Chapter 5:Sensate Focus 1: The Non-Demand Touching Suggestions
Before clients begin practicing Sensate Focus, there are some preliminary suggestions that make it less likely that there will be distractions, and that make it more likely that the touching sessions will go well. By going well we do not mean that there will be no problems. What we mean is that the problems that arise can be framed positively as being exactly the reasons for which clients have come to therapy, and as providing the opportunity to offer an intervention, a suggestion, or a skill. These preliminary suggestions are outlined in Appendix B and described in detail below.
Environment, Comfort, and Privacy
Couples are encouraged to have their touching sessions in any way that makes them feel as safe and comfortable as possible. For instance, it is usually helpful for them to be in a private, quiet setting with some lighting, a comfortable temperature, and as few external distractions as possible. For some couples, the bedroom is the best place while for others it is associated with too many negative experiences. Removing common interferences is important. These may include pets, children, telephones, television, music, and any other potential distractions. Locking the door may seem intuitive to therapists but this is not necessarily the case with clients.
Clients are encouraged to set aside some unpressured time together before the touching sessions begin. This is best done when clients are alert, and not right before they go to sleep or have just finished a large meal.
They begin the touching sessions with the clinical, here-and-now, self-responsible attitudes described previously, not with any expectations of sexual desire, arousal, or any other emotion. In fact, looking forward to the touching session, or experiencing any particular emotion like excitement or eager anticipation, is not required to initiate and participate in a touching session. In order to take away the pressure that arises from demands for specific emotions or arousal, the clients are discouraged, during both this pre-session time and the Sensate Focus opportunities themselves, from trying to cultivate a romantic or relaxing atmosphere. Participants, and often therapists as well, think that incorporating candles, music, or other supposedly romantic accessories into Sensate Focus will help it go more smoothly. However, attempting to create this type of atmosphere may be experienced as an unspoken demand for specific emotions like arousal, pleasure, relaxation, and enjoyment.
For the touching sessions themselves, clients are asked to have uninterrupted blocks of time during which they have a reasonably good chance of not being disturbed. If therapy is done intensively, clients may be asked to schedule as many as one or two touching opportunities daily. In a once-a-week outpatient setting, this is often changed to include something like two or three touching sessions a week.
Participants are initially encouraged to allow the sessions to happen spontaneously but no less often than every 48–72 hours. This is to make sure that sessions are taking place often enough to keep the physiological pot simmering on the back burner, so to speak. If the clients are having difficulty with this spontaneous approach, they are encouraged to formally schedule the touching sessions in the same way they would schedule any other appointment during the week. This often creates an opportunity for the therapist to discuss spontaneity being unreliable as a basis for creativity and sustaining intimacy in the early phases of Sensate Focus, and in long-term relationships in general. Much like having a dinner party, if you do not schedule the event and prepare for it, it is unlikely to take place. However, this does not mean that spontaneity will not take place during the event itself.
During the Sensate Focus sessions, the person touching is encouraged to touch long enough to get over any initial discomfort, and long enough to practice returning the focus of attention back to temperature, pressure, and texture, but not so long as to get tired or bored. The initial sessions often last between five and 15 minutes for each partner, but clients are discouraged from watching the clock or basing their length of touching on how long the partner touched. A shorter session during which they actively focus on the touch sensations, and return their attention to these sensations when distracted, is more helpful than a longer session during which they allow their minds to drift, especially to what is going on with their partners.
It is often the client with the apparently presenting dysfunction who is encouraged to initiate the first Sensate Focus session. This relieves partner pressure to initiate and also may help with the partner’s feelings of rejection based on prior history of unsuccessful initiation. The other partner initiates the second touching session, and from then on they may alternate. However, the initiation varies according to client personality, relationship dynamics, and cultural scripts. If one partner is especially apprehensive, he or she may initiate all of the sessions for a while, or might request that the other person do so. As with all aspects of Sensate Focus, this is open to collaborative planning between therapists and clients, and incorporates clients’ feedback.
When initiating, participants are encouraged to do so by formally saying something like, “I would like to do the touching session now.” This formality decreases the likelihood of one partner’s failing to accurately interpret any informal cues from the initiator to begin the session. It also elicits anxious thoughts and emotions associated with the sessions because there is nothing like formally declaring that the touching session is going to happen to trigger the very roadblocks to sexual functioning for which the clients are seeking therapy. Thus, the formal initiation of sessions can be diagnostic as well as therapeutic.
