Awareness Integration Therapy for Generalized Anxiety Disorder
Introduction
The primary goal of this case presentation is to illustrate the effectiveness of the Awareness Integration (AI) Model on lowering anxiety symptoms in clients. Assessment, conceptualization, and intervention methods related to the AI model will be included in this discussion. Anxiety disorders have a high prevalence within the general population. The lifetime prevalence of anxiety disorders among American adults is 28.8% [1] and up to 33.7% of the population are affected by an anxiety disorder during their lifetime; thus, creating considerable individual and societal burdens [2]. People with common mental health conditions, including generalized anxiety disorder (GAD), strongly prefer psychological versus pharmacological treatments [3]. Therefore, clinical psychologists must attend to this high impact societal need by developing and disseminating efficient and effective interventions. There is compelling evidence that a client-preferred treatment type influences a client’s receptivity to interventions and results in their overall mental health outcomes [4]. As a new multi-modality model, AI aims to enhance selfawareness and increase self-esteem. Zeine [5] indicated that the AI model allows for the release of negative beliefs and emotional charges attached to beliefs that have been assigned based on an uncomfortable circumstance or set of circumstances originating in childhood. The client can then re-integrate through the therapist’s flexibly structured questions and expansive interventions, which connect the client’s core beliefs and emotions with locations in the body where their emotions are stored. The re-integration process also includes addressing relevant and/or original memories, past traumas, and/or psychological blocks, resulting in reduced symptoms of anxiety and depression. Further, AI promotes clear, realistic, and positive attitudes in clients, so they learn and implement new skills leading to effective, productive, and functional lives [5,6]. The advantage of using awareness integration therapy (AIT) over other psychotherapeutic models, rests on the fact that it is a comprehensive model. It encompasses cognitive, emotional, physical, and behavioral components while supporting the client in dealing with the past and present as they scaffold a trajectory leading toward their future creation of fulfillment in life [7]. AIT is unique in that, unlike past models, it concentrates on the dismantling of negative core beliefs that one has assigned to themselves. The individual’s identity, once based on trauma, is transformed. Neutral or positive functional beliefs and attitudes are incorporated into every area of the client’s life, and the negative beliefs are transformed and impact the client’s identity. Rather than merely challenging beliefs with either question or replacing them with surface adaptive thoughts, emotions, and behaviors, AIT dismantles the chosen and assigned core belief so that the trigger no longer gets activated. Therefore, the client can assume a healthier identity with long-lasting changes. Presuming that the reader is already familiar with AI/AIT in its standard form, this report will not provide a detailed account of its rationale and basic structure. Other readers are strongly encouraged to read Awareness Integration Therapy: Clear the Past, Create a New Future and Live a Fulfilled Life Now by Foojan Zeine, PsyD. These manuals provide session-by-session examples for applying AI with a comprehensive evidence-based description of the named psychotherapeutic modality
Case Selection, Context, Method
The selection of the participant was based on the following six factors, as follows:
(1) Despite being in therapy for almost one year and receiving CBT and Emotion-Focused Therapy by other clinicians, the client’s mother stated, “He has not been benefiting from therapy anymore, and the symptoms were exaggerating.”
(2) The client’s mother persisted in having him be accepted by the clinician (same as the writer of this report) and counted on them as their “last hope.” Learning this information, the clinician developed deep empathy for the client.
(3) AIT was utilized as the only modality during the second course of the client’s therapy.
(4) There were no interruptions during the course of therapy, and all 16 sessions took place continuously.
(5) The client’s progress through the course of therapy was objectively measured.
