This article describes a female university student aged 22-year-old. The client was referred by a psychiatrist, from Addiction Clinic, Psychiatry & Mental Health, Hospital Sultanah Bahiyah for crisis management for panic attacks and supportive counseling as well as motivational interviewing on her substance use. The client presented with complaints of having panic symptoms such as hand tremors, sweating, unable to talk to anyone, and dizziness. She also complained of having difficulty sleeping due to fear of having a nightmare of traumatic events, overthinking, low self-esteem, and loss of focus in her study. The assessment was done on both the informal and formal levels. For informal assessment, an intake interview was conducted to gain information about her background and substance use history; the mental status examination was done, a life event chart was used, and for the purpose of formal assessment TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use Tool) and Stages of Change was used. The score of each test suggests that the client is having substance use problems (i.e alcohol & nicotine) and her stage of change is contemplation. The primary diagnosis is F10.10, Alcohol Use Disorder, Mild, and the secondary diagnosis is F43.0, Acute Stress Disorder. In terms of intervention plan rapport building, supportive psychotherapy, psychoeducation, relaxation techniques, addiction cycle, and relapse prevention technique were used. The overall outcome of the process was an improvement of her alcoholic symptoms due to traumatic events and desirable behavior in getting sober from alcohol use. After the sixth counseling session, her stage of change progressed from contemplation stage to preparation. 

According to National Institute on Drug Abuse, (NIDA, 2010) dual diagnosis is a term that commonly used in describing the occurrence of two disorders in the same person, either at the same time (co- occurring comorbid conditions) or with a time difference between the initial occurrence of one and the initial occurrence of the other (sequentially comorbid conditions). The comorbid pose a double treatment challenge not only for clients, but also for addiction counselor in terms of making assessment and constructing treatment plan. 

Sources and Reason for Referral

The psychiatrist at the Addiction Clinic, Psychiatric and Mental Health Department, HSB, Alor Setar has referred this patient for crisis management and supportive counselling. She was initially referred by Medical Officer from health clinic for further psychiatric assessment to rule out anxiety with Major Depressive syndrome. She voluntarily seeks treatment by herself at a local health clinic in Kedah. She was previously not on any medical follow-up and came upon the referral appointment by the health clinic. She seems concerned with her current problem and seek for professional medical treatment.

The client complained of panic symptoms worsening for two to three months whomever she met people i.e., friends or strangers in person or through voice call. She will suddenly leave the conversation or hang up the call. She will experience hand tremors, sweating, and unable to talk. Besides, she also easily tends to become overthinking how people may judge or dislike her. She claimed of been downgraded by friends/other people (i.e., when friends correct her English grammar in a joking way, she took it seriously), and scolded by her superior in front of the customer. Furthermore, she also complained of being unable to sleep at night because of horrible nightmares about the ‘sexual assault’ incident she had.

She reported that the incident happened in the earlier year of 2022 where she claimed she had been sexually assaulted by a male acquittance. She reported she was drunk when that happened and could not recall whether she consented or not. She has been not able to focus and concentrate on her study and became quieter since then. 

Personal history

She has no known medical illness and prescription drug allergy. She also has no pass medical and surgical history. This was her first psychiatric contact.

Family history

Her father passed away 18 years ago due to Ischaemic Heart Disease (IHD). She was only 5 years old at that time. Her mother is 50 years old and works as a staff nurse at the Ear Nose and Throat (ENT) clinic in Hospital Sultanah Bahiyah. She has a brother aged 25 years old and is currently self-employed. She is the second child of her mother’s first marriage. Later, her mother remarried, and she has a stepfather and two stepsiblings; aged 15 and 12-years old. The client was raised by her grandparents.   

Educational history

She received primary and secondary education at national schools in Kedah and she passed successfully all the major examinations. Currently she is persuing her undergraduate studies in cognitive science at one of public universities in Malaysia.   

Occupational history

To support her studies in the city, she did a part-time job as a barista at a few places including the bar. During this this that she learned drinking alcohol and smoking. She claimed that she felt more confident by consuming alcohol so that she can easily mingle with friends.

Sexual history

She reported that she has been ‘sexually assaulted’ by her male acquaintance during one of their gathering parties. She did a police report and retrieved it a week after due to uncertain consequences that could come with it. She refused to let her family know about it and only keep to herself. Safety assessment was conducted during the session no immediate danger were identified in the client. 