Because most couples approach the initial Sensate Focus sessions with some degree of apprehension, it is not at all uncommon for them to talk nervously and to giggle during the initial touching. This is normalized, but they are urged to talk about their anxieties, only before and after the sessions and in the therapist’s office. During the sessions they are invited to practice internal, mindful focus in order to minimize distractions caused by sounds and the content of what they may say. For example, the therapist may suggest something like this:
It is very understandable that you might find yourself talking or chuckling during these early sessions because you feel uncomfortable. However, one of the purposes of the session is to learn how to manage your discomfort by refocusing on touch sensations. Rather than talking or laughing when you are feeling anxious, try returning the focus of your attention to temperature, pressure, and texture. As you practice this, you may not feel as nervous and you may be less likely to talk or giggle. Additional strategies might include the suggestion of taking a deep breath.
Although talking and sharing is often included in Sensate Focus 2 suggestions, it is discouraged while clients are mastering the basic concepts and skills associated with Sensate Focus 1. The goal of the initial Sensate Focus suggestions is to keep things as simple as possible so clients will succeed. The more types of sensory information they process, in this case, auditory if it involves talking, the more complex the sessions become. Therefore, one of the preliminary suggestions is to keep other sensory input to a minimum. Second, talking and sharing often stimulates more analytical and conscious portions of the brain, and the whole purpose of the initial Sensate Focus exercises is to move away from conscious analysis into sensory experience. Showing and telling, other than within the parameters set by the clinician, are discouraged.
There are two exceptions to talking during Sensate Focus 1 sessions. The first is when one person has finished touching and signals the desire to “Switch” during the session or “Stop” at the end of the session. The second is when anxiety peaks in the touching and then the use of a code word and a change of action are encouraged to manage the anxiety and move through it. The code word should be chosen by the couple prior to the session, and should be positive or neutral in nature. Examples include “change” or “something else.” The idea is for clients to acknowledge their anxiety, communicate it, but then move beyond it in a productive, refocusing way rather than stopping the session at that point.
Initial Sensate Focus includes the suggestion that participants wear little if any clothing during the touching sessions. This is to reduce the likelihood that clients will interpret the removal of clothes as a seductive prelude to a sensual or sexual encounter, thereby placing demands on themselves to feel romantic or sexually stimulated. It is also useful in the desensitization of modesty and an opening to physical and emotional vulnerability. However, as with all suggestions, this one can be changed to include nightwear or underwear, or any other covering on any part of the body, necessary to allay anxiety as much as possible. This is especially true in the early Sensate Focus sessions or when initiating the next level of touching sessions in which additional parts of the body are added to the touch or new positions are assumed. This is most relevant when working with trauma survivors.
As Sensate Focus progresses, partners may alternate who is doing the touching (by saying “Switch”) and who is stopping the touching (by saying “Stop”), or they may modify it according to their needs and the instructions offered. However, they are encouraged to do no more than is suggested by the therapist. This includes engaging in anything that means something sexual to them, or adding on more touching sessions than is suggested by the clinician. More touching sessions are not necessarily more therapeutic.
Throughout the sessions, kissing and full-body contact are discouraged in order to reduce expectations that the touching is supposed to be romantic or sexual. Another limitation is that the person touching is guided to use only fingers, palms, and backs of hands. If arousal occurs, clients are encouraged to take note of this very natural experience but asked to take no further action.
Upon hearing the limitations put on the touching sessions, most people’s anxiety immediately goes down. They say things like, “I was able to really touch without worrying because I knew nothing else could happen. It was such a relief.” Not only does this ban help remove pressure but it also uses the paradoxical nature of sex as a natural function to the couple’s advantage: just as responsiveness is less likely to occur if there is a demand for it, it is also more likely to occur if it is restricted.
Initially, Sensate Focus 1 begins with a clear verbal invitation by the partner who touches first. (These specific suggestions are outlined in Appendix B). As noted, often the partner with the apparent presenting problem is encouraged to initiate and touch first in an effort to nullify pressure from the partner and limit partner rejection. However, this can be changed with client input. For example, sometimes a client might be comfortable initiating but would prefer to have the partner touch them first.
