced people, indigenous populaces, kids, and youths, manhandled ladies and
the disregarded elderly. This just validates that socio-economic factor greatly affects
the prognosis of the disorder. He further added that there is still an enormous gap
between the need for treatment of mental disorders and the resources available to
the people who need those essential services. In other words, there is a great
scarcity in the mental health aspect, be it in the resources including manpower,
finances, education and other related factors. Chattu (2017) added, ‘there is still an

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enormous gap between the need for treatment of mental disorders and the resources
available to the people who need those essential services.”

The Philippines in terms of its mental health is still in the process of

development. As of this time, the Mental Health Act of 2017 is still in the process of
becoming a law. In the study of Tolentino in 2004, only 2-3% of the national budget
is allocated for health care-a figure way below the World Health Organization’s
recommendation for developing countries. The country only spends 0.02% on mental
health. Mostly, mental illness is not covered by most health maintenance
organizations, nor by the Philippines health insurance system (Tolentino, 2004).
With this, the Philippines has a long way to the implementation of the mental
health law. But the government and its people are already on the way to implement
it.

DISCUSSION

Statement of Objectives

The primary objective of the study was to uncover the current mental
condition of the Mr. C. Also, the study wanted to explore the role of the different
risk factor of the person with Schizophrenia and how these factors affected the
client as a person. The study also wanted to identify the level of disability of the
client as well as his dimensions of psychosis. And lastly, the study wanted to
discover the support systems of the client that may help or may exacerbate his signs
and symptoms.

Methodology

The study utilized the purposive sampling, case study approach. With only
one participant, the researcher tried to decipher the information on the client
through various sources-family members of the client, neighbors, and relatives.
Also, the researcher adopted the triangulation philosophy. The researcher used the
in-depth interview with the members of the interview and coded similar themes
that were common to all the interviewed person.

Tools

Since the study utilized the triangulation philosophy, the researcher also
used various tools to assess the client, family members, and the people surrounding
the client. The researcher used the different tools that were adapted and developed
by the American Psychiatric Association. Moreover, the researcher was able to get
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the permission to use the tools since the tools are openly-accessed on the website of
the American Psychiatric Association. Also, the researcher also utilized the World
Health Organization’s Disability Schedule 2.0, 35-item, proxy administered.
Permission was also given to the researcher in using the said tool for the tool was
openly-accessed online.

To distinguished the general disability of the client, the researcher

administered the World Health Organization’s Disability Schedule 2.0, 36-item,
proxy administered (WHODAS 2.0). The objective of the tool was to have an
objective tool in measuring the different facets of disability of the client and that
includes cognition, mobility, self-care, getting-along, life activities and participation.
After the World Health Organization’s Disability Schedule 2.0, 36-item, proxy
administered (WHODAS 2.0), Cultural Formulation Interview - Informant Version
of American Psychiatric Association was administered. The tool’s objective was to
identify the domains that involve the client’s mental disorder. Since it is a cultural
formulation interview form, the researcher had the chance to see the cultural
background of the client. It has five (5) domains, namely: relationship with the
patient, cultural definition of the problem, cultural perceptions of the cause,
context, and support, cultural factors affecting self-coping and past help-seeking
and cultural factors affecting current help-seeking. And lastly, to have a picture of
the severity of the psychosis of the client, Clinician-Rated Dimensions of Psychosis
Symptom Severity of the American Psychiatric Association was used. It has eight
(8) domains-hallucinations, delusions, disorganized speech, abnormal psychomotor
behavior, negative symptoms (restricted emotional expression or avolition),
depression and mania. All of the tools were administered to the selected family
members and neighbor of the client except for the Clinician-Rated Dimensions of
Psychosis Symptom Severity of the American Psychiatric Association.

Procedure

Upon having the approval from the professor of the advanced clinical
psychology, the researcher scheduled the client, selected family members, relatives
and neighbors of the client. Upon receiving the permission of the client’s primary
caregiver, the interview was conducted using the cultural formulation interview,
informant version. After the interview, each participant of the in-depth interview
session was also scheduled to answer the WHODAS 2.0, proxy administered. After
the using the tools mentioned, an interview on the background of the client was
asked on the selected family members and neighbors. They were asked about the
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past and current experiences of the client. After the interview of the people that
surrounds Mr. C, he underwent Mental Status Examination and Clinician Rating
Dimensions of Psychosis Symptoms Severity Measure.

