Awareness Integration Theory Case Report: Therapeutic Intervention for Anxiety and Depression in a Transexual Male College Student
One clinical psychotherapist’s case report about a 19-year-old Caucasian transexual male college student with above-average intelligence is presented. Client had previously been diagnosed with generalized anxiety disorder, gender dysmorphia, and obsessive-compulsive disorder tendencies. The client sought therapeutic services due to low self-esteem that promoted feelings of awkwardness in social situations, worry that others are mad at him, and a desire for deeper relationships with friends. Therapist followed the six phases of Zeine’s model of awareness integration therapy (AIT) based on AI theory. AIT has been found to successfully reduced anxiety symptoms in clients diagnosed with generalized anxiety and other disorders. AIT aims to enhance one’s self-awareness about internal processes, increase self-esteem, release past traumas and psychological blocks, reduce anxiety symptoms, and regulate thoughts, emotions, attentions, intentions, and actions. Therapist’s treatment plan and client’s goals aligned with the six phases of AIT by: (a) increasing insight into the historical and current sources of low self-esteem; (b) decreasing the frequency of negative self-descriptive statements; (c) increasing the frequency of positive self-descriptive reports; (d) decreasing anxiety level while increasing the ability to function daily and learn; (e) implementing mindfulness exercises to reduce anxiety and worry; and (f) taking committed actions toward living a valued life. Therapist helped client access and gain awareness of the correlation between the way he perceives the world and how he relates to and behaves towards others. Client enhanced his abilities to incorporate new understanding of how he viewed the world following therapy, and made better decisions regarding himself and his personal identity. Client’s scores on the posttraumatic stress disorder checklist (for DMS-5), the generalized anxiety disorder screen (GAD-7), and the patient health questionnaire (PHQ-9) decreased signicantly following 10 months of AIT. Client reported his anxiety had decreased, and he felt condent about initiating and participating in social interactions.
Awareness Integration Theory Case Study
This article presents one clinical psychotherapist’s case report following the process of guiding a client through the six phases of Zeine’s model of Awareness Integration Therapy (2014) based on Awareness Integration Theory (AIT). The client’s presenting problem was difficulty ending friends and maintaining relationships. He complained of low self-esteem, always worrying about other people being mad at him, feeling awkward, and not having deep relationships with any friends. Compared to the general population, male transgender individuals have three times higher anxiety symptoms, which indicate the client could have anxiety disorders (Walter, 2016). Important determinants of anxiety symptoms included low self-esteem and interpersonal functioning (Walter, 2016). According to Walter (2016), transgender clients presenting anxiety symptoms benefit from interventions that focus on the clients’ self-esteem and interpersonal issues, and emphasize the significance of access to transgender health services. Anxiety disorders are the most common mental illness in the general population, affecting 18% of the population in the United States (12 months prevalence) and 13.6% in Europe (lifetime prevalence). Cross sectional studies described higher prevalence rates of anxiety symptoms in the transgender group than in the cis population. The prevalence of anxiety disorders ranges from 17% to 68%. The most common anxiety disorders found were specific phobias, social phobias, panic disorders, and obsessive-compulsive disorders (Nessa 2016). Individuals in the emerging sexual and gender minority categories (pansexual, demisexual, asexual, queer, questioning, and transgender/gender nonconforming) report significantly higher rates of depression and anxiety when compared with cisgender/ heterosexual individuals, and even significantly more than those who identify as gay/lesbian (Borgogna et al., 2019; Bouman et al., 2017). The rates of depressive symptoms (51.4% for transgender women; 48.3% for transgender men) and anxiety (40.4% for transgender women; 47.5% for transgender men) within the current study far surpass the rates of those for the general population. The need to focus on interventions that reduce avoidant coping strategies, while simultaneously increasing social support, to improve mental health for transgender individuals is eminent (Budge et al., 2013; Bouman et al., 2017; Millet et al., 2016). Additionally, issues that have an emotional component in friendship may include a sense of lack of belonging, being judged or rejected can cause anxiety and shame leading to a low self-esteem. One can become depressed simply because they didn’t attract as many friend requests on social media as others. Others can feel controlled by needing to please their friends, leading to harboring feelings of sadness and anger (Zeine, 2017). The psychotherapist determined AIT to be the best choice of treatment for this current client. As an applied model, clinical studies have demonstrated that AIT had been 76% effective in reducing depression, 60% effective in decreasing anxiety, 43% effective in increasing self esteem, and 20% effective in increasing self-efcacy (Zeine, 2014). Zeine et al. (2017a) found that following a therapeutic six-hour AIT six-hour workshop, a client experienced 27.5% decrease in depression, 37% decrease in anxiety, 15% increase in self-esteem, and 13% increase in self-effcacy. Additionally, applying AIT as a self-help module in a study conducted with college students at California State University Long Beach, Zeine et al. (2017b) found following a module on AIT, that college students experienced less stress, and reported experiencing less anxiety (21.72%) and depression (68%).