Regardless of who initiates, the couple begins the session in a place where, and any position in which, each partner is comfortable (often lying on the bed in the bedroom). They can adjust that position any time. They may begin lying side by side, one person may be kneeling above or next to the partner, or one person may be standing next to the bed while the partner is lying down. Both the person touching (Toucher) and the person being touched (Touchee) can modify their positions as they desire. The Toucher touches long enough to allow his or her mind to move from everyday thoughts to the more sensory-oriented focus, but not so long that he or she gets bored or tired. A suggested time frame is about 5 to 15 minutes for each partner to touch but, again, clients are strongly urged to avoid looking at the clock. Partners are encouraged to lie next to each other when the session ends.
Clients are initially encouraged to refrain from discussing the sessions as they are lying together or immediately afterwards. This is because the tendency is to move to evaluating the session rather than just staying with the sensory experience.
Writing Down Touching Session Information
Rather than talking about the touching session, clients are encouraged, as soon as possible after each session, to write down specific information about the touching opportunities. Making these notes reinforces focusing on the reliable information that will be most helpful for resolving their sexual concerns, namely, the touch sensations and managing distractions. The specific information includes three types of experiences.
On what were you able to focus during the sessions? On what sensations were you able to focus, and where? Were you able to touch for your own sensory interest meaning were you able to focus on temperature, pressure, and texture? For example, what was the temperature of your partner’s left hand as opposed to his or her right upper arm? These questions are aimed at assessing whether clients are able to touch for their own interest because if they are able to describe sensations then they are touching for themselves as opposed to for their partners.
What were some of the distractions (defined as anything other than temperature, pressure, and texture) towards which your attention moved? Some examples might be, “Am I doing this right?”, “Is my partner having a good time?”, “I forgot to buy milk at the grocery store!” These questions are intended to assess the types of distractions experienced by clients, especially the extent to which they are evaluating their experiences.
When you noticed your mind wandering to anything other than the touch sensations, what did you do? Were you able to focus back on the sensations and, if so, on what sensations, and where? These questions are designed to assess whether clients are actively managing distractions.
The importance of thinking about and writing down this information as soon as possible after the sessions cannot be overemphasized. This encourages clients to be descriptive with the information they bring to therapy (the sensations) rather than judgmental (how good or bad it was). It also provides the therapist with precise information about what the Sensate Focus opportunity was like for the clients. By the time participants arrive at the therapy session, they have a tendency not only to forget the details of their experiences during the touching sessions but also to speak in general, conceptual, or evaluative terms when describing the experiences in the therapy session. They are likely to report things like, “The session was fine,” “Everything went well,” “She felt the same all over,” and “We did what you said.” This information is not helpful and tells the therapist very little about how the participants actually experienced the Sensate Focus opportunities. The more concrete the information they have written down following the touching sessions, the more likely the therapist will have a subjective frame of reference for what Sensate Focus was like experientially for the clients, and the more likely the therapist will know precisely the next steps to suggest. This benefits the participants by moving Sensate Focus along as productively and as efficiently as possible.
During the Sensate Focus sessions, the Toucher has contact with the partner while focusing on his or her own sensory experience in a mindful way. The Touchee is also focused on his or her experience of the touching. This point is emphasized frequently.
Handriding, and Positive Handriding
Touching for your interest is different from selfishness because the partner’s experience is not ignored. In fact, one of the Touchee’s responsibilities while being touched is to non-verbally move the Toucher’s hand away from any area the person being touched experiences as physically uncomfortable, extremely emotionally uncomfortable, or ticklish. Alternately, the Touchee can temporarily place his or her hand over or under the Toucher’s hand to regain a greater sense of control as needed. This is referred to as handriding. This does not mean that the Toucher cannot return to that area at some later point in the touching. This is a good example of practicing the mindful attitude: the person being touched may experience the same touch in the same area quite differently at another time, and the person touching is practicing the mindful attitude to touching the partner.
Later, positive handriding is added. This assists the person being touched to communicate about what he or she might find interesting for the Toucher to touch. The Touchee places one hand on top of or underneath the Toucher’s hand, indicates the way in which he or she might be interested in having the Toucher touch in terms of location, degree of pressure, and type of motion, and then removes his or her hand after a few seconds.