(6) Following the sessions, the clinician concluded from the overall assessment that there were significant improvements in the targeted areas; and also, improvements in the client’s Tic disorders. The therapist noted the reduction in Tic disorders and viewed it as a potential area for further study as a possible somatic effect of the AIT model. The 16 sessions were offered through the Simple Practice video format. AIT was the sole therapeutic modality for the second course of therapy. Data sources included the therapist’s session notes and reflections; the client’s and client’s parents’ reports; the client’s selfreported measures; and GAD and PHQ-9 questionnaires. Specific information, the client’s name or the names of his parents, were not/will not be revealed due to standard ethical procedures, the client’s rights, and the need for confidentiality
Case Description and Case Formulation
The client was a 21-year-old American male college student of Iranian and Hispanic descent, referred by his parents for treatment of extreme anxiety. Family history included the client’s mother being diagnosed with anxiety, father diagnosed with a history of depression, and one half-brother identified with an unspecified mental illness. The client’s parents were divorced, and he had previously lived with his father for several years. During the course of therapy, the client lived with his mother. Strengths included the client’s willingness to engage in treatment and supportive family. Limiting factors included relatively the client’s low stress coping skills, unresolved childhood trauma, previous unsuccessful therapies, and relative social isolation (partially due to some anxiety about social skills). A history of chronic worry and facial and upper body tics were revealed during the client and therapist interview session and as a result of a review of the client’s medical and psychiatric reports. The client met the DSM-5 Generalized Anxiety Disorder and Provisional Tic Disorder (previously known as Transient Tic Disorder) criteria. He also described the frequent presence of obsessions and compulsions. According to the client, he had received CBT and Emotion-Focused Therapy and was taking anxiolytic medications. His psychiatrist had included the possible diagnosis of a Cluster A personality disorder. For the client, crisis issues involved extreme anxiety and complaints about low self-esteem. Other symptoms experienced by the client included irrational fears, suppressed rage, low self-esteem, identity conflicts’ depression, anxious insecurity related to painful early life experiences, and ascription of his parents as emotionally neglectful (too busy, absent, etc.).
Treatment Approach The nine theoretical principles of AIT were followed. They are, as follows:
(1) Recognizing internal experiences as a perceived reality versus an absolute external reality
(2) Potentially learning more useful and productive capabilities and thought patterns
(3) Building skills and attitudes to maintain a happy and enjoyable life coming from a lifetime of experiences
(4) Connecting the man-made internal meaning learned from external events and the personal identity that is formed for use in external applications
(5) Mentally storing humanly-interpreted experiences including those cognitively, emotionally, and somatically learned
(6) Integrating a disintegrated structure of belief-emotion-body
(7) Bringing self-awareness and the conscious act of making choices regarding the creation of a positive lifestyle
(8) Skill building on how to enhance individual capabilities, experiences, results, and relationships
9) Learning how to consciously and intentionally envision desired results, and raise the probability of attaining the result by planning and acting [5,8].
Treatment Approach
The nine theoretical principles of AIT were followed. They are, as follows:
(1) Recognizing internal experiences as a perceived reality versus an absolute external reality
(2) Potentially learning more useful and productive capabilities and thought patterns
(3) Building skills and attitudes to maintain a happy and enjoyable life coming from a lifetime of experiences
(4) Connecting the man-made internal meaning learned from external events and the personal identity that is formed for use in external applications
(5) Mentally storing humanly-interpreted experiences including those cognitively, emotionally, and somatically learned
(6) Integrating an un-integrated structure of belief-emotion-body
(7) Bringing self-awareness and the conscious act of making choices regarding the creation of a positive lifestyle
(8) Skill building on how to enhance individual capabilities, experiences, results, and relationships
(9) Learning how to consciously and intentionally envision desired results, and raise the probability of attaining the result by planning and acting [5,8].
Treatment Plan and Goals
Goal 1:
(a) Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired, (b) Stabilize anxiety level while increasing ability to function on a daily basis, (c) Resolve the core conflict that is the source of anxiety, (d) Enhance the ability to effectively cope with the full variety of life’s worries and anxieties, (e) Learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning.
Goal 2:
(a) Elevate self-esteem, (b) Develop a consistent, positive self-image, (c) Demonstrate improved self-esteem through more pride in appearance, more assertiveness, greater eye contact, and identification of positive traits in self-talk messages, (d) Establish an inward sense of self-worth, confidence, and competence, (e) Interact socially without undue distress or disability.
Goal 3:
(a) Develop an awareness of how childhood issues have affected and continue to affect one’s family life; (b) Resolve past childhood/family issues, leading to less anger and depression, greater self-esteem, security, and confidence; (c) Release the emotions associated with past childhood/family issues, healing and resulting in less resentment and more serenity [9].
Therapist and Relational Factors
The role of the therapist, the therapeutic relationship, the therapist’s thoughts/emotions/behaviors in relation to the client, and the therapeutic process can be systematically assessed when being formulated based on the AI approach. Therapist and relational factors, in this case, were assessed as follows.
