“Sexuality is not mere instinctuality; it is an indisputably creative power.”
(Jung, 1966, para. 107)
Sex. So much has changed in the last 50 years since the publication of Masters and Johnson’s Human Sexual Response (1966) and Human Sexual Inadequacy (1970). And so much has not. So much is easier. And so much is more complicated than ever.
Brief Overview of the Field of Sex Therapy
Thanks to the contributions of many different clinicians, researchers, and sexologists working with many more diverse populations than Masters and Johnson, we know a lot more about the physiological bases of sexuality and the biomedical sources of sexual concerns. We also know much more about psychological, relational, lifestyle, and cultural factors that contribute to sexual problems. Thanks to these same professionals, we know a lot more about ways to treat sexual distress and to improve sexual satisfaction across many populations, often requiring modifications in the original Masters and Johnson sex therapy and Sensate Focus protocols.
However, we are also aware that sexual functioning and its meaningfulness are so multidimensional that understanding just the physiology or just the psychology or just the cultural factors is not enough to explain many sexual problems and dissatisfactions. To add to the complexity, we also know that treating sexual concerns and dissatisfactions is not a simple matter of using this approach or that. We also know that many people are often still too uncomfortable to talk about their sexual concerns and to seek out professionals who can help them. This is unfortunate because we definitely know that sexuality specialists today have more tools to help individuals and couples experiencing sexual dysfunctions.
Why Are We Writing This Manual?
We hope that Sensate Focus in Sex Therapy: The Illustrated Manual will help health professionals become more comfortable with and knowledgeable about how, when, and why to use the power of Sensate Focus. We anticipate that by making this manual available to clinicians and their potential clients, we will lessen the discomfort of people thinking about meeting with a health professional.
We are particularly excited about two additional and specific reasons for writing this manual. The first is clarifying Sensate Focus, both in theory and practical application. This is something that has never been done before. The second is shining the spotlight back on the whole person. The field of sex therapy appears to be gravitating towards what we believe is an overemphasis on the biological view, and we want to keep the psychological, relational, cultural, and spiritual work integrated with the biological.
While there are many excellent publications on how to do sex therapy, there is nothing that has been published in any depth about the foundational centerpiece of sex therapy that is Sensate Focus. The main reason we want to publish this manual is to clarify one of the most powerful approaches to resolving sexual dysfunctions that is already in the hands of clinicians and has been for nearly 50 years. This deceptively simple, straightforward series of touching opportunities developed by William Masters and Virginia Johnson (1970) can have a profound impact on resolving sexual dysfunctions. It may also optimize the intimate and sexual relationship specifically, and enhance the overall relationship generally.
However, despite its power and the fact that Sensate Focus continues to be widely used by sex therapists (Weiner & Stiritz, 2014), and after more than three and a half decades of our practicing, presenting, and publishing on Sensate Focus, we realize this time-honored foundation of sex therapy remains confusing to many. It is often applied differently than what we believe makes it most effective practically, and differently than what makes its application consistent with its theoretical underpinnings. This has resulted in misunderstandings over the purpose, value, and procedures of Sensate Focus.
Witkin … reflects the widespread objection to the Masters and Johnson [Sensate Focus] assignments – that they block spontaneity. Ironically, this is precisely their objective. The fact that this is not generally known arises from Masters and Johnson’s way of presenting their work. Outside of participation in their full-time training program or attendance at their training seminars there is no way to become familiar with many of the essentials of their model …
Not only has their model yet to be completely presented in published form, its deceptive simplicity has made it seem limited at best. This is a crucial misunderstanding. Masters and Johnson’s therapy is a revolutionary departure, even from subsequently established approaches that are thought to be based on it and simply to go beyond it.
