The Reintegrative Protocoltm

First published: Journal of Human Sexuality 2018, Volume 9, 59-69

The Reintegrative ProtocolTM

Joseph Nicolosi Jr., Ph.D. 1 The Breakthrough Clinic, Westlake Village, CA

The Reintegrative Protocol™ is a trauma treatment approach which uses the same method, regardless of the client's gender or sexuality, since its aim is to facilitate the resolution of trauma. However, clients often report spontaneous sexuality change as a byproduct of the protocol's repeated use. This paper will specifically examine the protocol’s application within the context of treating males presenting with same-sex attractions and will provide instructions for using self-compassion as a method of trauma resolution, as well as optional instructions for EMDR-trained psychotherapists who wish to use EMDR as a method of trauma resolution.

Introduction treatment of a variety of clinical symptoms, particularly in mitigating negative responses to The Reintegrative Protocol™ is a versatile unpleasant events (Leary, Tate, Adams, Allen, clinical trauma treatment for males and & Hancock, 2007), the association between females, regardless of their sexuality. In the childhood maltreatment and subsequent following example I will specifically illustrate emotional regulation difficulties, and problem how the Reintegrative Protocol™ would be substance use (Vettese, Dyer, Li, & Wekerle, applied to males with same-sex attractions they 2011). It is also linked with increased wish to explore and will include optional psychological well-being (Neff, Kirkpatric, & EMDR instructions for therapists qualified to Rude, 2007). use EMDR therapy. Therapists not trained in A growing body of empirical research EMDR therapy may use the mindful self- also supports the safety and efficacy of EMDR compassion version of this protocol. therapy for resolving a variety of clinical A substantial volume of empirical disorders. Twenty-four randomized controlled evidence supports the psychological benefits of trials now support the positive effects of EMDR mindful self-compassion, for example its therapy in the treatment of emotional trauma demonstrated safety and efficacy in the and other adverse life experiences relevant to

1 J.J. Nicolosi Jr. is a licensed clinical psychologist and founder of The Breakthrough Clinic and Reintegrative Therapy®1. He became an EMDRIA Approved Consultant through the EMDR International Association and has at- tained his Feeling-State Addiction Protocol certification by Dr. Robert Miller. Special acknowledgment to Robert Miller, Ph.D. for his development of feeling-state theory and practice. Correspondence concerning this article should be addressed to Joseph Nicolosi, Jr., The Breakthrough Clinic, 128 Auburn Ct. #209 Westlake Village, CA 91362 E-mail: [email protected] clinical practice (Shapiro, 2014) and the appropriate to the situation” (Shapiro & Forrest, American Psychiatric Association has 1997, p. 25). Adaptive affects, such as recommended EMDR therapy for many patients fear about being too close to a cliff remained, (APA, 2004). EMDR therapy is widely viewed while inappropriate, maladaptive affects (for as an integrative approach with other example, the feeling of terror induced by therapeutic modalities (Shapiro, 2002). simply being exposed to the word “cliff”) According to EMDR therapy, overwhelming, spontaneously dissolved. dysregulating experiences in the client’s life This method of reprocessing is of great disrupt the ability of the client’s nervous system significance when the client and therapist to adaptively process, encode and store discuss such an important topic as sexuality. information related to the traumatic event, Religion, societal pressure, self-image and leading to the client’s trauma-induced irrational health concerns all come into play. maladaptive negative cognitions, propensity toward addictions and other PTSD symptoms Reintegrative Therapy® as distinct from so- (Shapiro & Forrest, 1997). The systematic called “conversion therapy” implementation of bilateral stimulation (most commonly administered through bilateral eye When some individuals hear how movements) is believed to contribute to the Reintegrative Therapy® can lead to changes in client’s adaptive reprocessing of these traumatic clients' sexuality, they sometimes assume it is events, and as a result, the client’s negative a so-called “conversion therapy”— a broad, ill- cognitions, propensity toward addiction and defined term used to describe efforts that other PTSD symptoms often resolve (Shapiro & “seek to change an individual’s sexual Forrest). orientation” (see S.B. 1172, 2011-2012). With proper EMDR therapy, changes in Reintegrative Therapy® itself and this protocol the client’s affects and cognitions are common, are categorically separate from “conversion with no ideological influence from the therapist. therapy” or “sexual orientation change For example, a therapist believing the client’s efforts” (SOCE) for several reasons. fear of heights is irrational