AIT Process for the Therapist/Coach
Phase 1
Thoughts, Feelings, and Behaviors toward the Client Therapist (Th.)
thoughts: “Positive: Client is capable.” “Negative: Client is lost; Client is spoiled.” Th.
feelings: “Positive: Compassionate.” “Negative: Occasionally disconnected.” Th.
behaviors: “Positive: Unconditionally acceptant.” “Negative: Occasionally impatient.”
Phase 2
Assumptions about Client’s Thoughts, Feelings, and Behaviors toward Therapist/Coach Th.
assumed thoughts: “Positive: Client thinks I am knowledgeable.” “Negative: I cannot be as helpful as I am supposed to; I am old.” Th. assumed feelings: “Positive: Client feels comfortable and safe with me.” “Negative: Client thinks I am a bit boring.” Th.
assumed behaviors: “Positive: Client is pleasant; client is cooperative.” “Negative: Client is exaggerating/dishonest/ manipulative; Client wants to be extremely polite; Client wants to impress me to avoid deep work.”
Phase 3
Thoughts, Feelings, and Behaviors toward Self as you Engage/ Interact with Client Th.
thoughts: “I am sure AI will help this client. I must make him become better.” Th.
feelings: “I am worried when thinking I must be helpful.” Underlying core belief: “I am responsible for other people’s feelings and behaviors = I am a failure when others don’t change.” Underlying feelings: “I am worried about feeling embarrassed later.” Th.
behavior toward self: Worrying self, Self-blame for the possible failure. Positive: “Do something, study the case, consult with more experienced peers.” Negative: “Scolding myself: You are confused, client is not changing quickly, and that is my fault.”
Phase 4
Integrative Processes of Identifying and Replacing Integration: Identifying the dysfunctional core belief of “it is my fault” and the related feeling of core shame. Integration: Replacing the above with the healthier options through engaging the current adult experience and choosing to take the following steps:
A. Validating and experiencing the shame,
B. Therapist reminding herself of the past experiences where she decided to choose shame and its related behavior/s to protect herself from further pain,
C. Identifying the strengths, including the history of success with other clients,
D. Distinguishing current facts versus assumptions about the current self,
E. Bridging between the current self and the self-perception from the past,
F. Therapist defining her responsibilities as a human being and as a psychotherapist, the limitations, and choosing healthier options. These resulted in being aware of her position, making the right choices, and feeling more confident and peaceful, which positively impacted the client’s therapeutic relationship.
Phase 5
Mission Statement as a Therapist/ Coach, Goals, Action Plan Mission Statement of the Therapist.
“I fully utilize my expertise and my compassion to help this client in the best way.”
Phase 6
Maintenance Structure
1. Using the grounding techniques
2. seeking personal therapy when facing inner conflicts and/or asking for consultation when being challenged with the process
3. using sticky notes around the laptop with necessary reminders and keeping new material/ information available
4. contacting the client and his mother (per his permission) after a month.
Goals
(1) Observing the dynamic of the sessions, maintaining the trust in the therapeutic relationship by active listening, unconditional acceptance, being flexible, being present and aware of personal thoughts/emotions/countertransference
(2) Focusing on AIT as the main modality
(3) Keeping the client in therapy.
Action Plan
(1) Creating a detailed treatment plan, reviewing (learn more if necessary) about Tics disorders and GAD, consulting with client’s psychiatrist
(2) Educating the client about Awareness Integration Therapy
(3) Objectively evaluating the progress at the beginning and at the end.
Objectives
(a) Level of anxiety
(b) Level of self-esteem
(c) Presence, severity, and frequency of Tics.
(4) Asking for client’s feedback about the session at the end of each session
(5) Review of the Tx; plan for each meeting prior to the meeting.
Course of Treatment and Monitoring of Treatment Progress Area of Life: School
The AI Model intervention goes through 6 phases in many domains of life relevant to the participant. This report briefly describes each phase prior to the same phase applied to the client. The phases will not be repeated in the next module.
Phase 1
AI, as Assured in multi-phases, start AI with inducing awareness of the participant’s thoughts/perceptions, emotions, and behaviors in relation to their external environment and how those constructs impact their lives. Questions in this phase include the client’s thoughts, feelings, and behaviors regarding a specific area of life. In addition, the client is asked about the way he thinks, feels, and behaves toward that specific area affect his life. Generalized belief systems tend to become prominent during this phase of therapy [5].