The Purpose of Handriding and Positive Handriding
Handriding not only protects the person being touched but also, when positive handriding is added, allows him or her to indicate non-demand, exploratory preferences. All of this also frees the person touching to focus on his or her own experience without having to be concerned about distressing the Touchee. This is because the person touching knows as a result of handriding that the person being touched will let him or her know if anything is uncomfortable or, eventually, of interest.
In the absence of any feedback from the Touchee, the Toucher can explore the partner’s body for his or her own interest. If the person being touched moves the Toucher’s hand, the Toucher is encouraged to interpret this not as a failure to touch correctly but rather as a compliment from the Touchee who feels trusting enough to share critical information about self-protection and self-interest. This allows the Toucher to cultivate a more healthy self-focused attitude, free to explore the partner’s body without having to worry about whether the Touchee is comfortable or not. It is also easier for the Touchee to become absorbed in the sensations of being touched because he or she is reassured that the Toucher will respond to the handriding directions. It is difficult to say “Yes” to becoming absorbed in the touch for your own interest if you cannot say “No” to it.
Both handriding and positive handriding are intended to foster a positive feedback loop of trust with touching. This non-verbal communication is especially critical in cases of low desire and sexual trauma where partners being touched must perceive themselves as having more control over the touching than may be the case with other clients.
Touching for Interest vs. Pleasure
While touching the partner, the Toucher focuses on his or her own sensory experience by turning attention to the reliable sensations of temperature (cool or warm), pressure (hard or soft), and texture (smooth or rough). This means that the person touching is doing so with a non-demand attitude of interest, curiosity, and exploration rather than with a goal-oriented, pleasuring mindset. This is the complete opposite of a massage during which the person touching contacts the partner’s body with the expressed intent of trying to make relaxation, enjoyment, or pleasure happen for the Touchee.
However, it is not just the Toucher who is focusing on sensations for his or her own interest. Besides moving the Toucher’s hand away if something is physically uncomfortable, the other responsibility of the person being touched is to focus on the tactile sensations wherever the person touching is having contact with his or her body. This includes the Touchee’s taking notice of the temperature, pressure, and texture wherever the Toucher’s hand is placed.
The Toucher is encouraged to touch long enough to get over any initial discomfort, but not so long as to get tired or bored. Either partner can say, “Switch,” and the Toucher becomes the Touchee. When the second partner has finished touching, then he or she may say, “Stop,” and the partners complete the session by lying next to one another. While it is usually the second Toucher who ends the sessions, it is also helpful to suggest that either partner can always say, “Stop” at any point during the Sensate Focus exercise. While the couple is encouraged to do no more than is suggested, they are also told that they can always do less. This is, once again, intended to remove pressure to produce any particular emotion, including arousal.
Managing Distractions Through Cognitive-Behavioral Mindfulness
Each person is encouraged to manage distractions by practicing a mindful redirection of attention away from the distractions and back onto an awareness of the dependable and available touch sensations. This combination of what could be described as cognitive-behavioral mindfulness involves bringing attention back to the touch sensations whenever there is a distraction but especially whenever attention wanders to anxiety-provoking thoughts. The person being touched also has the option of managing pressuring distractions by moving the Toucher’s hand away if anything is uncomfortable or ticklish. This helps the Toucher manage distractions having to do with concerns about causing the Touchee discomfort or ticklishness.
Clients are informed that it is, in fact, impossible to continuously focus on any one thing, including sensations. The way the brain works is that attention is always jumping from one thing to another. The important skill in Sensate Focus is not to prevent thinking about other things but to recognize and practice refocusing attention when it drifts onto other things besides sensations.
Sensate Focus was originally designed as a hierarchy of relatively invariant touching exercises, using the power of physiological tension that builds by both increasing sensory touch and also limiting sexual release to the couples’ advantage. In this manual, instructions for implementing Sensate Focus 1 will follow this hierarchy. We recommend not only that clients complete each level of the hierarchy before proceeding onto the next one but also that they include all of the previous levels in each of the subsequent touching sessions. This allows time for couples to cultivate a non-demand, non-pressuring mindset at the beginning of each touching session.
Having said that, the hierarchy of touching suggestions is nonetheless not invariant. It is subject to adjustment based on the goals, values, and sexual practices of the couples. The decisions about changes in the hierarchy are made in discussion between the therapists and clients. The specific sexual difficulty reported by the couple, and the unique individual and couple dynamics, will dictate the structure, pacing, and processing of changes in the order of the touching sessions. Individual and couple dynamics are addressed in vivo as partner pressure, avoidance, couple conflicts, or pressuring for goal-oriented achievements arise. This is the art of using Sensate Focus in sex therapy.