never needs to argue First, Reintegrative Therapy® with or in any way coerce the client into the treats trauma and addictions. Changes in therapist’s own belief about what heights sexuality are a byproduct, not the goal. As constitute a danger to the client. In proper a consequence, Reintegrative Therapy®, EMDR therapy, rather than debate with the and the Reintegrative Therapy Association client about whether his fear of heights is (a 501(C)3 non-profit organization) take no appropriate or not, this topic can be bypassed stance as to whether homosexuality should by allowing the client to reach his own be considered a mental disorder. Second, conclusions as the trauma-induced components Reintegrative Therapy® methods are used with of the client’s memories and triggers resolve— no modifications related to the clients' or any fears which remain after the reprocessing therapists’ gender or sexual orientation. are considered ecologically sound. Examples of Providing a client with same-sex attractions this were noticed by the creator of EMDR the exact same protocol as a client with therapy, Francine Shapiro, when she noted heterosexual attractions helps bypass the that…. “EMDR would not desensitize a complicated ethical and religious “landmines” person’s negative feelings if they were related to the religiously and politically charged topic of sexuality. The client is free to come to females regardless of the client’s sexual his own conclusions about his sexuality. No orientation, male clients with same-sex ideological dogma by the therapist needs to be attractions have reported decreases in their introduced in order for the protocol to work. same-sex attractions and, for some clients, Third, Reintegrative Therapy® employs increases in their heterosexual attractions as a only established, evidence-based treatment spontaneous byproduct of its use, so this approaches (such as mindful self-compassion particular article will illustrate the protocol’s and EMDR), the same approaches used by other use when applied to a male in this population. clinics throughout the world that seek to treat The Reintegrative Protocol™, when trauma (as opposed to “conversion properly applied, allows both client and therapies” which seek to change sexual therapist to bypass every one of the four ethical orientation). problems which may narise i “conversion therapy.” The client and therapist do not need Avoiding the pitfalls of “conversion therapy” to try to change the client’s attractions— the protocol involves exploring the client’s The Reconciliation and Growth Project (see attractions from a neutral stance of curiosity ReconciliationAndGrowth.org/guidelines), and then seeking to resolve the trauma an organization of mental health professionals memories which lie beneath with standard and academics from diverse sexual identity trauma treatments. The use of a treatment and religious backgrounds, seeks to foster protocol means the client and therapist do not “dialogue among people with differing need to adhere to any particular ideology or perspectives on faith-based values and causal model about sexuality, nor do they have sexual and gender diversity.” Among them to posit any particular moral, political or is Lee Beckstead, Ph.D., a member of the religious stance on the topic. The protocol- APA’s Task Force on Appropriate Therapeutic driven approach reduces and can even eliminate Responses to Sexual Orientation. The the therapists’ ideological influence in the organization highlights four specific client’s treatment. interventions they consider to be inherently The Reintegrative Protocol™’s four- unethical and potentially harmful when phase approach consists of history and addressing sexuality, gender and faith: evaluation, preparation, assessment, and 1. Fostering expectations of a specific reintegration. After describing the steps sexual orientation or gender identity involved in each phase, I conclude this article outcome with some theoretical discussion of the 2. Using direct or indirect coercion protocol’s approach. 3. Basing interventions on bias, unfounded theories, or prejudice Phase 1: History and Evaluation 4. Limiting the exploration of sexual 1. Obtain history, frequency and context orientation, gender and faith identity and of the client’s symptoms (for behavioral expression possibilities addictions, this is the addictive behavior). Though Reintegrative Therapy® is a 2. Evaluate the client for safety factors sexual orientation-neutral approach which that determine whether he has the coping skills employs identical methods for males and and integrative capacity to manage potentially high levels of negative feelings. If the client is The therapist would inquire: too fragile for trauma or addiction work, “Tell me about the sexual fantasy or ex- supportive psychotherapy and instruction in perience that you want to work on. Tell me calming and stabilization skills would be in about it in as much detail as you’re willing to order until the individual is prepared