Phase 1 in this Case
Thoughts: “Positive: School is necessary,” “Negative: I must go to school.” Feelings: Positive: Nothing. “Negative: I don’t like school.” Behaviors: “Positive: I force myself to go to school,” “Negative: I am reckless, I don’t like to be in the class, I don’t take more than a class or two.” Impact of the above on your (client’s) life: “I cannot focus, I don’t have motivation.”
Phase 2
This phase has three functions, as follows: (1) Individual becomes aware of their own personal projections of others’ opinion, and perception of them; (2) Enhance participant’s recognition of the way internal meanings are assigned to these observations; (3) Assessing how these internal projections impact life and build skills to reality check with the outside world. Questions in this phase include how the client assumes others’ thoughts, feelings, and behaviors toward himself. And eventually, they are asked, “How does the way you assume people think, feel and behave toward you affect your life?” This phase is very impactful for people with high levels of anxiety and social phobia [5].
Phase 2 in this Case
Others are thinking of school and me: “Positive: He is good now.” “Negative: Teachers in the past thought I was not capable.” Feelings: “Positive: they are worried about my future,” “Negative: I assume others are worried about my school being dropped.” Behaviors: “Positive: I assume Family is supporting me with school,” “Negative: teachers were mean to me in elementary and middle school. Some classmates too”. Impact on life: “When others are supportive, I feel more pressured, and I feel like a burden when I cannot go to school or finish it on time.”
Phase 3
This phase is the most important one since it is geared toward the individual’s awareness of their own identity, and these questions, in particular, capture the participant’s core beliefs. Questions in this phase include: As you see yourself among people, looking at them while they’re looking at you, what do you think about yourself? How do you feel about yourself? How do you behave towards yourself? Do you judge yourself? Are you compassionate? Are you ok? If there is no negatively charged emotion experienced, then the individual will proceed to Phase 5 within that area. If there are negative core beliefs and charged-up negative emotions, then continue on Phase 4 [5].
Phase 3 in this Case
Relatedness Toward the Self as an Identity Thoughts: “I was a bad student and a bad kid in elementary and middle school; I am not a good student; I am a burden.” Feelings: “I feel worried and then sad.” Behavior toward self: “I blame myself. Either force myself or hide”. Impact: “I feel more discouraged and sadder; I cannot continue going to school.”
Phase 4
In this phase, the structure of AI focuses on simultaneously experiencing the connection between thoughts, formulas, and schemas with emotions and the body areas that maintain and reconnect intense emotions with the origin of the memory that one has decided upon the negative core belief from a traumatic or uncomfortable experience. In this phase, irrational thoughts and strategy of decision making are under scrutiny, while the individual examines, and self-assesses how negative thoughts and emotions induce a blockage towards rational and logical thought processes. By now, the participant has gained an awareness and capability to release the negativity and replace it with tolerance and effective management of emotions. Questions in this phase include: When you say [negative core belief], how do you feel about yourself? Where is the feeling in your body? What is the intensity on a scale from 1 to 10? Encourages the participant to go toward the original memory from the felt sensation and the body and emotions, release, heal and integrate the separated or dissociated part into the whole system. A re-evaluation of the belief system about self gets created. Therefore, new emotions and behaviors get associated with the self as the source of relatedness with the outside world [5].
Phase 4 in this Case
Integrating the Past into the Present 1. Identifying the core belief, “I am a bad student; I was a bad student; I am a burden.” 2. Identifying the related emotions, “Worried.” The client was able to locate the emotions in his body and score them on a scale of 1-10. When letting the emotion with the body part and all cells go back to the first time experiencing the same emotions, client saw himself at age 11-12. Through accessing and reliving multiple memories, client remembered that he had been called a bad boy by some teachers, friends’ parents, and some classmates. Note: The worries and anxiety were experienced in his hands. The core shame and then the loneliness was constantly experienced in his chest and torso. 3. Client was helped to acknowledge, validate, and learn to contain emotions. 4. Client was assisted in identifying the unmet need at the time of the incidents. 5. Facilitating to bridge present to the past: Client was asked to observe the past, offer empathy and compassion and share his current thoughts and beliefs about his child/childhood experiences. The current young adult was able to offer company and share that he has not only survived but also succeeded at school challenges and was liked by classmates later. 6. Client shared his experience with phase IV. He stated that there is a specific time and memory that he refused to share. He emphasized this is where he feels the deepest shame and regret, and he is not ready to experience it. 7. The core belief of “I am not a good boy, I am a burden” was repeated in the people module, parents’ relationship module, and self-module. Dismantling the old dysfunctional beliefs: Working through phase IV resulted in client creating a new perspective of self, empowering the self, and self-respect.