Research environment

The study was conducted in Purok Top hills, Sitio Pilit in Barangay
Cabancalan, Mandaue City, Cebu, Philippines. According to the census of
population in 2015, Cabancalan is about three kilometers from the center of
Mandaue City. It is bordered to the north and northeast by Barangay Canduman, to
the northwest by Barangay Talamban in Cebu City, to the south by Barangay
Banilad in Mandaue City, to the east by Barangay Bakilid and to the east by
Barangay Casuntingan, respectively. Currently, the barangay has 14, 132 residents
(Census of Population, 2015).

The significance of the study

The study could primarily benefit the client who faced signs and symptoms of
Schizophrenia. The results of this study will provide in-depth knowledge as to the
importance of community support and rehabilitation in treating Schizophrenia.

For the immediate family of the client, this study will provide important
feedback to the kind of family member they have. This will help the family on their
coping styles and their relationships to the client and to the people in the
community.

For the local government unit in Barangay Cabancalan, the study may give
an idea of the current mental health status of the barangay. The output may also be
a basis for a community mental health program that will truly benefit the people in
the barangay.

For the mental health practitioner, this study may aid in their future studies
especially in the current community mental health situation in the place. As an
aspiring researcher, there is definitely scarcity in studies in community mental
health in the Philippines.

PRESENTATION OF DATA

Case Illustration

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This part of the study tackles the presenting issue, depiction and case
formulation of the client.

Presenting Problem and Client Description

Mr. C (not his real name) was unemployed male in his 50’s. He was an
elementary drop-out and was not able to finish his studies. Both of his parents were
a witness to the World War II. He was the second to the last of a five-sibling family.
He was also a “lumad” (local) in Sitio Pilit, Barangay Cabancalan Mandaue City.
He was born and raised in the same house where the researcher made the study.
His father roots can be traced in Mandaue City in Pilit Cabancalan Mandaue City.
He had never been into marriage and did not have any child. He had a 28-year
history of psychosis and hallucination. The first episode of psychosis emerged when
the Mr. C experienced the wrath of Typhoon Ruping in 1990. It was noted by a
neighbor that he was alone in the house when the typhoon came. He did experience
the wrath of the typhoon; saw the houses being downed by the typhoon. After
which, he was brought to the nearest mental health facility and was diagnosed with
a nervous breakdown. It was noted, that he was only admitted once and was able to
go home after the prescription of the drugs. He was an outpatient at that time. And
that was the last time when Mr. C received a medical attention in his life. Mr. C
was not able to go back to the mental facility because of various reasons. First, the
family of Mr. C did not have enough financial resources to support his recovery with
his disorder. Second, most of his family members are already old, and that no one
can monitor and accompany Mr. C with his appointments with his doctors. And
lastly, upon interview, the researcher found out that Mr. C had a fear in visiting the
mental health facility. This came from the family members of Mr. C. Upon asking
the family members, they did not know why Mr. C is afraid to go to the mental
facility. Also, when the researcher asked Mr. C on the reasons why he did not like to
visit the mental facility, he just answered “dili” (no).

The researcher was able to talk to Mr. C but there were sometimes wherein
some of Mr. C’s answers did not fit the question of the researcher. In terms of
mental status, he was able to get the current dates, times and the following dates.
This means that the client was aware of the things happening to him.

Mr. C came from a family of devout Roman Catholics and was one of the five
children of parents who were a survivor of the Second World War. There was no
family history of mental disorders in the family. His mother and father died
naturally of old age. Mr. C is currently living with his sister while his other siblings

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formed their own families respectively. Her sister is the one who took good care of
Mr. C. His nephews and in-laws are the ones who assisted Mr. C in the house.

At present, the day of Mr. C would start from a bath. His nephew and in-laws
would bath him. After the bathing him, he will then eat together with his family
members. After, he will be roaming around and just do nothing. Oftentimes, he was
seen to be asking for alms to the people that he had an encounter with. Then spends
the money on carbonated drinks and on cigarettes. Also, he was seen to be doing
some tasks such as bringing the sacks of cement to the construction site. Her sister
is not really into this since he had a condition and she was worried that it may
affect his current condition. Whenever her sister will know that he was doing a
physical task, her sister will go immediately stop him.

Mr. C was able to work as a blacksmith at a local company in the barangay.

But he stopped because of his mental condition and that was the last employment of
Mr. C.