for more give me.” direct and challenging psychotherapeutic work, The client may respond: such as this protocol. “This ideal man performs oral sex on me, as he praises me.” or, “I’m having sex Phase 2: Preparation with two men I’ve just met. Their only desire is to meet my every need.” 3. Explain the Reintegrative Protocol™ 5. Identify the specific feelings and how complex emotions can sometimes lie associated with the most powerful moment of beneath our traumas and addictions, and how the sexual experience and allow the client to self-compassion can help with their resolution. experience this feeling as intensely as he can. If EMDR therapy may be appropriate, informa- Time must be taken for him to carefully identify tion about EMDR therapy for processing dis- the feeling he gets from this (i.e., powerful, turbing memories can be provided. bonded, worthy, wanted, for example). It is very important that he knows his therapist is Phase 3: Assessment accepting of him so that he can enter the sexual trance state during this moment, and it is crucial 4. Identify the specific element of the that the therapist be truly accepting of this part target behavior that has the most emotional of his client. If the client is vague or unable to intensity associated with it. For sexual discuss his sexual fantasy or his feelings behaviors, this would be the peak moment of associated with it, this is likely an indicator of the client’s most powerful sexual fantasy significant client shame. In order for the client (Figure 1). to make productive use of this protocol, he must

CLIENT

OTHER

Fig. 1 Examining activating event. be able to join the therapist in maintaining a Therapist: mindful stance of openness, acceptance and “Go outside of yourself in the third curiosity about his sexual thoughts and feelings. person and look in at yourself, directly Therefore, the therapist may need to spend extra into your own eyes. Take your time and time, even several sessions if necessary, in this just notice what you see in him phase of the protocol, both modeling for the [speaking as if the client’s eyes were in client and supporting him in developing the third person].”). understanding and non-judgmental curiosity about his sexual fantasy and the feelings he The therapist must be careful to move associates with it. Sexual abuse victims often slowly at this point, asking open-ended have difficulty with this if their sexual fantasy questions if needed. It is crucial that the client is relates to an abuse memory, so it can often be allowed to come to his own conclusions, at the helpful to provide psychological education pace that works for him. This is not a time for about how complex, conflicting feelings often analysis or interpretation of his answers. As the emerge after a trusted caregiver becomes client imagines being outside of himself and sexually abusive. peering steadily into his own eyes, exploring 6. Once the client is visualizing the what affects are inside, his only job is to “let peak moment of his sexual fantasy and allowing whatever happens, happen” (Shapiro, 2002, p. himself to intensely experience its associated 38) with no moral judgment or pressure from emotion, ask the client to imagine taking a the therapist as to what he should see. stance of being outside of himself in the third The therapist may need to gently and person and look deeply and directly into his repeatedly draw the client’s attention back to own eyes and notice what he sees (Figure 2). the visualization of looking deeply into the client’s own eyes to help the client maintain that Therapist: gaze. The therapist must be steadfast in gently What’s an earlier time he’s felt this guiding the client back to peering deeply into way…? What happened in his life that his own eyes. With a stance of openness, caused him to feel this way in the first curiosity and gentleness, the therapist may place…? inquire: The client will likely associate an What are you seeing in his eyes…? important memory which relates to his unmet What do you think he’s wanting…? emotional need: What do you think he’s hoping he’ll get “I’m alone on the playground, and from this…? everyone is ignoring me. Or, “I What feeling do you see behind the feel- remember my mom shouting at me, and ing you just mentioned…” I was afraid of her.” The client’s awareness of his emotional motivations likely presents itself in a specific Spontaneous associations to childhood order: (1) sexual fantasy trance, (2) underlying memories often occur with no prompting from emotional desire (craving) and (3) the the therapist, particularly with clients who have originating unmet need which is the result of used this protocol with their therapists several the individual’s early emotional trauma and times. experiences of neglect (Figure 3). If memories are identified, the therapist 7. Once the client is able to see and has a choice point: he or she can now shift experience the originating unmet need, ask him directly into EMDR therapy phase three to