Usually clients in Sensate Focus 1 complete the hierarchy before initiating Sensate Focus 2. In this sense, Sensate Focus 1 is like systematic desensitization as the clients are introduced in a small, step-wise fashion to increasingly anxiety-provoking experiences. They are then given the provided therapeutic skills for managing and, therefore, desensitizing themselves to these anxieties while increasing their level of comfort. As a result of the incremental nature of the exercises, coupled with the skills, clients are less likely to fail. Success is simply practice, regardless of the immediate results. If they interpret themselves as unsuccessful, their experience is reframed as a learning opportunity, and the roadblocks are processed.
Individual Self-Discovery and Touch
Although working with couples is emphasized, an individual may present alone for sex therapy, or the presenting sexual concern may prompt individual touching sessions for one or both members of the couple (see Illustrations 5.1, 5.2, and 5.3.).
For example, cases of Penetration Disorder (Vaginismus), Premature/Delayed Ejaculation, or sexual trauma often benefit from focusing on the individual at least at the beginning of treatment. The identified client, who may be extremely anxious, is provided an opportunity to develop an increased level of comfort and skill with touching for self-interest prior to being introduced to the greater complexities associated with the couple’s Sensate Focus. Self-Sensate Focus is the same as systematic desensitization in that the client is introduced in a step-wise fashion to potentially increasing anxiety-provoking situations.
The individual begins self-Sensate Focus in much the same way as when touching the partner during the couple opportunities, touching all over the body while avoiding breast, chest, and genital contact or contact with any area of the body that represents something sexually or emotionally uncomfortable (see Illustrations 5.2 and 5.3.). The skills are exactly the same as when the couple is involved. The individual client focuses on the touch sensations of temperature, pressure, and texture, only in this case when touching his or her own body. The client is both the Toucher and the Touchee. This is handled by having clients focus on the sensations in their hands wherever they are touching themselves.
When clients involved in self-Sensate Focus report decreased apprehensions, are able to report details of tactile sensations from touching different areas of his/her body, and are adept at managing distractions by refocusing on these touch sensations, they can be encouraged to incorporate breasts, chest, and genitals into the contact. If or when touching becomes too anxiety provoking, these clients can move away from touching breasts, chest, and/or genitals. Suggestions may include having as many as one self-touching session a day, schedule permitting, but usually no more than six in a seven-day period.
When clients are engaged in self-Sensate Focus, they allow the focus of their attention to move to the touch sensations in their body wherever they are touching. If their attention seems to move primarily on either their hands with which they are touching, or on where they are touching, they are encouraged to intentionally move their attention to the other source of sensations.
Breasts/Chest and Genitals Off Limits
When describing the following positions to couples, it is helpful to let them know, “There is nothing magical about the positions. The positions are not going to make anything happen in and of themselves. Instead, they merely provide reasonably comfortable ways partners can touch as much of each other as possible without Touchers having to move too much.”
The couple’s phase of Sensate Focus 1 begins with breasts, chest, and genitals off limits (see illustrations 5.4, 5.5, and 5.6.). We highly recommend having all couple’s sessions begin with this touching component in order to allow time for cultivating a non-demand, touching for one’s interest, mindset. The person touching has contact with all of the partner’s body, front and back, avoiding breasts, chest, and genitals (and any other part of the partner’s body that, to the couple, represents something sexual). The person touching focuses on his or her own experience of the different temperatures, textures, and pressures of the partner’s skin and hair, and brings attention mindfully back to these sensations when distracted.
When clients are able to touch for self-interest, focusing on sensations, and bringing themselves back from anxiety-provoking distractions, they begin Sensate Focus with breasts, chest, and genitals included. If they are not ready, they may stay at the breasts and genitals off limits stage with the addition of water soluable, non-lanolin, hypoallergenic lotions to vary the sensations and to signify that progress is being made. However, the lotion is not intended to suggest a demand attitude to produce arousal or any other kind of pleasure; instead, it is a tool for increasing variations in the touch sensations.