Case Formulation

Mr. C met the diagnostic criteria for Schizophrenia, unspecified,

characterized by non-bizarre delusions. There was no evidence of any existing
personality disorder. He also had varicose veins on his legs and the veins were
visible on the eye. He had never sought medical attention on his varicose veins.
Also, Mr. C was a frequent user of cigarette. According to his relatives, one pack of
cigarette won’t suffice in a day. Also, the intake of carbonated drinks was not usual.
According to his relatives, he drank carbonated drinks as if it is water. His relatives
were worried that he may develop diabetes. But it was not confirmed that Mr. C
had diabetes since he did not consult any physician.

During the intake interview, Mr. C was able to answer the questions. But he
repeatedly asked for rewards every time the researcher asked a question. Most of it
was a peso or a five peso. In terms of his answers to the questions, there were also
contrasting answers. When he was asked about his address (“Asa ka nag put
Kuya?”), he answered “Mandaue, color blue, motor ko.” (Mandaue, color blue, I will
go.) The first answer is certain but the following words are not really connected to
the question of the researcher. When Mr. C was asked again regarding his job, he
answered, “kada tuig, trabaho, walay trabaho” (every year, job, there is no job).
Similar to the question earlier, his first words were related to the question but as
when the first letter was done, the remaining words were really not related to the
question. And lastly, before the intake interview, he was asked by the researcher,
“Naa pa kay mga pangutana Kuya?” (Do you have any more questions?) He
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answered, “imong load, palit kag load.” (Your load, you should buy load.). His
answer to this question does not really have a connection to the questions being
asked from the researcher.

FINDINGS

This section contains the results of the assessment tool that was used in the
study of the client.

Results of the World Health Organization Disability Assessment Schedule

2.0 (WHODAS 2.0)

On the assessment Mr. C using the World Health Organization Disability

Assessment Schedule 2.0 (WHODAS 2.0), he showed an overall general disability
score of 73. He generated an overall score of 2 which can be translated as a mild
general disability. On the table below, domain 1 which is the understanding and
communicating got the highest score while domains 2, 4 and 5 got the lowest score
of zero. These domains were getting around, getting along with people and life-
activities household, respectively.

Table 1 Profile of Mr. C on World Health Organization Disability Schedule 2.0

(WHODAS 2.0)

Raw
Average
Domains Domain Interpretation
Domain Score
Score
1. Understanding and
20 3 Moderate
Communicating
2. Getting Around 6 1 None
3. Self-care 9 2 Mild
4. Getting along with people 13 3 Moderate
5. Life Activities- Household 4 1 None
6. Life-Activities-Work 6 2 Mild

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7. Participation in society 13 2 Mild

General Disability Score 73 2 Mild

The table showed that understanding and communicating got the highest
score with an average domain score of 3.3. This was noted when the relatives of Mr.
C was asked by the researcher. It was noted that he had real difficulty in
communicating to other people especially to the ones he does not know. Domains 2
(getting around) and domain 5 (life activities-household) got zero scores or no
disability at all. This is because Mr. C. doesn’t have any physical handicapped. He
can walk normally like others. Another domain which has a zero disability is
domain 5 (life activities-household). Mr. C does not do the household chores in the
house for his relatives are the one who does the household chores.

Results of the Clinician-Rated Dimensions of Psychosis Symptom Severity

On the results of the clinician-rated Dimensions of Psychosis Symptom

Severity, Mr. C. got equivocal scores on the following domains: hallucination,
delusions, abnormal psychomotor behavior, impaired cognition, and mania. On the
other hand, negative symptoms and depression were not present on Mr. C. Lastly,
disorganized speech got the highest score on the table.

Table 2 Profile of Mr. C on Clinician-Rated Dimensions of Psychosis Symptom

Severity

Domains Score Interpretation

1. Hallucination 1 Equivocal
2. Delusions 0 Not present
3. Disorganized Speech 2 Present
4. Abnormal Psychomotor Behavior 1 Equivocal
5. Negative Symptoms 0 Not present
6. Impaired Cognition 1 Equivocal
7. Depression 0 Not present
8. Mania 0 Not present

The disorganized speech got the highest score because, during the initial
interview of Mr. C, the researcher noticed some answers that were not related to
the questions. Also, on the other domains, hallucination was also visible to Mr. C.
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There were times when Mr. C was talking to himself as if he has someone talking
with. Abnormal Psychomotor behavior can also be seen on him because, during the
interview with his relatives, he was seen lying on the street, doing nothing. And
lastly, Mr. C tends to show cognitive impairment. This was noticed by the
researcher when he was asked about the details of his family. He was not able to
answer accurately the question.