associate back to an earlier memory from the (assessment) by identifying the images, third-person perspective (Figure 4). negative cognitions, positive cognitions, etc., and then continue to phases 4-7 for memory “Look deeply into the eyes of your reprocessing. For EMDR trained therapists, the younger self. Can you see the need in him? following steps of this protocol are not needed, If you take in a deep breath and open since the therapist may continue from this point your heart toward him, look directly into with EMDR therapy’s standard protocol. If his eyes. What do you feel inside EMDR therapy is not suitable, then continue yourself when you see his unmet with the following steps (below) and use needs?” mindful self-compassion to process the As the client gains access to his own feelings of trauma(s) instead of switching to the EMDR care and compassion, the therapist then standard protocol. encourages him to express that compassion toward his younger self: Phase 4: Reintegration “If that feeling inside you could express itself toward him, what would you do or say?” 8. Once the client has identified the For some clients who have difficulty earlier trauma memory, begin to resolve it using accessing feelings of compassion, this difficulty mindful self-compassion. At this point, the can often be remedied by the therapist asking therapist asks the client, who is still in the third- the client how he would treat his own child in person observer state, to access feelings within that moment: himself of compassion toward his younger self “Look deeply into his eyes. If you had a (Figure 5): son whom you really loved… and that child was in this situation, how would you feel toward him? How would you ward his imagined child, the therapist can ask feel if you really opened your heart to- him to now express this toward his younger ward your child in that moment?” self: The client may initially report feeling “If that feeling there in your heart felt overwhelmed by the pain of the child, stating really free to express itself in that mo- that he cannot possibly give the child what he ment, what would you say or do toward needs. This objection is typically voiced by your younger self?” clients who have low self-worth, believing they Clients typically are moved to care for have little of value to offer others. This road- their younger selves, holding, guiding and block is easily addressed with brief education listening. As his younger self (which holds onto and encouragement from the therapist. The the original unmet needs) is cared for, brought client needs to be taught that, although children close and “reintegrated” with the observing, can be easily hurt, they can also be easily reas- caring adult self, the therapist might facilitate sured with a small amount of compassion from this process by asking the client: a benevolent caregiver. The therapist can con- “In that moment, look deeply into the tinue: eyes of your younger self. What does he “See if you can offer him (the client’s know about himself in that moment…? younger self) the compassion that you What does he know about you in that do have. You don’t have to solve all of moment…? his problems right now, and you’ll be Clients who are able to feel and express surprised how far your care will go for their compassion toward their younger selves in him.” the memory will often respond by saying Once the client is able to access this something like: sense of care and compassion and openness to- “He knows he’s acceptable,” and “he behaviors. He likely experiences himself and knows I’ll always be there for him.” the other person as equals and is less likely to The development of self-compassion experience the original sexual fantasy/memory can sometimes require frequent intentional as affectively dysregulating (Figure 6). efforts. This is something the ancient tradition of mindfulness has taught us. Discussion 9. Ask the client to go back to the original sexual fantasy or memory identified in Clients who have difficulty feeling and phase 3. Therapist: expressing self-compassion likely did not “What is your emotional reaction to this receive much compassion from their caregivers original scene now? when they were young, contributing to their What do you know about it now, that core unmet need and leading them to instead you didn’t when we began? enact self-criticism toward their younger selves. What do you think is the connection Sexuality change in the client as a result of this between the sexual fantasy and the process occurs as a byproduct of resolving the memory we worked on?” core unmet need (the third and deepest layer of By this point, the client has very likely lost his Figure 3), and is not the goal of the treatment sense of unrealistic idealization of the other itself. This is distinct from general forms of person in the fantasy, lost his shame about “conversion therapy,” which seek to modify the himself for having the sexual desire in the first sexuality (the most superficial layer of Figure