It is during the initial touching sessions when breasts/chest and genitals are off limits that handriding is introduced. As suggested, if and when the clients who are being touched experience anything as physically uncomfortable, highly emotionally uncomfortable, or ticklish, they are to move the Toucher’s hand away from that area, or place his or her hand under or over the Toucher’s hand for a moment to regain a sense of control. The person being touched places his or her hand on the hand of the person touching for a few seconds, moves it away from the uncomfortable area for that moment, and then takes the hand off the Toucher’s hand since the person touching is still primarily directing the touching. As suggested, this not only protects the Touchee from having to grin and bear any distressing touch but also frees up the Toucher to touch for his or her own interest without having to be concerned about the partner’s experience.
Breasts/Chest and Genitals On Limits
When both partners are able to touch for their own interest and bring themselves back from distraction with breasts, chest, and genitals off limits, the breasts, chest, and genitals are added into the touch (see Illustrations 5.7, 5.8, and 5.9.). The couple begins the Sensate Focus opportunities as before, touching initially with breasts, chest, and genitals off limits until they are centered on tactile sensations. Then breasts, chest, and external genital touching are incorporated into the touch, and full-body touching for self-interest begins. Clients are encouraged to attend to changes in sensory experience, not to stay focused solely on the breasts, chest, or genitals once these are on limits, and to move away from and then back to these areas in order to have a full-body touching experience. This moving around to all areas of the body also serves the purpose of moderating anxiety associated with touching any particular part of the body.
The couple is offered two positions when breasts, chest, and genital touching are added (see Illustrations 5.7 and 5.8.). In the first position, the Toucher sits up with the back against a headboard or wall, supportive pillows behind, and legs spread out in front in a “V” shape. The person being touched lies on his or her back between the Toucher’s outspread legs, face towards the ceiling, genitals close but not touching the other person’s genitals, with knees bent, calves up and over the partner’s thighs, and feet placed down on the outside of the partner’s hips.
If the person being touched feels too exposed or vulnerable in this first position, the Touchee can sit between the Toucher’s outspread legs, with the back up against the Toucher’s chest, both partners facing forward, and with the Touchee’s legs draped over the Toucher’s in a wider “V” (see Illustration 5.9). We sometimes described this as the motorcycle position with the person being touched in the front. The person touching can reach around the partner’s body to include the breasts, chest, and external genitals into the contact.
Initially, if either partner experiences arousal, he or she is encouraged to do one or a combination of things. First, since one of the purposes of Sensate Focus is to allow clients to experience and be aware of their arousal in a non-demand way, if either or both become excited, they are invited to attend to their arousal as it is, until and unless it becomes uncomfortable or distracting.
If or when arousal becomes uncomfortable, extremely distracting, or is experienced as goal-oriented, the Touchee may choose to handride the Toucher’s hands away from that area so that this does not become a focused, demand distraction. If visual sensations become overly stimulating, clients are encouraged to close their eyes.
If the Toucher is touching for self-focused interest, and if the Touchee is absorbed in the sensations, the Touchee may, in fact, become orgasmic. This is not a problem because, again, just as sexual responsiveness cannot be made to happen, it can also not be prevented from happening. Therefore, as long as being orgasmic is not the intention of the Touchee or the Toucher, it is framed positively in terms of natural function, and the partners are encouraged to continue on with the Sensate Focus exercise. If a male partner has ejaculated, he can use a towel to dry off but then return his focus to other touch sensations. Being orgasmic is the one time not to stop the Sensate Focus session. This is to reinforce the notion that there is no necessary connection between a specific sexual response and anything in particular having to happen as a result of that response.
Moving from Absorbed In Sensations to Absorbed By Sensations (or Sensuality)
It is at this point that the Sensate Focus 1 attitude of touching for one’s interest begins to dovetail with the Sensate Focus 2 attitude of touching to include both focusing on the other person as well as moving beyond absorption in sensations into absorption by sensations. Focusing on and being absorbed in sensations is the precursor to losing awareness of and being absorbed by sensations. Being absorbed by sensations might be described as the subjective experience of sensuality. This experience of sensuality in turn is what ultimately serves as the most powerful portal into sexual responsiveness. As the sensual experience of absorption by the sensations results in the loss of consciousness as to sensations and even time and place, the client is highly likely to be carried along into sexual arousal and pleasure.