Phase 5
This phase is a proactive step, and the participants are coached and guided through steps in visualizing and committing themselves to a new and improved self. This phase concentrates on building a positive attitude with the thought process of being in control of one’s own perceptions and actions towards self and others. Questions in this phase are phrased and structured to explore each individual participant’s values and beliefs. Who do you intend to be? How do you intend to think, feel, and behave? In this phase, the participant’s response determines the degree of success in implementing AI’s strategy toward individual anticipation of accomplishments [5].
Phase 5 in this Case
Live Intentionally This phase started after phases 1 to 4 were completed for all modules. At this point, client had gained more awareness, power, and motivation to make healthier choices. Client stated that he felt “more in charge and less of a burden.” * Mission statement: I intend to be a better student; I intend to finish college. * Healthy core beliefs: “I am capable of being a good student,” and “I can be independent, I am not a burden.” * Feelings: “I feel better about myself, exciting, good in my torso.” * Values: “I intend to be a committed and responsible student.” * Behaviors: “I commit to set goals and have plans, and I intend to stick to my goals.” Goals: Long-term goals included finishing college in two years. Based on the future desired career, the necessary classes and the focus of study were clarified. Action Plans: taking more classes in each semester (classes specifically named), having a study buddy or a tutor if necessary, attending classes, completing the homework assignments in a timely manner, following the detailed plans for the current classes (plans made by details in the session). Reward: playing video games. Consequence: losing game time.
Phase 6
Final phase includes structuring a functional value
system including intentions, emotions, and behaviors that can
assist the individual in everyday life and a constructive mindset
to be the desired positive self. This designed self can be set up
as external visual feedback through collages to create consistent
reassurance and guidance [5].
Phase 6 in this Case
Sustaining Multiple ways of creating external feedback were discussed. Client superficially agreed with one or two; however, he stated that he is confident that he does not need to do so. Using a calendar or a planner efficiently was the choice that the client was more comfortable with. The client was educated about how to apply AI in his personal life by practicing in the sessions. Client chose one or two areas/concerns to practice. Plan: Follow up after a month of termination.
Area of Life: Parents' Relationship
Phase 1
Thoughts: “Negative: They had a horrible relationship when they were together,” “Positive: now they are communicating better after divorce.”
Feelings: “Negative: I hated it,” “Positive: but I am happy they divorced.”
Behaviors: “Positive: I am supportive and kind to both parents when they talk about their relationship” “Negative: I was trying to hide or playing on my devices when they were arguing; I don’t have good memories about it.”
Impact of the above on your life: Positive: Nothing. “Negative: I prefer to be alone” I am happy about their divorce (client was about 6 or 7 years old at the time of divorce and was staying with his father until his tics got worse).
Phase 2
Thoughts: Positive: Nothing. “Negative: I assumed others think I was the reason that my parents had to stay with each other.”
Feelings: Positive: Nothing, “Negative: I assume others pity me; they feel bad for me.”
Behaviors: Nothing positive. “Negative: I don’t know, probably looking at me differently?”.
Impact: Positive: Nothing. “Negative: I don’t like to be around people.”
Phase 3
Thoughts: “My dad told me that it was not my fault that they divorced, but I know that I have been a burden.”
Feelings: “I feel worried most of the time.” Sometimes I feel “guilty and then sad.”
Behavior: I warn myself by saying: “It is not your business,” or I embarrass myself by saying: “they had to stay together because of you for a while; all of you suffered.”
Impact: “I am not kind to myself, I don’t like to be alone with myself, I prefer to play video games all the time”.