Social history

Client reported regular social life with her friends. She has had ‘a tense relationship’ with her mother and not so close with the stepfather. However, she is fond with her other stepsiblings. 

Psychological Assessment

Informal assessment

The client came with her mother but was seen alone during the first contact. The client’s body is thin and slim, with tan, brown skin color and straight hair on the first look. She shows good hygiene from his physical appearance. She was dressed in white shirts and tight jeans with a ponytail tied hair. She colors her hair browned and wore spectacles. In the beginning, Se appears reserved, and only talks upon asking. She is moderately cooperative and maintains moderate eye contact with the counselor. The counselor was able to build rapport with the client, but she was not forthcoming. Hence, the trust is not yet attained to allow her to share her story and feeling. Noticeably, her sitting posture was relaxed but slightly bend over with her legs crossed. Besides, the client seems alert to the time, place, and people.

Mental State Examination (MSE)

MSE was done during the first session of referral to assess their verbal & nonverbal symptoms of illness by the counselor. It provides the basis for psychiatric diagnosis and clinical assessment. A comprehensive and effective MSE also provides the initial screening information required to make a therapeutic decision and undertake any additional assessment and treatment needed for a particular client (Polanski & Hinkle, 2000). From the first impression of the client to the attended counselor, her eye contact was fair, and often look down. She was tearing up in the middle of the interview. Her hands tremor on and off during the session with restless body signs. Her speech was coherent and relevant but with minimal response. Her mood was anxious and sad with congruent affect. She denied any perceptual disturbance. No suicidality ideation or self-harm was noticed.

Formal assessment and results

The following psychometric test was used to assist in the formal assessment.

1) TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use Tool)

For the past 12 months, she had alcohol consumption for at least once a week. She usually drinks Whisky (distilled alcohol) and spends RM300/bottle. She also smokes cigarettes occasionally whenever she consumes alcohol socially with her friends. She admits that she had tried smoking once but did not like the taste and effects. She denied any prescription drug use or abuse such as pain killers and sleeping pills.

2) Stages of Change Assessments

The score of this test shows that she is currently at the contemplation stage of her substance use.

SNA is a female university student aged 22 years old. She was referred by the psychiatrist to a counselor for crisis management of her current panic attack syndrome and supportive counseling. Recently she had been sexually abused under alcohol intoxication while she went out drinking with her friends in KL. However, she was unaware whether she had consented to have sexual intercourse and only realize the next morning after the hangover. She was scared, panicked, and had pain and bleeding from her intimate part. Since the incident, she started to develop panic symptoms, frequent nightmares about the guy who raped her, and was unable to talk to anyone.

Her childhood history suggests that she did not receive adequate attention, love, and affection from her parents. Her father died when she was 5 years old, then her mother was married to her stepfather, and she was put under her grandparents’ care from she was 7 years old until 15 years old. She did not develop a good relationship with her stepfather and her mother took care of her again after her grandparents passed away. However, her relationship with her mother did not go well as she frequently was scolded for not doing any chores or taking care of her stepsister. Her mother works as a staff nurse and often does overtime job to support their family’s financials.

SNA started to consume alcohol and smoke cigarettes when she was 20 years old. It was being introduced by her friends and she usually drinks alcohol and smokes cigarettes recreationally whenever she hangs out with her friends. Most of the time she drinks whisky and spends around RM300/bottle every week. She also had been introduced to smoking weed, but she only tried it once because she personally dislikes the taste and the effects. But continue to drink alcohol and smoke cigarettes. She denies smoking every day but only during consuming alcohol.

The traumatic incidents that happened to her caused her to behave differently than she used to. She refused to let her mother know because she is afraid of her mother’s reaction and chooses to keep it to herself. She felt very unfair towards the guy friend who had sexually abused her but did not have the strength to lodge the police report. She was afraid of any unexpected consequences that may happen to her but decided to get treatment for her current condition from medical professionals.

Currently, she had good insight into her problem, but her judgment is still poor in term of resorting to her emotional pain through an unhealthy coping mechanism by consuming alcohol. She prefers to consume alcohol whenever she felt stressed to numb her emotional pain. Nevertheless, she is motivated to seek treatment, but the client’s currents ongoing stressor include living with her unsupportive mother, carrying heavy subjects for current semester and a recent encounter with the guy that raped her.