(Apfelbaum, 1995, pp. 23–24)
On this basis, we have decided that a more complete, detailed, yet reader-friendly published manual on Sensate Focus is long overdue. That is the primary purpose of this Illustrated Manual. We are intending to cover all aspects of Sensate Focus, including both the practical details of its application so clinicians will know how to use it, and also its theoretical underpinnings in order to clear up any misunderstandings about its purpose. We hope that by including both the practical and the conceptual we will appeal to a variety of readers. New clinicians will find it helpful in the real world of therapy. More seasoned therapists may be intrigued with the historical perspective and become more confident about adding sexuality interventions into their practice. Sexuality professionals and other practitioners will find helpful suggestions for working with a wider variety of clients than was the case in the days of Masters and Johnson.
In doing this we hope to clarify how to apply Sensate Focus in a manner we believe to be most effective in the treatment setting. This is based on the more than 60 years of experience we have between the two of us. However, we are also hoping this manual will stimulate more research that will empirically and more rigorously validate our experience than has been the case up until now.
Addressing both the application and conceptual foundation of Sensate Focus is probably a reflection of the differences between the authors. Linda tends to look at sexual problems from a more practical perspective: “What do I need to suggest to clients to help them right now, and how can I put it in terms they will immediately understand?” This most likely comes from her educational and professional background as a systemic-oriented social worker and trainer. Constance often emphasizes the theoretical: “How can I help the clients understand the larger context of their concerns so they will become more interested in them, more motivated to work on them, and more motivated to continue with their progress?” This is probably associated with her education and training as a more depth- and Jungian-oriented clinical psychologist. Clearly both viewpoints are critical, and we hope that by working together we offer a comprehensive overview of Sensate Focus that will be both helpful and interesting.
Defining Sensate Focus and its Purpose
Sensate Focus is a set of touching suggestions that serves as a powerful therapeutic approach for helping people experiencing sexual concerns. While we will be focusing mainly on Sensate Focus with sexual dysfunctions, we will also be describing to a limited degree some of the effects Sensate Focus can have on greatly improving sexual intimacy and overall relationship satisfaction. We refer to the concepts and techniques for resolving sexual dysfunctions as Sensate Focus 1. We refer to concepts and techniques for enhancing intimacy and relationship satisfaction as Sensate Focus 2. We will discuss Sensate Focus 2 in more detail subsequently and we will distinguish Sensate Focus 1 and Sensate Focus 2 throughout this manual.
Detailing Instructions and Offering Illustrations
While Masters and Johnson acknowledged the lack of specific information on the use of Sensate Focus, they never published a precise description of the instructions. This manual will do just that. However, perhaps its most important contribution will be providing not just written instructions but also visual illustrations about how to use Sensate Focus. We have taken our inspiration from The Illustrated Manual of Sex Therapy (1975; 1987) by Helen Singer Kaplan. In it, Dr. Kaplan made a point of writing in a less academic style so her work would be more accessible to clinicians and laypersons alike. Perhaps even more significantly, she provided illustrations to both clarify the positions and activities used in sex therapy techniques and also to suggest “the beauty and humanity of sex”:
In the past … I have had to rely on my verbal descriptions. Often these do not convey the various positions with sufficient clarity and I have had to make sketches to illustrate what I was asking them to do. On some occasions members of the staff have actually had to demonstrate some of the more difficult positions … It is the objective of the drawings … to provide clear illustrations for commonly suggested positions … The drawings will, apart from merely illustrating specific positions, also, I hope, convey the beauty and humanity of sex, fundamentals to successful sex therapy.
(Kaplan, 1987, p. 5)
Shining the Spotlight Back on the Whole Person
Another reason we decided to publish this Illustrated Manual is to emphasize the need for a refocusing on the entirety of each client’s experience. We do this by raising awareness of the history of Sensate Focus and the advances in modifications for more diverse populations. We are going to describe using Sensate Focus with people experiencing a variety of sexual dysfunctions, physical challenges, psychological concerns, relationship dynamics, lifestyle stressors, and value systems.