Phase 4
Integrating the past into the present
1. Identifying the core belief: “I am a burden.”
2. Identifying the related emotions, “Worried.” By acknowledging the emotions, locating them in the body, and engaging the muscle memory, client was able to experience his worry as a second grader when his parents were together. He stated that he could remember many “lonely times” in his elementary school at that time. When he could not focus, he was deeply sad and felt lonely. Thinking through the young boy, client thought it might have been his fault, and he was not a good boy.
3. Client was helped to acknowledge, validate, and learn to contain emotions.
4. Client was assisted in identifying the unmet need at the time of the incidents. “I needed to be validated, accepted.”
5. Facilitating to bridge present to the past: client was asked to observe the past, offer empathy and compassion and share his current thoughts and beliefs about his child/childhood experiences. The current young adult was able to offer company and share that. he has been in charge of the adult’s decision, it was not his fault that his parents divorced, and he was the result of their love for each other, not a burden.
6. The current adult also shared his opinion about the situation, including the divorce, its impact on him as a child, and the reasons for client’s behaviors in the past. He realized that he had been partially carrying other peoples’ opinions or an assumption about himself (Am I really a burden? Who said so?).
7. Client shared his experience with phase IV. One more time, he stated that there is a specific time and memory that he refused to share (during middle school). He emphasized this is where he feels the deepest shame and regret, and he is not ready to experience it.
8. Dismantling the old dysfunctional beliefs: Working through phase IV resulted in client creating a new perspective of self. Compassion and some acceptance of himself were experienced and replaced with guilt and self-rejection. In addition, he realized that he had been surviving a tough situation as a child, “I should have been strong, or I just became strong?”.
Phase 5
At this point, client had gained more awareness, power, and motivation to make healthier choices. Client stated that he felt “freer and less of a burden.”
* Mission statement: I intend to be independent.
* Healthy core belief: “I can be independent; I am not a burden.”
* Feelings: “I feel better about myself, motivated and lighter in my chest, no worries in my hands.”
* Values: “I intend to be a committed and responsible person.”
* Behaviors: “I commit to set goals and have plans for my life” and “I like to learn more about relationships.”
Goals: Long-term included “I like to forgive myself.”
Action Plans: Listing his positive impacts on his parents’ relationship, listing what he likes to learn from this relationship, and his takeaway. Phase 6
Not completed. Mostly focused on personal goals of working on his relationship with his girlfriend and hanging out more with his friends.
Treatment Outcome
Based on treatment goals and measurement, the results are as follows:
1. Anxiety was decreased by 50% (from 9-10/10 to 3-4/10)
2. Self-esteem increases by 60% (from 2-3/10 to 8-9/10)
3. Client was assisted in refocusing on his school
4. Tics were experienced occasionally and lasted shortly. GAD questionnaire, self-report measures, and parents’ reports were considered to measure the anxiety and self-esteem level of the client in the pre therapy and post therapy relevancy. Generalized Anxiety Disorder (GAD) was defined based on DSM-5: Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities such as school performance. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Client found it difficult to control the worry. Client was experiencing Motor tension, autonomic hyperactivity, and hypervigilance.
Self-Esteem:
Low Self-esteem criteria included making selfdisparaging remarks; seeing self as unattractive, worthless, a loser, a burden, and unimportant; taking blame easily; lack of pride in grooming; difficulty in saying no to others; assuming being disliked by others; fear of rejection by others, especially peer groups; lack of any goals for life and setting of inappropriately low goals for self; inability to identify positive characteristics of self; anxious and uncomfortable in social situations [9].
Summary
Client was a 21-year-old male returning client with the presenting problem of high anxiety and low self-esteem. Client had a history of Tic disorders and OCD and was taking medication. Prior, client was in therapy for almost one year, which had been helping him with staying in school, but no further improvement in his anxiety or obsessions. Both parents and one half-brother were reported to suffer from anxiety and/or another sort of mental problem. Client received Awareness Integration Therapy for 16 sessions on a weekly basis. Six phases of the following modules were completed: People, acquaintances/far family, school/work, money, friends, siblings, romantic relationship, siblings, father, mother, parents’ relationship, and self. Client was observed to be resistant and self-interruptive during phase 4 of some modules. However, according to the client and his parents, his anxiety and depression decreased, his self-esteem increased, the frequency of tics was less, and client was more motivated, goal-oriented and, in general, more independent. Client was recommended to continue therapy at the time or PRN. He preferred to terminate and approach as needed.