The history taking of SNA’s life events shows that she had been drinking alcohol for the past 2 years. Specifically, in the fifth edition of the Diagnostic and statistical manual of psychiatric diseases (DSM-5) of the American Psychiatric Association, alcohol use disorders are defined as problematic patterns of alcohol use leading to clinically significant impairment or distress. DSM-5 stated that alcohol use disorder (AUD) or alcoholism is a chronic, relapsing disease that is diagnosed based on an individual meeting certain criterion. DSM-5 changed from differentiating alcohol abuse and alcohol dependence to a single category of Alcohol Use Disorder (Thompson, 2018).

There is a close association between alcohol use and sexual assaults reported. Alcohol contributes to sexual assault through multiple pathways, often exacerbating existing risk factors. Beliefs about alcohol’s effects on sexual and aggressive behavior, stereotypes about drinking women, and alcohol’s effects on cognitive and motor skills contribute to alcohol- involved sexual assault (Mouilso & Wilson, 2019). Furthermore, 30 percent of all sexual assaults and 75 percent of sexual assaults occurring on college campuses, occur when the perpetrator is under the influence of alcohol. In many cases, the victim is also intoxicated. Drinking makes it easy for the perpetrator to ignore sexual boundaries, while the victim’s intoxication makes it more difficult to guard against an attack (Alcohol & Sexual Assault | Butler University, n.d.).

Alcohol's disinhibiting properties may also impair judgment and unleash aggressive, antisocial behaviors that may mimic certain externalizing disorders, such as antisocial personality disorder (ASPD). Psychiatric symptoms and signs also may vary depending on when the patient last used Alcohol and when the assessment of the psychiatric complaints occurs. For instance, alcohol–dependent patient who appears morbidly depressed when acutely intoxicated may appear anxious and panicky when acutely withdrawing from the drug (Peace & Mellsop, 1987).

Whereas Acute Stress Disorder according to DSM-5 is caused by trauma and can occur within the first month following the event. It is a psychological condition that causes a strong emotional response within the individual. People with ASD experience mental shock, severe anxiety, and other symptoms (KM, 2017). Unlike PTSD, ASD is a temporary condition, and symptoms typically persist for at least 3 to 30 days after the traumatic event. Besides, many symptoms of ASD may overlap with those of Post-Traumatic Stress Disorder (PTSD). However, if the symptoms persist, for longer than a month, a doctor will usually assess them for PTSD (Eske, 2019).

From the presenting symptoms presented by the client, she can be diagnosed as the following:

Primary diagnosis: F10.10, Alcohol Use Disorder, Mild, Secondary diagnosis: F43.0, Acute Stress Disorder (DSM5)

Client’s prognosis

The prognosis of the client is positive as the client’s insight about the problem was good and the motivation level of the client was considerably good. The client shows good adherence to the treatment plan and commits to the counseling session well. She did not miss any appointments and complied with her medication as prescribed by the psychiatrist. Improvement in her behaviors, interaction, and rapport was also seen as it was observed by the counselor and further discussion with the medical team. Positive observable changes were also seen in the client’s mood. The client’s mother was also invited to discuss her condition by patient consent as well as to provide good support for her recovery

Short-term goals

1) Providing supportive counseling to build a level of trust with the client and create a supportive environment that will facilitate the client to share her unresolved issues.

2) Allowing client to ventilate her emotional distress at her convenient

3) Teaching and practicing appropriate relaxation techniques (i.e., deep breathing techniques) to enable her to manage the stress, and to be calm and relaxed in panic- provoking situations and thoughts.

4) Asking the client to do journaling in between her treatment appointments

5) Teaching coping mechanisms and skills to communicate effectively with her mother

6) Provide/suggest the client to join the Stop Smoking Clinic at a nearby health clinic.

Long-term goals

7) Enabling the client to stay sober from alcohol and smoking cigarettes

8) Have a better relationship with her mother and other family members

9) Completing her undergraduate study on time

10) Achieving life goals and life freedom for the client to grow

Individualized intervention plan was created to help the client to find solution and have better insight about her problem and to aid the process of adjustment, to promote a positive self-concept and to let her learn to make a wise decision about her life as well as to interact with others effectively. A healthcare professional will work closely with a person to develop a treatment plan that meets their individual needs. For this case, it is an immediate need to treat for ASD first by focusing on reducing symptoms, improving coping mechanisms, and preventing PTSD. AUD will be treated alongside according to the client’s progress.