Awareness Integration Therapy
The Awareness Integration (AI) model was used to treat this client, a 19-year-old Caucasian transexual male college student with above average intelligence. By using Awareness Integration Therapy (AIT), the therapist aimed to support the client in the following processes:
(1) enhancing the client’s self-awareness about his internal thought processes
(2) increasing his self-esteem
(3) releasing his past traumas and psychological blocks
(4) reducing his anxiety symptoms
(5) and regulating his thoughts, emotions, attentions, intentions, and actions (see Zeine, 2021).
Awareness Integration Model
The AI model is a multi-modal psychological model that increases self-awareness, eliminates psychological barriers and/or prior traumas, fosters clarity and a willingness to learn, and applies new abilities for a happy, successful, and effective life. According to Zeine (2014) the AIT model combines elements of well-established psychological theories and methods, including cognitive behavioral therapy, emotion focused therapy, existential psychotherapy, humanistic theories, attachment theories, eye movement desensitization and reprocessing, hypnosis, mindfulness, traumainformed and mind-body theories. According to Zeine (2021), AI is based on the following nine principles:
1. Reality is the experience of the observer/perceiver. Every human being observes/perceives and creates reality based on their state of being, beliefs, emotions, and behaviors. In this way, human beings are co-creators of their reality.
2. Every human being has the capacity and potential to learn the skills needed to have an enjoyable, happy, functional, and successful life.
3. Skills are learned through physical and psychological development; personal experiences; and mirroring parents, teachers, peers, media, and culture.
4. The human mind perceives and creates meaning internally for all external stimuli that results in a subjective reality that may vary from actual events and the realities of others. Through the invented reality, one creates formulas, beliefs, and personal identities that relate to self, others, and the universe at large.
5. Human beings store experiences cognitively, emotionally, and somatically. The unintegrated experiences await integration. Negative core beliefs, including the emotions that are produced by them and the area of the body experiencing the emotions at the time of the original incident, repeatedly resurface in automatic thinking patterns. These negative core beliefs create a withholding and survival-based attitude. This attitude is triggered by an event and creates a result that prohibits the individual from achieving optimal potential beyond survival, even when there is no real threat. This attitude holds back one’s ability to live a fulfilled life.
6. As the unintegrated belief-emotion-body state is attended to, released, and integrated into the whole system, neutral and positive attitudes, beliefs, and emotions can be experienced. In the human organism, there appears to be a self-organizing and a self-management mechanism that is always operating to keep the system in balance and maintain a homeostatic state. If this mechanism is overwhelmed, compartmentalization occurs to bring the system back into homeostasis for a brief time. In the long term, the system will be off balanced if these compartmentalized states are not integrated back into the whole system. Therefore, when the traumatic memory is accessed, and the system gets activated, the information is moved to an adaptive resolution and then integrated.
7. Through self-awareness, integration of one’s experiences, and the creation of conscious choices regarding beliefs, emotions, and actions, one can choose a positive attitude for the creation of a new, positive reality and, therefore, produce intended results.
8. New skills can be learned and practiced in a neutral and positive environment to enhance life’s capabilities, experiences, results, and relationships.
9. Conscious intentionality and envisioning of a desired result, in combination with effective planning and timely scheduled action plans, raise the probability of achieving the desired results in all areas of life.
AI aims to promote consciousness, integrate all fragments of the self from the past into the present, develop a vision for the future, establish clear objectives and action plans, and establish an external feedback loop to guarantee long-term success and fullling life (Zeine, 2021). As an applied therapy, the most essential and unique technique of AIT entails the individual identifying one’s negative and unreasonable fundamental beliefs, the systems they devised to live by, and the identities they built, maintained, and operated. AIT enables the dismantling of the individual’s undesirable core beliefs and releases emotional and physical charges that persist from incomplete experiences and memories. This approach promotes self-integration, enabling skill development and the creation of a desired and intended future without the past hindering the present.