place, and gained insight into the true 3). Sexuality change is “conversion therapy’s” motivations behind his sexual feelings and goal, not its byproduct. In this protocol, no effort whatsoever is made to modify the client’s resulted in the relinquishing of his masculine sexual fantasy. The change only occurs on the strivings. deepest layer (layer 3– originating unmet need), Clients during phase 3 of this protocol which often causes layer 1 (sexual trance state) who, for example, report sexual fantasies in to simply disappear as a byproduct of the which they feel “bonded” will likely resolution of layer-3 dynamics. This has a wide spontaneously associate back to memories of variety of applications— clinicians have being “alone” after inverting their gaze through reported notable success in treating symptoms their own eyes. Likewise, clients reporting of Posttraumatic Stress Disorder, Other sexual fantasies of feeling “powerful” in phase Specified Disruptive, Impulse-Control and 3 will typically report experiences of feeling Conduct Disorder, and a variety of paraphilia “powerless” and “stuck” when they invert their disorders with consistent use of the protocol. gaze. The emotional magnitude of the client’s In our experience of working with men addictive, compulsive behavior is generally in who report same-sex attractions, at the end of direct proportion to the magnitude of the phase 3, the client will virtually always client’s identified trauma memory (Figure 7) spontaneously recall a moment of profound leading many clients and therapists to view the shame and attachment loss, typically at the client’s addictive behavior as a deficit-driven hands of other hostile and rejecting males, an phenomenon. experience which, the client often reports, This phenomenon is consistent across however, offer a different explanation (Rosik & the behavioral spectrum— a gambler who has a Popper, 2014). rush of the feeling of “winning” will often With regard to male clients with same- spontaneously associate back to memories of sex attractions, gay affirmative theorists have “losing.” Binge eaters wishing to explore their traditionally posited that this phenomenon can bingeing behavior, who report feeling, for be explained by the theory that the boy was example, “complete” while bingeing, often rejected by his father and peers for being born spontaneously associate back to moments of gay, i.e., the client’s homosexuality was present emotional deprivation and “emptiness” (Figure from birth, and the boy was rejected by other 8). males, either consciously or unconsciously as a When applied to men with same-sex result of this. In contrast, reparative therapy has attractions, this clinical observation has led postulated that traumatic rejection from the several clinicians to view the client’s presenting father and same-sex peers originally blocked material as a compensatory phenomenon— an the boy’s masculine strivings, and due to this attempt to restore affect dysregulation and sense traumatic shame and attachment loss, the client of identity— and therefore remediate the effects unconsciously developed reparative attempts to of affectively dysregulated symptoms created meet these unmet attachment needs in the form by trauma and neglect experiences during the of same-sex attractions. Gay-affirmative client’s developmental years. Other theorists, theorists and reparative therapy theorists therefore posit reverse cause-and-effect client to resolve this, and should do so before explanations. moving forward with this protocol. The client’s Fortunately, this protocol allows the experience of an open, accepting therapeutic client and therapist to side-step this cause-and- alliance is the foundation for productive effect question. Regardless of the source of the therapeutic work, as well as the understanding client’s homosexuality, he is now able to access that clients have the right to set their own and resolve his early trauma using this protocol. therapy goals, and to change those goals when Resolving underlying trauma with self- they wish. compassion is beneficial to the client, making It is significant to note that clients this exercise a worthy therapeutic intervention consistently report the realization that their for clinicians who approach the topic of emotional states of compassion and shame are sexuality from many vantage points2. diametrically opposed to one another. As they The protocol-driven approach reduces grow in their capacity to give and receive and at times, even eliminates the therapists’ compassion, they notice less shame in their ideological influence in the treatment. This every day lives. protocol, when properly applied, prevents the Lastly, clients who feel overwhelmed by therapist from leading the client to a specific seeing negative affect in their own eyes during conceptualization of the causality of his phase 3 may benefit by viewing their own eyes behavior. The inversion of the trance-like from a distance. Viewing the eyes from a feeling will