The field of sexology has become increasingly medicalized over the past several decades. It began with the contributions of Helen Singer Kaplan in the mid-1970s, and has been both helpful and not so helpful. There is no question that one of the most important advances in the sexuality field has been the development of medications and procedures to address sexual dysfunctions. We now have increasingly accurate medical assessments and interventions to help people who are experiencing hormonal, cardiovascular, neurological, anatomical, and illness-related problems affecting their sexual functioning.
However, we need a wake-up call because this same emphasis may demote sex therapists to a secondary rather than a collaborative role, or to no role at all. This is a big problem. While medical interventions are most useful for those clients who are experiencing medical or mixed etiologies, they do not address the psychosocial difficulties that arise even in cases where the primary etiology is medical. Many clinicians tell us, “Sexual dysfunction is inevitably complicated. It is multi-causal (biopsychosocial), multidimensional (psychological and interactional), and has multiple effects on the person, the partner, and their relationship” (Metz & McCarthy, 2012, p. 213). Despite this, eminently respected sex therapist and psychologist Michael Perelman notes,
Regrettably and more rapidly than any sex therapist could imagine, the exaggerated mid-century notion that psychological problems caused most sexual dysfunctions was replaced by a media-fueled equally fallacious argument that sexual problems were almost exclusively the result of organic causes. Dismissed from the public discourse and all but forgotten was the truism that every sexual disorder, regardless of the severity of its organic etiology, also has a psychosocial component – if not causative, then certainly consequential.
(Perelman, 2016, p. 40)
Nowhere is the influence of this emphasis on medicine and biology more evident than in the recent publication of the controversial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2015). In this bible of clinical diagnoses, the psychological, relationship, lifestyle, and social contributions to sexual dysfunctions have been relegated to “associated features”: “One new exclusion criterion was added: the disorder should not be better explained by a ‘nonsexual mental disorder, a consequence of severe relationship distress (e.g., partner violence) or other significant stressors’” (IsHak & Tobia, 2013, p. 2). This suggests that, according to the DSM-5, an individual’s psychological disorders, a couple’s significant relationship problems, or other significant lifestyle concerns may not be the primary diagnosable cause of sexual dysfunctions.
It is a rare case in which there is solely a medical component to a sexual dysfunction. Even if physiological problems contribute to the onset of the dysfunction, individual, relationship, and other psychosocial factors also often play a significant role in the origin of a sexual concern, and a much more significant role in maintaining the problem. For example, Perelman’s (2009) Sexual Tipping Point® model reminds us of the mind–body connection.
The Sexual Tipping Point® model depicts the continuously dynamic and variable nature of an individual’s sexual response on a distribution curve … [It] easily illuminates the mind–body concept that mental factors can “turn you on” as well as “turn you off”; the same is true of the physical factors. Therefore, an individual’s Sexual Tipping Point represents the cumulative impact of the interaction of a constitutionally established capacity to express a sexual response elicited by different types of stimulation as dynamically impacted by various psychosocial-behavioral and cultural factors. An individual’s threshold will vary somewhat from one sexual experience to another based on the proportional effect of all the different factors that determine their tipping point at a particular moment in time, with one factor or another dominating while others recede in importance.
(Perelman, 2016, pp. 40–41)
Perelman’s model emphasizes the need to look at medical issues. However, it also reminds us not to let the popularity and apparent convenience of medical approaches overwhelm and distract us away from the role that the psychological, relational, and other factors play.
Stanley Althof, Executive Director of the Center for Sexual and Marital Health in South Florida, notes,
It seems odd that combined pharmacological and psychological treatment of sexual problems has not established itself as a mainstream intervention for either mental health clinicians or sexual health physicians who treat sexual problems … Studies on combined medical and psychological therapy all demonstrate that combined treatment is superior to medical treatment alone.
(Althof, 2010, p. 125)
Throughout this manual we are going to be shining the spotlight back on the psychological, relationship, lifestyle, and cultural factors influencing sexual dysfunctions in order to rebalance the current trend towards medicalization. We believe strongly that the field is in danger of losing sight of the complexity, power, and mystery of sexuality if these variables are not re-emphasized and valued for the role they play.