There are six AIT intervention phases. Each phase has procedures aimed at a particular type of awareness, integration, and intentionality in action. The three ways of relating are defined as the process of awareness followed by integration, envisioning, and manifestation. The therapist follows the client’s lead in exploring each intervention phase, as follows:
- Seeing the self as the one who observes – thoughts, feelings, behaviors, and impact – the outside world and relates to objects or people from the self, standing here in the body (Phase one).
- Assuming and projecting from here how others “out there” view – thoughts, feelings, behaviors, and impact – the self and then being able to respond as if the assumptions are real (Phase two).
- Splitting the self and relating to different parts of self from an observer or an interactor out there to the self – thoughts, feelings, behaviors, and impact (Phase three).
- Integrating the split selves, past traumas, unfinished businesses into the current state (Phase four).
- Envisioning, planning, implementing, manifesting, and experiencing out-there/in-between the self within the parameters of the body and other (Phasefive).
- Establishing structures to actualize and sustain a fulfilling life (Phase six).
Phase I is intended to encourage awareness of how the client’s perceptions, mental processes, emotions, and behaviors relate to their external environment and how those attitudes affect their day-to-day life.
Among the inquiries in this stage are: What comes to mind when you think about (someone or a particular idea in life)? How do you feel about (individuals or concepts in a particular area of life)? How do you act toward (individuals or concepts in a particular area of life)? How does your attitude toward (individuals or ideas in a particular area of life) affect your life and others?
Phase II has the following three purposes: To:
A) Make the client more aware of how they project other people’s thoughts and feelings toward them
B) Improve the client’s capacity to observe how other people behave toward them and to observe the meanings they attribute to that behavior and
C) Identify how these constructs have an impact on the client’s life.
This phase includes the following inquiries: What do you assume others think of you? How do you assume people feel about you? What actions do you observe from people, and what meaning do you assign to others’ behaviors? How do your presumptions impact your own and other people’s lives?
Phase III strives to promote client awareness of their thoughts, feelings, and behaviors about their identity in each area while also considering how their identity interacts with and reacts to these different areas.
Questions are: What are your thoughts about yourself in this area? How do you feel about yourself in this area? How do you behave toward yourself? And the impact of your attitude toward yourself?
Phase IV guides the experience of connection between thoughts, formulas, and schemas with emotions and the body areas that maintain and reject intense emotions. This process becomes necessary when the student ends a negative core belief about the self or the world which holds a heavy emotional charge. In this phase the core belief is linked to the emotion which is stored in the body and the associated memory that initiated the belief and then allow the release of negative core beliefs, hidden intentions, shadows, and emotions locked in the body. This process also allows one to gain awareness of the ability to be with, tolerate, and manage emotions effectively. Questions in this phase include: When you say [negative core belief] how do you feel about yourself? How do you feel when you say this to yourself? Where is the feeling in your body? What is the intensity on a scale from 1 to 10? Then one is guided to focus on their body in the location that the emotion is residing and then to allow the emotion to take one to the first time he/she experienced this kind of emotion and decided the negative belief. The client then allows an integration between the adult side of the self which is present now and the past/ young part of the self which is still compartmentalized.
Phase V aims to commit to actualizing an intended life through thinking, feeling, acting upon new and chosen values, and fostering a healthy and workable attitude and identity. As a result of this new commitment, short- and long-term goals are established, scheduled, and concrete action plans are created to achieve the intended result. The therapist will determine at this stage which abilities the client has already mastered, and which still require development.
Phase VI aims to create a sustainable structure to work as a feedback loop and assure the maintenance of the action plans and the intended and actualized results. The form can vary from visual collages to audio recordings or symbolic rituals.
AIT aims to identify and integrate the fractured elements of the “Self” due to upbringing or psychological traumas, heal the past, envision the future, and live in the present time intentionally. Through this complex process, one becomes aware of negative thoughts and harmful mental and emotional coping mechanisms ingrained in their fundamental beliefs and replaces them with constructive, helpful, and positive concepts.