During this absorption, the Toucher can continue to touch in the area that appears to be arousing or pleasurable for the Touchee as long as the Toucher can do so for his or her own interest, and as long as the person being touched does not move the Toucher’s hand away or transition into a goal-oriented mindset.
When the experience of becoming absorbed by the sensations washes over the clients, an “oops” may occur when the couple goes beyond the suggestions, perhaps even to intercourse. This is managed by normalizing their desire to go with their arousal and delight, but then they are encouraged to return to the guidelines in order to keep the Sensate Focus sessions from becoming goal-oriented and losing its effectiveness.
Generally after the first experience of breasts, chest, and genitals on limits, clients are asked to do a clinical look at their own and/or each other’s genitals (see Illustration 5.10). If one or both report being unfamiliar with their own genitals, the individual clinical look is conducted first. With some lighting on, clients are asked to look at and explore their genitals first by themselves and then eventually with one another. The main purpose is for them to identify the different areas of their genitals. For example, in the case of women, they identify the location of their clitoris, the clitoral shaft, and the inner and outer labia. This experience not only gives them a chance to gather accurate information about their genitals but it also brings about a sense of intimate sharing and breaking down barriers of ignorance and discomfort. It promotes more disclosure in Sensate Focus 1 of what is of interest to each, and in Sensate Focus 2 of what is pleasing.
When partners can touch for their own interest, focus on sensations and bring themselves back from distractions when breasts, chest, and genitals are added, the couple moves on to include mutual touching (see Illustrations 5.11, 5.12, and 5.13). Partners lie next to each other, sit facing each other, or get into any other position with which they are comfortable and that allows them to touch each other as completely as possible. They begin to touch each other at the same time for their own interest. At first they avoid breasts, chest, and genitals until they are able to focus easily on the sensations in this position.
Eventually clients include the breasts, chest, and genitals into the mutual touching as they would any other part of the body, focusing on temperature, pressure, and texture. Mutual touching may not be as easy as it sounds because now they are receiving sensation from two sources simultaneously: where they are touching; and where they are being touched. Clients are confronted with a dynamic tension between different demands for their attention. They are encouraged to let their attention go where it will, but if they are noticing themselves primarily focused on where they are touching, they also move their attention to where they are being touched, and vice versa. They are now learning to focus alternately on each source of stimulation until the sensations meld into a global absorption. In this way, they are learning to honor the space between them and the interaction that connects them.
We have emphasized touching at the same time during the mutual touching. However, clients are encouraged to alternate between touching simultaneously and touching each other one at a time. Just because mutual touching has been put on limits does not mean that clients always have to be touching simultaneously. This reinforces the fact that the touching is increasingly an organic dance between the partners.
Up to this point the person being touched has been encouraged to either move the Toucher’s hand away, or to handride the Toucher's hand, if there is anything the Toucher is doing that is uncomfortable or ticklish. During mutual touching, if not earlier during breasts, chests, and genitals on limits, a positive handriding suggestion is added.
Positive handriding involves the Touchee’s placing one hand on top of or underneath the Toucher’s hand, lacing fingers in between the Toucher’s fingers (see Illustration 5.14 and 5.15). Then the Touchee briefly uses this hand to move the Toucher’s hand not only away from areas that might be uncomfortable or ticklish but also towards areas that might be of interest to the Touchee.
The person being touched keeps the hand on or under the Toucher’s hand for a few seconds, and then takes it away since the person touching is still, for the most part, in charge of directing the touching. The Touchee may also demonstrate interest in being touched with lighter or firmer pressure or a different kind of motion. In essence, positive handriding is used to suggest location, degree of pressure, and type of motion.
It is critical that the therapist choose words carefully when describing positive handriding at the risk of its being interpreted as a technique for producing pleasure, relaxation, arousal, or orgasm. The person touching is counseled to move the Toucher’s hand to some area of the body the Touchee might find interesting or of interest. These words are recommended because interest has already been defined as exploring temperature, pressure, and texture in the moment. Interest does not involve trying to force specific emotional responses.
Positive handriding allows the person being touched to do several things. First, it gives the Touchee a greater sense of control. Second, it facilitates experimenting with touch sensations in particularly sensitive areas of the body.