Treatment options for ASD may include (Bryant, 2017):

i) Cognitive behavioral therapy (CBT). Doctors usually recommend CBT as the first- line treatment for people with ASD. CBT involves working with a trained mental health professional to develop effective coping strategies.

ii) Mindfulness. Mindfulness-based interventions teach techniques for managing stress and anxiety. These can include meditation and breathing exercises.

iii) Medications. A healthcare professional may prescribe antidepressants or anticonvulsants to help treat a person’s symptoms.

Implementation of therapeutic strategies: -

Session 1

The first session was very brief for clients under crisis which require immediate intervention. Psychiatric has referred this client for crisis management. Only minimal information about client’s background was gained and further intake interview is required for the next session. The conversation between counsellor and client is focused on minimizing the stress of the event, providing emotional support, and improving the individual’s coping strategies (Cherry, K, 2022). Due to limited time available, the counsellor only manages to teach and practice client with deep breathing techniques to help her feels calm. Doing breathing exercises every day will help to prevent panic attacks and relieve them when they are happening (Health Scotland, 2022). At the end of the session, client was given some homework to record the breathing techniques exercise by using a worksheet. Client’s expectation and goals from counselling session were also asked for her to write down as a guide for the counsellor.

Relaxation techniques

Relaxation skills are excellent tools for the treatment of stress, anxiety, and anger. In addition to being easy to use, relaxation techniques are some of the few tools that offer an immediate sense of relief from the symptoms of mental illness (Relaxation Techniques (Guide) | Therapist Aid, n.d.). In addition, progressive muscle relaxation was used because he reported muscle stiffness and pain. At first, a deep breathing technique was used in which the client was asked to sit in a comfortable posture and make herself. Then she was asked to inhale air from her nose slowly for 3 – 4 sec and try to stay the air inside her lungs then smoothly exhale the air out from her mouth. The client was asked to repeat the breathing exercise for 3 – 4 times to make sure she understands and do it properly.

Session 2 – Second session was more proper meeting with the client. During the session, counsellor did the intake interview on personal background and substance use history to frame the client’s issue for intervention plan according to her needs. Formal assessment using TAPS and Stages of Change questionnaires was done to assess the client’s issue.

Intake Interview

The intake process is vital to the formation of any counselling relationship. It is the foundation structure of the therapeutic relationship development. There are some important considerations counsellors need to keep in mind. First, the intake process consists of both the intake form and the initial session. Usually, the client will be asked to complete an intake form prior to the first session so that important information about the client is gathered and is kept on file. The counsellor may want to consider how much to ask on this form as well as what most people may be comfortable sharing. Whatever is not asked on the form (or filled out on the form), will need to be asked by the counsellor in the intake session (Bagley, 2013).

Session 3 – Notably during this session, client had committed self-harm. She made several cuts on her wrist and arm using blunted instrument. It was due to her current trigger at home involving her mother and course mate. Supportive counselling to allow emotional ventilation was done during the session to make the client feel release and calm. At the end of the session counsellor had discussed with the client to invite her mother on the next session. Client agreed and consented with the suggestion but asking to keep silence regarding the rape incidents and not to disclose to her mother. Counsellor noted and respect client’s request.

Supportive psychotherapy

Supportive psychotherapy is the attempt by a therapist to help patients deal with their emotional distress and problems in living. The therapist provides an emotional outlet, the chance for patients to express themselves and be themselves. Supportive psychotherapy was done with the client to enhance his relationship and provide him reassurance, guidance and unconditional positive regard. So that he easily shared his real-life events and feelings regarding these events, and both worked productively. The five steps of psychotherapy, which were a therapeutic relationship, listening, emotional release, information, advice and encouraging the client's hope, were done during management. After this technique, the client's hesitation was reduced, and he could discuss his relationship conflicts and break up in detail, which helped him with his catharsis (Neuman, 2013).