The client is a 19-year-old Caucasian transexual male college student with above-average intelligence who had previously been diagnosed with generalized anxiety disorder, gender dysmorphia, and obsessivecompulsive disorder tendencies. He self-referred himself to therapy. The client is a second-year college student in a teacher preparation program pursuing a B.A. degree in education with an overall grade point average of 3.5. He lived in university housing with another transexual male student for the past year. The client is currently taking Zoloft and testosterone. He has not had any suicidal attempts and denies suicidal ideations. The client has a long history of social anxiety and avoidance of social interactions. He reported that he had attempted therapy several times but did not experience benets from the treatment. The client’s rst experience with therapy was when he was 13 years old. He reported that he met with the therapist once and commented to the therapist that he did not want to be there. The therapist decided not to continue therapy with him. He further reported that he was in group therapy for a brief period when he was 15 years old. He stated that therapy was mandated by his insurance company as a condition of the policy because he was a transexual person and wanted to go through the transition process. The client’s family includes his mother, father, half-brother, and halfsister. He reported that his siblings have no contact with the family by choice. He expressed that he is not close with his parents and does not get along well with his mother. He suggested that his parents have been supportive of his transition process. The client is partially nancially supported by his parents and is working part-time at a sandwich shop while he is in university. The client has been dating a girl for the past two years. His girlfriend is also a student, and they often commute to campus to spend time together.
The sessions were conducted in Zoom video format. The client attended 50-minute weekly sessions with minimal interruptions in scheduling based on illness or other convicting schedules. In the following section.
Course of Treatment
The course of treatment includes the plans and goals for the client and the therapist’s reection process. Detailed information is provided for each phase to give the reader a sense of the dynamic processing that occurs as therapist and client interact.
- The treatment plan and goals for the phases are designed to do the following:
- Increase insight into the historical and current sources of low selfesteem
- Decrease the frequency of negative self-descriptive statements and increase the frequency of positive self-descriptive statements
- Decrease anxiety level while increasing the ability to function daily
- Learn and implement mindfulness exercises to reduce anxiety and worry
- Take committed action toward valued life
Phase 1: Think, Feel, and Behavior Toward This Client
Therapist Thought: “He is lost,” “He is confused,” “He is a victim of life circumstances.” “He is committed,” “He wants to do better,” “He is young and has his whole life ahead of him.”
Therapist Felt: Compassionate, sympathetic, reserved, and challenged. Therapist Behaved: Compassionately, nonjudgmentally, acceptingly; actively listened as the client describes his thoughts and emotions
Phase 2: Assumptions of How the Client Thinks, Feels, and Behaves Toward the Therapist
Therapist Though: “He is confident, knowledgeable, accepting.” “Therapist is too old… Not much experience working with trans individuals.”
Therapist Felt: “He feels safe, accepted, cared for, valued, and completely understood.”
Behaviors: Shows up for sessions regularly and reflects on what is discussed during the session.
Therapist Behaved: “Avoids delving into deeper issues.”
Phase 3: Therapist's thoughts, feelings, and behavior toward self as she is with this client
Therapist Thought: “I hope I can help him,” “I am nonjudgmental and accepting,” “I have wisdom and can guide him in the right direction.”
Therapist Felt: Hopeful, skilled, eager to help, and worried that I may fail.
Therapist Behavior: Review AIT methods and interventions, consult with colleagues, prepare for session, be available and accessible to listen; avoid acting impatiently and filling in words for the client during brief moments of silence.
Phase 4: Integration Process (Thoughts, Feelings, Behaviors)
- Identify your own negative core beliefs and assumptions about self
- Be open to feedback from colleagues
- Focus on my strengths vs. acting based on fear of failure
- Understanding own limitations and being OK with it
- Practice mindfulness
Phase 5: Mission Statement as a Therapist, Action Plan (Thoughts, Feelings, Behaviors)
- Be fully present during sessions with the client
- Be aware of personal thoughts and biases and not allow that to be a barrier in the therapeutic relationship with the client
- Continuously sharpen my therapeutic skills
- Educate myself regarding transsexuality
- Develop an accurate treatment plan; review regularly and revise accordingly
Phase 6: Maintenance Structure (Thoughts, Feelings, Behaviors)
- Regularly seek feedback from the client to ensure that client’s concerns are being addressed during therapy.
- Periodically evaluate the progress of the client by using structured and semi-structured measures.
- Thin out the frequency of the sessions as the client makes sufficient progress
Six Phases of AIT
The following narrative contains representative discourse that occurred during AIT sessions with the client. It contains direct quotes from both the therapist and the client. The therapist’s thoughts, feelings, and behaviors are included for each phase.