Discussion, Limitations, Implications, and Recommendations for Research
In conclusion, through Awareness Integration Therapy (AIT), client was able to access a different perspective of self, and this awareness resulted in fewer inner conflicts and being able to choose healthier and more productive goals. According to Lou and colleagues, 2017, self-awareness provides the information essential for conscious self-monitoring or metacognition. Objectively, AIT has been helpful in improving the symptoms of anxiety and low self-esteem in this client. Considering that emotions primarily involving anxiety, tension, stress, and frustration have been associated with exacerbated tics [10], we may conclude that by alleviating depression and social isolation and lessening the distress, AIT might have helped with the presence, the severity, and the type of the tics in this client. Future research might be suggested to find any potential neurobiological connections or correlations between anxiety [11,12], self-awareness [13,14], and tic behaviors [15,16] by concentrating on the insula, a brain area that is involved in all three Int J Psychiatr Res, 2022 Volume 5 | Issue 4 | 7 of 7 © 2022 Madani Hila S, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License of these conditions. It is valid to consider the limitations of having access to the previous psychotherapy data, which may have affected the results. In addition, different approaches, including medication, AIT, and relaxation techniques, have been taking place at the same time. Therefore, there is a need for further clinical studies that utilize AI intervention separately to reveal more statistically proven results. It is recommended to have studies on both short- and longterm effects of AI, as well as comparative studies to identify the AI model as one of the most appropriate forms of psychological therapy in treating anxiety disorders.
References
1. Bhatt VN, Baker MJ, Jain VB. Anxiety Disorders. 2019.
2. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century, Dialogues Clin Neurosci. 2015; 17: 327- 335.
3. Hirsch CR, Beale S, Grey N, et al. Approaching Cognitive Behavior Therapy for Generalized Anxiety Disorder from A Cognitive Process Perspective. Front Psychiatry. 2019; 10: 796.
4. Lindhiem O, Bennett CB, Trentacosta CJ, et al. Client Preferences Affect Treatment Satisfaction, Completion, and Clinical Outcome: A Meta-Analysis. Clin Psychol Rev. 2014; 34: 506-517.
5. Zeine F. Awareness integration: a new therapeutic model. Int J Emerg Ment Health. 2014; 16: 278-283.
6. Zeine F, Jafari N, Foroozesh M. A Non-Invasive Recovery Methodology in Reducing College Students’s Anxiety, Depression, and Stress. TOJET. 2017.
7. Zeine F. Awareness Integration Therapy: Clear the Past, Create a New Future, and Live a Fulfilled Life Now. Cambridge Scholars Publishing. 2021; 10: 1-5275-6831-8.
8. Zeine F, Jafari N, Haghighatjoo F. Awareness Integration: An Alternative Therapeutic Methodology to Reducing Depression, Anxiety, While Improving Low Self- Esteem and Self-Efficacy in Separated or Divorced Individuals, Research Article Open Access Mental Health in Family Medicine. 2017; 13: 451-445.
9. Jongsma A, Peterson ML, Bruce TJ. The Complete Adult Psychotherapy Treatment Planner, fifth edition. Whiley. 2014.
10. Leisman G, Sheldon D. Tics and Emotions. Journal of Brain Sci. 2022; 12: 242.
11. Uddin LQ, Nomi JS, Hebert-Seropian B, et al. Structure and function of the human insula, J Clin Neurophysiol. 2017; 34: 300-306. 12. Martin EI, Ressler KJ, Binder E, et al. The Neurobiology of Anxiety Disorders: Brain Imaging, Genetics, and Psychoneuroendocrinology. Psychiatr Clin North Am. 2009; 32: 549-575.
13. Lou HC, Changeux JP, Rosenstand A. Review article: Towards a cognitive neuroscience of self-awareness Neuroscience & Biobehavioral Reviews. 2017; 83: 765-773.
14. Craig AD. How do you feel — now? The anterior insula and human awareness, Nature Reviews Neuroscience. 2009; 10: 59-70.
15. Leckman JF, Bloch MH, Smith ME, et al. Neurobiological Substrates of Tourette’s Disorder. J Child Adolesc Psychopharmacol. 2010; 20: 237-247.
16. Verma S. Pediatric Tourette Syndrome Workup. 2020.