Session 4 – In this session client has brought her mother to talk and discuss about her condition – Psychoeducation on client’s diagnosis was given by the counselor. The following has been constituted on the psychoeducation:

i)              explaining to her mother in therapy the ways a mental health condition might impact function of her daughter

ii)             explaining how a prescribed medication can counteract and alleviate symptoms of a mental health condition

iii)            counsellor hospital providing support and education to family members of those receiving treatment

Psychoeducation

Psychoeducation refers to the process of providing education and information to those seeking or receiving mental health services, such as people diagnosed with mental health conditions (or life-threatening/terminal illnesses) and their family members. A goal is for the patient to understand and be better able to deal with the presented illness. Also, the patient's strengths, resources and coping skills are reinforced to avoid relapse and contribute to their health and wellness on a long-term basis (Reyes, 2016). The outcome of this technique was positive, and the client developed proper insight into his problem and how his problem progressed.

Session 5 – During this session, client had shown improvement in term of her ASD symptoms. She also admits that her mother has slightly change after the last session and seem to show care towards her in term of her emotional needs. Counsellor has taken this opportunity to explore the opportunity to help her with alcohol consumptions issue by using motivational interviewing techniques.

Motivational Interviewing (MI)

Motivational Interviewing (MI) is a therapeutic technique used to address substance use disorders (SUD) by strengthening client’s motivation and commitment to achieve sobriety or abstinence. Most client develop an addiction as a coping mechanism to deal with other traumas or other issues that stem from their everyday life. Despite the inevitable health issues, financial costs, and social and legal consequences of substance abuse, the idea of living without drugs or alcohol can be intimidating. The idea of giving up one’s drug of choice can outweigh these negative consequences, ultimately resulting in a lack of true motivation to get sober. For others, a pessimistic attitude keeps them from recovery. They feel like sobriety is not a realistic goal, that they do not need to quit because they aren’t ready, or it will be too hard. Motivational interviewing helps people overcome their fears or uncertainty, fostering patients’ ambition to get sober and begin their journey to recovery (Addiction Support Center (SAMHSA), 2020).

Session 6  – Psychoeducation on relapse prevention

Relapse prevention technique

The relapse prevention approach is used with the client to develop coping skills to manage high-risk situations, make lifestyle changes to decrease the need for the drug, prepare for interrupting lapses so that they do not lead to relapse, and prepare the client for managing relapse so that potential harms may be minimized. Both internal experiences (e.g., positive thoughts related to substance use or negative thoughts related to sobriety that arise without effort, called “automatic thoughts”) and external cues (e.g., people that the person associates with substance use) were discussed and identified during the session (Recovery Research Institute, 2021). In the relapse prevention technique, the client was asked to explore the past situations, events and triggers that may have led to relapse. She was also encouraged to avoid the situations and events that can cause her the trigger to relapse. As she continues with the therapy she admits that she felt less the urge to consume alcohol and whenever she attempt it she will easily vomit which could help her to avoid. Goal setting was also done at this step, in which the client was asked to set goals that would make her enthusiastic and keep him away from relapse. She wants to focus on her study and plan to furthering her study in oversea. The outcome of the technique was positive. The client was fully aware of her problem, and by goal setting and trigger identification, she also became aware of preventing relapse.

After-care Management

Client is set to continue her appointment with psychiatrist at the addiction clinic and continue supportive counseling with the counsellor. However, the frequency of appointments will be based on client’s progress and response with the current treatment. The following are the suggested interventions for after-care management to be done by the clients in between the treatment intervals at home or back to her campus:-

1. Reinforcement of breathing techniques
2. Continual of journaling therapy
3. Positive coping mechanism practices

Marked improvement was observed in client’s problems from session one to session six in term of her psychiatric symptoms. Client was able to socialize again with her friends and family members as usual. Even though she has not yet decided to take legal action on the perpetrator who rape her under alcohol intoxication, she was keen to finish her undergraduate study on time and focusing on getting better. In term of alcohol use, client has reduced her craving for alcohol. Other than these marked improvements, client’s mood, behavior, and self- harm show positive observable changes seen throughout the session. Great rapport and trust were able to develop between the counsellor and clients.

The following are the recommendations for the clients to enhance her recovery treatment: -

I.              Proper follow-ups should be taken, and new techniques for coping mechanism should be applied with the rehearsal of the old ones.

II.            On daily basis, journaling should be practiced by the client to help her ease her mind whenever she felt stress or trigger and bring to the next session for further discussion.

III.           Sessions should be offered to the client upon request and her problem and current issues should be inquired.

IV.           Family therapy should be provided to the client’s family.