Phase I: Thoughts, Feelings, Behaviors Toward Friends
Therapist. “What do you think of friends? Share both positive and negative thoughts.” Client. “Cool to have friends to hang out with….Socializing can be exhausting….I don’t fit…..Don’t know what to say.” Therapist. “How do you feel about friends? Share both positive/pleasurable and negative/uncomfortable emotions.” Client. “Relieved because I do not have to interact…..Awkward, weird, alone.” Therapist. “How do you behave toward friends? Share both actions/behaviors that create favorable results and the ones that create unfavorable results.” Client. “Avoid interaction, avoid social gatherings….Keep to myself….Go out of my way to ensure no one is upset or mad at me.” Therapist. “How you think, feel, and behave toward friends impacts your and others’ lives. Share the positive and negative impacts.” Client. “Do not have many friends….Scared of talking with people….Missing out on much fun….Avoid feeling anxious when around people….Avoid feeling weird.”
Phase II: Prompts and Responses
Therapist. When friends are around you, what do you assume they think about you? Share your positive and negative assumptions. Client. “Friends think I am annoying,” “they don’t know if I’m a girl or a boy,” “weird,” “charismatic” Therapist. When friends are around you, how do you assume they feel about you? Share your positive and negative assumptions. Client. “Unsure,” “bored,” “not excited.” “curious” Therapist. How do you experience or assume their behavior toward you when friends are around you? Share both positive and negative observations and assumptions. Client. “Engage in small talk,” “avoid one-to-one interaction with me,” “don’t ask to hang out” “Are nonjudgmental,” “laugh at my silly jokes.” Therapist. How has the way you assume friends think, feel, and behave toward you when they are around you impacted your and others’ lives? Share positive and negative impacts. Client. “Friends do not pursue a relationship with me,” “I’m lonely,” “Friends find me nice because I always try to please them.”
Phase III: Prompts and Responses
Therapist. When you are present with friends, what do you think about yourself? Share positive and negative thoughts. Client. “I think I am too self-conscious and uptight,” “I’m awkward,” “I’m more concerned about my feelings”, “I’m bad at making conversations. “I forget things a lot,” “I’m indecisive,” “I’m too passive, I don’t stand up for myself”, “too scared to stand up for other people,” “I don’t matter,” “I am irrelevant.” “I have much love to give,” “I’m funny and have a good sense of humor.” Therapist: When you are present with friends, how do you feel about yourself? Share positive and negative emotions. Client. “Insecure,” “sad,” “lonely,” “mad,” “frustrated,” and “scared.” “Happy that I have the desire to make it better.” Therapist: When you are present with friends, how do you behave toward yourself? Share positive and negative behaviors. Client. “I blame myself,” “I constantly criticize myself,” “I compare myself with others”, “I belittle myself.” “I feel good about myself because I showed up despite all my fears.” Therapist: How does the way you think, feel, and behave toward yourself around friends impact your life and others’ lives? Share the positive and negative impacts. Client. “I don’t have as many friends as I like to have,” “I don’t have close relationships with many people.” “I always feel scared and think people are mad at me.” “I feel encouraged to be better.”
Phase IV: Integrating the Past into Present
Therapist. When you say that “I am irrelevant” and “I don’t matter,” one or more feelings arise. Tell me about the feeling that you are experiencing. Client. “Feeling dismissed,” “invalidated,” “scared,” “let down,” “alienated.” Therapist. Tell me the location of feeling dismissed, invalidated, scared, alienated, and let down in your body. Client. “Chest,” “neck and shoulders.” Therapist. On a scale of zero to ten, with zero meaning no feeling and 10 meaning the most extreme amount of feeling, tell me the intensity of the feeling dismissed, invalidated, scared, alienated, and let down in your neck, chest, and shoulders. Client. “Eight” Therapist. Now close your eyes. Focus on the area or your body where you experience that feeling of being dismissed, invalidated, scared, alienated, and let down. Let yourself fully experience the emotion and allow it to take you with the muscles in your body, with every cell of your body, back to the rst time you ever experienced this feeling and told yourself, “I’m irrelevant” and “I don’t matter.” Please share with me when the earliest memory appears. The client then saw himself at age 10 -11 and described several different experiences of being at home with his immediate family. His mother and father spent much time with his older siblings, at the dinner table or during family times but completely ignored him as if he was not even present in the room. He described several situations when he left the room for long periods, and the parents did not even notice him gone. On rare occasions that he got his mother’s attention, it was to be blamed for something he did wrong or did not do. He was the youngest of the siblings, with a significant age difference. As you see the younger you in the memory, tell me your thoughts about what is happening to you. Client. “I am not important to my family,” “My siblings do not care about me.” Therapist. As you look at the child, tell me how old you are. Client. “10 -11” Therapist. Tell me how the child thinks about the event and the people in the event and feels about the event and the people. Client. “The child thinks he is unimportant to the family and his parents care more about his