Results of the Cultural Formulation Interview (CFI)-Informant Version

On this section, the Cultural Formulation Interview (CFI) – Informant

Version of the American Psychiatric Association was used to gather information on
Mr. C. The Cultural Formulation Interview (CFI) - Informant Version was
administered to the nephew and one close neighbor of Mr. C.

Relationship of the patient. The nephew of Mr. C has been with him since when
was still a child. The nephew was raised and born in the same house where Mr. C
was living. The nephew of Mr. C was considered to be his primary family. On the
other hand, his neighbor named Mrs. E (not her real name) was her neighbor when
Mr. C was still an infant until now. They lived in the same vicinity, approximately
two houses from each other. He saw Mr. C almost every day and he had the chance
to saw him as well.

Cultural Definition of the Problem. Both the nephew and the neighbor of Mr. C
agreed that he has something on him that made him different from others. “Naay
diperensya, dili siya normal,” said the neighbor of Mr. C. “Lain ug panghuna-huna
si tiyo.” This was the statement of his nephew. His neighbor also noted that Mr. C
becomes wild if ever he will be provoked by other people “mang wild mana siya if
hilabtan.”

The neighbor of Mr. C was a witness to his behavior. “Tagaan nako na siya
ug sanina, pero iyang rapud gisi-on.” Also, she noted that he saw Mr. C lying on the
road doing nothing. She mentioned that he saw Mr. C roaming around the
community and asks for food from them.

When the neighbor and nephew of Mr. C was asked regarding on how would
they describe his problem to the people around Mr. C? His neighbor mentioned that
problems of Mr. C should be the primary concern of his family. His family should be
more responsible for taking good care of him because he needs special treatment.
His nephew also had a similar answer. He mentioned that all of the members
should be involved with our uncle.

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When they were asked to what troubles the most in connection to Mr. C, they
had different views on it. The neighbor was mostly concern about Mr. C’s wild-
aggressive behaviors. The reason why he has this wild-aggressive behavior because
whenever he was roaming around, he was teased by the children in the community.
His nephew, on the other hand, was mostly concerned with his vices and
consumption of carbonated drinks. His nephew recalled that a pack of cigarette
won’t suffice for his day and that he consumes carbonated drink as if it is water.
The family of Mr. C was worried that he may develop diabetes.

Cultural Perceptions of Causes. Both his neighbor and his nephew agreed that
the Typhoon Ruping in 1990 caused his current condition now. During the in-depth
interview with the neighbor of Mr. C, she noticed that he was left at the house when
the Typhoon hit the place. His neighbor added that he saw how the houses were
swift away and that according to her, caused his problem. His nephew, on the other
hand, did not have a really clear memory of the event since he was only six (6) years
old when the event happens. Aside from the experience of his neighbor, she also
added that Mr. C was using Marijuana as a recreation when he was still working
with his employer. She added that the Marijuana may contribute to the current
problem of Mr. C.

When asked on the community’s perception of the cause of the problem of Mr.
C, both of them had a different perception. His neighbor answered “libog, buang,
wala kasabot, kataw-anan…” His neighbor did not connote a certain perception of
the cause of the problem of Mr. C but described their perception towards Mr. C. His
nephew’s answer was different. According to him, stress from work may cause his
current problem.

Cultural Perceptions of Stressors and Support. The family was both identified
by his neighbor and nephew as a source of primary support. His nephew
commended that his family is the one who primarily supported Mr. C on his needs.
His neighbor added that his other neighbors were also a source of support. She
added that whenever Mr. C will be roaming around and asked for something to eat,
his neighbors would extend their help by giving him meals.

When it comes to the stressors of Mr. C, both his nephew and his neighbor
had different stands. His neighbor noted that Mr. C had a conflict with his
biological father. “Tiunan mana siya ug Sunday sa iyang amahan.” This was the
response of his neighbor when asked about the stressor of Mr. C. His nephew
mentioned that Mr. C had a conflict with his sibling and that he had the chance to
physically assault his sibling. “Padung buang na siya ato.” Commended by his

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nephew. There was little details that was shared from the nephew since he was only
six (6) years old at that time.

Cultural Factors Affecting Self-Coping. In order for Mr. C to survive the

everyday life. He did do errands of other people within the community. He was seen
by his neighbor to carry cements to the construction site and in return, he was the
certain monetary amount. His nephew also noted that Mr. C is very cooperative in
doing household chores. When he was asked to do the gardening, he will then do the
task accomplish it.