What We Are Going to Leave to Others
As a result of our highlighting the psychosocial factors involved in sexual dysfunctions, we are going to leave it to other clinicians and researchers to elaborate on the details of sexual medicine, including pharmacology, tests, and treatments. For now and for the most part, we are also going to leave it to others to detail the multidisciplinary approach to treating sexual dysfunctions that weaves together the biomedical with the psychosocial.
We are not going to include a history of the field of sex therapy or all the various models developed by others who work with sexual dysfunctions. However, we do want to take this opportunity to acknowledge some of the professionals who have influenced our thinking and practice. Stanley Althof (2010) does an excellent job of describing a number of these paradigms as they have emerged over the years: Kaplan (1974) “integrated psychoanalytic theory with Masters and Johnson’s cognitive behavioral understanding of sexual dysfunction” (p. 391). Linda De Villers and Heather Turgeon (2005) succinctly describe the behavioral model of Sensate Focus. Gerald Weeks and Nancy Gambescia (2009), and Katherine Hertlein (Hertlein & Weeks, 2009) emphasize an Intersystem Model, integrating individual, interactional, and intergenerational systems, and maintaining a focus on the couple during Sensate Focus. Tammy Nelson (2008) similarly emphasizes couples’ interaction and communication, and incorporates an Imago therapeutic approach to physical contact. Stella Resnick (2012) reminds us of the importance of the mind–body interconnection in a Gestalt- and embodiment-oriented approach. Gina Ogden’s (2001; 2013) many publications and workshops also remind us of the significance of these interconnections as well as those with the heart and spirit, while Mark A. Michaels and Patricia Johnson (2006) celebrate the sacredness of the body from a Tantric perspective that suggests another way to build and store sexual energy. These are concepts and techniques that parallel or dovetail with Sensate Focus. Peggy Kleinplatz and A. Dana Ménard (2007), and Kleinplatz et al. (2009), increasingly emphasize the existential and experiential aspects of sexuality, and psychologist Christopher Aanstoos (2012) takes the experiential even farther by zeroing in on the phenomenology of sexual experiencing. These are but a few of the valuable models and perspectives offered by professionals in the field of sex therapy.
Although we will describe the modifications to sex therapy and Sensate Focus that are helpful when working with diverse populations, we obviously cannot cover them all. We had to make some hard choices. We hope this manual will offer practical details on the use of Sensate Focus suggestions and shine the light on the many creative adaptations other clinicians have made to our understanding of its use with more diverse populations. We also want to prompt others to continue to develop, research, and elaborate on additional diversities and adaptations.
We have tried to weave the more general and conceptual underpinnings of Sensate Focus together with its practical application. Some people prefer the former, some the latter. Some chapters are weighted more in one direction and some in the other.
The second chapter, Sensate Focus, is balanced between the theoretical and practical, and offers an overview of what the field of sex therapy is all about in general and what Sensate Focus is all about in particular. It also distinguishes between the two phases of Sensate Focus, Sensate Focus 1 and Sensate Focus 2.
The next and third chapter, What Sensate Focus Is Not: A Little Bit of History About the Confusions, includes a more conceptual perspective on the history of the confusions that have abounded about the purpose and implementation of Sensate Focus. However, it also contains what we consider to be invaluable, practical information on the actual words to use and avoid using when giving Sensate Focus instructions.
The remainder of this manual is primarily practical in nature. Nonetheless, it continually references the conceptual information contained in the first three chapters.
Since our goal was to write a reader-friendly, less academic manual, we have tried to limit the use of citations. People often find these distracting when trying to digest the substance of material. However, if you would like more detailed references we encourage you to turn to our earlier publications. These include Avery-Clark & Weiner (2017, in press), Linschoten, Weiner, & Avery-Clark (2016), Weiner & Avery-Clark (2014), and Weiner, Cannon, & Avery-Clark (2014). We hope you find Sensate Focus in Sex Therapy: An Illustrated Manual a valuable resource, and we welcome your comments and contributions.