siblings. Maybe he did something wrong, which is why he is not loved. He thinks that his sibling are very smart, and he is not as smart as them. He feels scared and helpless because he does not know how to make it better. He feels jealousy toward his siblings and is scared that his parents will find out and be mad at him.” Therapist. Tell me how the child thinks about himself and how he feels about himself. Client. “The child thinks that he has done something wrong, and he feels scared.” Therapist. Tell me what the child needed at the time of the event that he was not getting. Client. The child wanted to be included in the family discussions and to be attended to and seen by them. He wanted to know what are the things that scare him and what are the things that make him happy.” Therapist. Tell me your thoughts about the child in the memory today, as you are today. Client. “The poor child is confused. He is a good kid and loves his family. He does not know how to belong.” Therapist. Tell me your feelings about the child in the memory today, as you are today. Client. “I feel compassion for the child and want to reach out and tell him it is all okay. He is lovable and is loved.” The client was asked to offer empathy and understanding to the child when he was 10-11 years old, related to his unmet needs. He was encouraged to validate that the child did not receive the love and attention he needed, not because he was not valuable or unworthy of love. The client was asked to remind the child that, as the future person of that child, he has traveled in the memory time machine and tell him that he knows he has survived the ordeal. He is now ready to take care of the child’s emotional needs. The client was guided to let the child know that he is now a grown-up and knows how to fulfill the child’s unmet needs now and promises that he will always be there to take care of all his realistically possible needs. The client was also guided to integrate that ego state and no longer need to see that part as a child and separate state, but a need that can be fulfilled by himself in different ways and more appropriate to his age by tapping into his strengths. The client went through this cycle of interaction with the therapist a few times until he could come up with a positive core belief and release the tension in his neck, shoulder and chest and rate the intensity of the negative emotion as 0.
Phase V: Committed Action to Valued Life
Therapist. Who do you intend to be? Client. “I want to be an exciting and passionate teacher who will motivate little children to do their best and be proud of who they are.” “I also want to be a loving and caring partner for my signicant other and develop long-lasting friendships and relationships.” Therapist How do you want to think, feel, and act? Client. “I want to think that I am OK, and I am enough, feel secure and safe and be available and accessible for relationships.” Therapist: What specic goals will help actualize your intentions? Client. “I will nish college in two years.” “I will develop relationshipbuilding skills.” “I will learn effective communication techniques.” “I have an action plan: Ÿ Take a full load of classes each quarter, attend classes regularly, study sufciently for tests, and complete assignments promptly. Ÿ Continue therapy to dismantle negative core beliefs in various areas of life and replace them with more positive/rational thoughts about self.”
Phase VI: Attainment and Sustaining of Goals
The client’s treatment plans and goals aligned with the AIT’s six phases and included: (a) increasing insight into the historical and current sources of low self-esteem; (b) decreasing the frequency of negative self-descriptive statements; (c) increasing the frequency of positive self-descriptive reports; (d) decreasing anxiety level while increasing the ability to function daily and learn; (e) implementing mindfulness exercises to reduce anxiety and worry; and (f) taking committed action toward a valued life. Through AIT, the therapist helped the client access and understand the correlation between how he perceives the world and how he relates to and behaves towards others. As the client enhanced his abilities to incorporate new understanding of how he viewed the world following therapy, he made better decisions regarding himself and his personal identity. Client’s scores on the posttraumatic stress disorder checklist (for DMS-5), the generalized anxiety disorder screen (GAD-7), and the patient health questionnaire (PHQ-9) decreased signicantly after 10 months of AIT. Based on the rst administration of the PTDS checklist for DSM-5 at the beginning of treatment the client earned a total score of 36, which indicated the client may benet from PTSD treatment; at the end of ten months of AITthe client had a score of 12 (a 66% reduction) , which indicated the client had mild anxiety (see Blevins et al., 2015). Based on the rst administration of the GAD-7 at the beginning of treatment the client earned a total score of 20 which indicated severe anxiety; at the end of ten months of AIT the client had a score of 5 (a 75% reduction) which indicated mild anxiety (see Spitzer et al., 2006). Based on the rst administration of the PHQ-9 at the beginning of treatment the client earned a total score of 18 which indicated moderately severe depression; at the end of ten months of AITthe client had a score of 6 (a 66% reduction) of which indicated mild depression (see Spitzer et al. in Kroenke et al., 2001). Moreover, the client reported following AITthat his anxiety had decreased and his condence about initiating and participating in social interactions had increased.
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