Cultural Factors Affecting Past Help Seeking. According to the nephew of Mr.
C, he had only once gotten in the hospital to seek medical attention. And that was
after he had shown signs and symptoms of Schizophrenia. He was then brought to
Vicente Sotto Memorial Medical Center in Cebu City. After that, he had never been
back to the said hospital. His nephew added that there were certain reasons that
they did not continue medical help. First is that they don’t have the sufficient
resources to let Mr. C continue with his treatment in the hospital. Second, Mr. C
had fear to his previous doctor but the reason was unclear that is according to his
nephew. Also, his nephew added that Mr. C did not take religiously his medication.

Cultural Factors Affecting Self-Coping and Past Help Seeking - Barriers.

Financial support was the main issue that hinders the overall medical treatment of
Mr. C noted by his nephew. They noted that they are not rich enough to take care of
the medication and rehabilitation of Mr. C. According to the neighbor of Mr. C,
“Murag dili mana sila magdunggan ug kaon. Kay kung busog siya, ngano mangayo
man siyag pagkaon sa silingan? ” This is quite in contrary to the first statement of
the nephew of Mr. C. There was also a time when the family of Mr. C tried to sway
him away because they had a visitor. “Basta naay bisita, pahawaon mana siya.”

Cultural Factors Affecting Current Help-Seeking - Preferences. On the help

that should be given to Mr. C, his neighbor and nephew had also a different
perspective. Mr. should seek medical attention as soon as possible. His family
should send him to a Psychiatrist or a Psychologist. He should be sent to a hospital.
On the other hand, his nephew noted that his big concern to his uncle is that he
should stop smoking a cigarette and should control the intake of carbonated drinks.

DISCUSSION

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This section will discuss the resulting themes and categories that were
gathered during the analysis of the researcher. Subheadings are labels that were
identified to emphasize salient concepts and ideas.

Emerging Themes

Self-Awareness. Mr. C as a general was aware of the things that happen in

his environment. He was able to determine to describe the current weather, details
of his family and even his everyday routine. This is in contrast to the argument of
some scholars. According to them, most of the person with Schizophrenia does loss a
sense of self. Loss of self is, arguably, at the core of the psychopathology in people
suffering from psychosis (Estroff, 1989). Across studies, the self is one of the big
factors in the disorder. "Individuals with Schizophrenia may pull back from other
individuals and from regular reality, frequently into an existence of odd convictions
(fancies) and visualizations" (Kring, Johnson, Davinson, Neale, 2014).

Risk factors. Upon the in-depth interview of Mr. C’s neighbor and his
nephew, several risk factors were observed by the researcher. Financial issue was
the primary risk factor for the mental condition of Mr. C. Lack of affordable and free
mental health condition was the concern of Mr. C. In the discoveries of Chattu in
2017, no gathering is safe to mental disarranges, however, the hazard is higher
among poor people, destitute, the jobless, people with low training, casualties of
viciousness, transients, and evacuees, indigenous populaces, youngsters, and
teenagers, mishandled ladies and the ignored elderly. This just validates that socio-
economic factor greatly affects the prognosis of the disorder. He further added that
there is still an enormous gap between the need for treatment of mental disorders
and the resources available to the people who need those essential services. In other
words, there is a great scarcity in the mental health aspect, be it in the resources
including manpower, finances, education and other related factors (Chattu, 2017).
Another health condition was the primary risk factor of Mr. C. It was noted that he
suffers from varicose veins on his two legs. Yet his family did not have him any
medical assistance because according to his family, they cannot afford to let him see
a physician.

Support systems. Upon the analysis of the researcher, there were two (2)
support systems that were identified. The first was on the primary family of Mr. C.
His family was his primary caregiver and provider. The community was also
another support system of Mr. C. Whenever Mr. C roams around the neighborhood,
some of his neighbors would offer their food for him. Some of his neighbors would
give him clothes if they saw that he doesn’t have one. Researchers agreed that not

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only psychopharmacology is the sole treatment of Schizophrenia but also

psychosocial interventions. Asher, Patel, in 2017 suggested that there is accord that
the treatment of Schizophrenia should join against crazy drug and psychosocial
intercessions keeping in mind the end goal to address complex social, financial and
wellbeing needs (Pattel, V., Chrisholm, D., Parikh, R., et. al., 2015; Patel, V., 2015;
Fleischacker, W.W., Arango, C., et. al, 2014; WHO, 1996).