cause the underlying trauma d i s t a n c e a l l o w s f o r m o r e g e n t l e memories to “auto-select” and come to the acknowledgment and resolution of the negative surface of the client’s awareness. It should be affect, without overwhelming and dysregulating noted that, in my experience, clients with same- the client during the process. sex attractions, regardless of their various cultural and religious backgrounds, are very Cautions and Contraindications likely to spontaneously associate to painful memories of shame and attachment loss from Several c a u t i o n s a n d p o s s i b l e other males. These clients who repeatedly use contraindications for this protocol should be this protocol with Reintegrative Therapy® noted. Individuals who have obsessive clinicians commonly notice that compulsive disorder (OCD) may need the compulsive, risky elements of their additional preparation to benefit from this sexuality are the first to diminish as they protocol, as the protocol requires sustained become aware of their underlying unmet attention on an emotionally charged topic emotional needs and resolve them through without lapsing into the ritualized mental self-compassion and/or EMDR. activities brought on by OCD, something with To a v o i d s o - c a l l e d “ i m p l i c i t which OCD sufferers have difficulty a v e r s i o n ” ( n o n - v e r b a l o r o t h e r w i s e (Hershfield, J., & Corboy, T., 2013). Untreated unacknowledged elements of coercion that may OCD may need to be treated in phase 2 of this be at play), clients are encouraged to inform protocol, and may take several months or their therapists right away if they notice longer, depending on how quickly the OCD themselves feeling any sense of judgment or symptoms can be diminished to a degree that coercion from their therapist. A competent the individual is able to successfully use the therapist can collaboratively work with the protocol. Males with same-sex attractions may be far more likely to have OCD (Sandfort, de Cognitive Behavioral Therapy. Oakland, Graaf, Bijl, & Schnabel, 2001). Though the CA: New Harbinger Publications. Leary, M. R., Tate, E. B., Adams, C. E., Allen, A. implications of this topic are outside the B., & Hancock, J. (2007). Self- discussion of this article, it is important to compassion and reactions to unpleasant acknowledge that clients often benefit greatly self-relevant events: The implications of from evidence-based OCD treatment, such as treating oneself kindly. Journal of P e r s o n a l i t y a n d S o c i a l “The Mindfulness Workbook for OCD Psychology. 92 (5), 887–904. http:// (Hershfield, J., & Corboy, T. 2013) during dx.doi.org/10.1037/0022-3514.92.5.887 phase 2 of this treatment protocol. The mindful Neff, K. D., Kirkpatrick, K., & Rude, S. S. self-compassion exercises help prepare the (2007). Self-compassion and adaptive psychological functioning. Journal of client for the self-compassion work in phase 4. Research in Personality, 41, 139–154. Clients with severely impaired ability to http://dx.doi.org/10.1016/j.jrp. recall childhood memories may require more 2006.03.004 time and understanding Miller, R. (2012) Treatment of behavioral . Transgender clients addictions utilizing the feeling-state may notice little to no sexuality shifts. addiction protocol: A multiple baseline Finally, clients who are gay-identified study. Journal of EMDR Practice and should be informed that the repeated use of this Research, 6(4), 159-169. http://dx.doi.org/ protocol may lead to decreases in the their 10.1891/1933-3196.6.4.159 Rosik, C.H., & Popper, P. (2014). Clinical same-sex attractions, and perhaps increases approaches to conflicts between religious in their opposite-sex attractions as a values and same-sex attractions: byproduct. Many clients who are gay- Contrasting gay-affirmative, sexual identified, but wish to explore their identity, and change-oriented models of therapy. Counseling & Values, 59, attractions in a neutral way, and to resolve any 222-237. http://dx.doi.org/10.1002/j. traumas they may discover, do not see 2161-007X.2014.00053.x this potential shift in their sexuality as a Sandfort, T. G. M., de Graaf, R., Bijl, R. V., & negative side-effect. Though they often give Schnabel, P. (2001). Same-sex sexual behavior and psychiatric disorders. Archives consent for their sexuality to possibly shift of General Psychiatry, 58, 85–91. http:// on its own to whatever that result may be, it dx.doi.org/10.1001/archpsyc.58.1.85 is only fair and responsible for the therapist to 5S.B. 1172, 2011-2012, Reg. Sess. (Cal, 2012). inform the client of this possibility before the Retrieved from https://leginfo.legisla- ture.ca.gov/faces/billNavClient.xhtml? repeated use of this protocol. bill_id=201120120SB1172 Shapiro, F. & Forrest, M. (1997) EMDR The References Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma. New York: Basic Books. American Psychiatric Association (2004). Shapiro, F. (Ed.) (2002). 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