Stigma. Stigma was prevalent not only in the community of the Mr. C but
also within his family. It was found out by the researcher that whenever there are
visitors who will visit their house, Mr. C will be treated unfairly. This was also
similar to his community. Often times, he was being the center of the grudge of
other people. He was teased and being bullied by others because he is different,
abnormal and crazy. There is a greater degree of Stigma and discrimination
attached to this and violation of human rights of people with Schizophrenia are very
common (Chattu, 2017). Also, Sahu and Mukherjee, 2018, guaranteed that "various
examinations archived see or experienced disgrace of the individual with
Schizophrenia (PWS), relatively little research has been done to investigate how
civility shame confines the social help and social open doors accessible to relatives of
disparaged people.

Limitations of the Study

The study results of the study were based on what Mr. C shared, his nephew and
neighbor. The narratives of their experiences and events were also limited to what
they can recall and they’re voluntarily sharing of this narratives. The researcher
tried to ensure accuracy through the use of written documentation and thru the use
of audio recording devices.

The researcher spotted that there were other possible sources of information
that was not included in this study. However, the in-depth interview, together with
the documentation and audio-recording may sustain the claims on this study.

CONCLUSION

The current mental state of Mr. C did not have the similar to other
researcher’s findings with a person with Schizophrenia. Most of them argue that
person with the said disorder has lost its sense of self. But in the case of Mr. C, he
had a full awareness of himself. Aside from the awareness, different risk factors
such as the family, socio-economic status and community may be a risk factor for
the development of the disorder. And lastly, support systems such as the family and
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the community were seen as a factor that helped coped the person with
Schizophrenia

RECOMMENDATIONS

To the client. There were numerous issues that were seen after the initial
assessment of the researcher of the client. And of this, the following should be done
to Mr. C: first, if that Mr. C should see a medical professional that would cater both
his physical and mental needs. As what has been in the previous chapters, it was
noted that Mr. C only had once seen a doctor upon his whole life. It should be clear
that his physical medical condition should be addressed too. Using of cigarette and
too much drinking of carbonated drinks may affect the health of Mr. C. With this,
closer monitoring of Mr. C should be practiced within his family. Second,
community-based intervention should be created to help people like Mr. C and other
related mental health concerns. Mental health is necessary but it should be reached
from the smallest unit in the community-the family. And in order to achieve that
endeavor, treatment and availability of mental health services should be in the
community. Third, psychoeducation to the family of Mr. C and to the community
where he belongs should also be conducted. Awareness is the key this problem and
to the underlying stigma of this disorder. By informing others in the community,
they will have a deeper understanding of the causes, effects, and treatment of this
disorders.

Application in clinical practice. Psychological assessment is crucial in this

study. Without the process, information and details can’t be generated from Mr. C.
With this, the researcher wanted to challenge fellow clinician to develop themselves
in their assessment skills. The clinician has had several issues with assessing
clients. But what is important is to have a reliable and valid diagnosis to have a
better treatment plan for the client. After the assessment, treating the client is the
next step. The researcher would like to recommend to venture out into a treatment
plan that is evidence-based and can be utilized using local population.

Use of community-based intervention. A crucial factor that would affect the

treatment of the client is its intervention. And that using community-based
intervention would benefit the Mr. C. There is no existing community-based
intervention that is available on the community of Mr. C. Hence, there is also a
scarcity of mental health practitioner in the locale. The researcher would like to
recommend to develop a community-based intervention plan to the community and
to train individuals who are willing to become facilitators of the said intervention.
Social support groups and self-help programs are also recommended by the

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researcher. With this, people with mental health issues can be accommodated. And
lastly, to build the network of the community-based intervention, the local
government unit should link with other institutions such as the academic, mental
health facilities to help them with the implementation of the program.

Future research. The researcher would challenge future researcher to generate

more studies in relation to community-based intervention, treating schizophrenia
and other related studies. There has been limited literature that is available yet the
issue is very prevalent in the country. Also, the researcher recommends creating
clinical-assessment tools that are normed and conducted here in the Philippines.
Most of the tools that are available are mostly in the western countries. Moreover,
generating studies using different therapies is also encouraged to have a more
evidence of empirically-based therapies and treatment.

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Mental Disorders, Fifth Edition. Arlington, VA.

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American Psychiatric Association. (2018). Cultural Formulation Interview,

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