Positive handriding also expands the Touchee’s non-verbal communicative repertoire from merely conveying what he or she doesn’t find comfortable to also conveying what he or she might find of interest. But it does something that is perhaps even more important: it initiates a more complex and eventually reciprocal form of communication between the partners (in this case, non-verbal) that lays the groundwork for Sensate Focus 2. Now clients can provide accurate information to each other about both what they don’t want as well as what they do want. When partners do this at the same time, they begin to move beyond the goal of working on the sexual dysfunction and towards intimacy enhancement.
As suggested, although positive handriding is often introduced during the mutual touching phase of Sensate Focus, it can be added earlier or later depending on the needs of the couple. As with all other aspects of Sensate Focus, there is no one time to use any particular skill, and no one way to apply that skill.
Partner Astride, Genital-to-Genital Contact Without Insertion
The next Sensate Focus experience is mutual touching with the addition of, in the case of heterosexual couples, the woman’s going astride her partner (see Illustration 5.16). Once again, it is highly recommended that the sessions do not start with this position but include all the previous positions in the hierarchy to allow for the cultivation of a non-demand, here-and-now mindset.
The astride position involves the client’s hovering over and facing the partner, her knees on the bed, supporting herself with her knees close to her partner’s body and with her non-dominant hand positioned above one of her partner’s shoulders, supporting herself in a tripod fashion with both knees and one hand. This leaves her other hand free. She does not sit directly on the partner, nor does she lie down. Rather, she hovers above at a 45-degree angle, much like a jockey on a horse. She is encouraged to use her partner’s genitals much as she would use her own hand, exploring vulvar, clitoral, and mons contact using her partner’s genitals but without insertion. She keeps going with the attitude of touching for focused self-interest and redirecting attention back to sensations.
Placing a pillow under the knees of the astride partner may be helpful for elevation when the astride partner is significantly shorter or the partner on the bottom significantly broader. In the case of same-sex couples, the positions for genital-to-genital contact can be modified according to the couple’s preferences, body fit and comfort. Lesbian couples may choose to lie flat on top of the partner, or assume a scissoring position. Male couples may stand or kneel facing each other and utilize genital-to-genital contact in these or any comfortable position.
While the client who is astride is focusing on the touch sensations of genital-to-genital contact, the other partner on the bottom has two responsibilities. The first is to refrain from any hip movement (“Your hips are led!”), and the second is to leave the genital-to-genital contact to the astride partner while focusing on the touch sensations wherever his or her hands are touching different parts of the astride partner’s body.
The astride partner may not be able to remain in this position for more than a few minutes before tiring. The couple is encouraged to change position when this occurs. They may resume touching in any of the earlier positions from mutual touching to my turn/your turn touching before resuming the astride, genital-to-genital touching at least one or two additional times.
When genital-to-genital contact in the astride position is paired with the preceding sensory experiences and the prohibition against doing anything intentional with any arousal, there can be a harkening back to earlier, and often exciting taboo-filled, experiences of youthful, playful exploration. It is difficult for most people not to experience arousal if this becomes the case.
However, with couples presenting with arousal or orgasmic difficulties, expectations for response may be amplified when genital-to-genital contact is included. The expectations and/or the natural waxing and waning of arousal that may occur in this position may rekindle what are referred to as fears of performance. Fears of performance are apprehensions about whether or not arousal or orgasm will occur. They are often accompanied by spectatoring, the observation of whether or not one is aroused or approaching orgasm. These fears of performance and spectatoring are addressed, providing the opportunity to discuss the fact that the partner with lower anxiety is perfectly capable of being orgasmic even when the anxiety-wrought partner is experiencing little or no arousal. This is particularly important for men suffering from erectile insecurity: It assures them that the partners’ absorption, arousal, and even orgasm do not depend on their penile engorgement. Therapists can offer a paradoxical injunction suggesting that clients intentionally allow for the gaining, losing, and regaining of arousal. This may interrupt fears of losing arousal and provides an opportunity for teaching skills to manage anxiety. It also frees both partners to experiment in terms of what they can attend to in ways that they most likely have never experienced before or at least not since they were much younger. All of this may evoke a previously unbeknownst or forgotten sexual vitality.
Partner Astride, Genital-to-Genital Contact With Insertion
Additional suggestions in the astride position may include insertion without movement, absorbing the sensations while resisting a goal-oriented agenda (see Illustration 5.17). The partner lying down is encouraged to keep the pelvis still throughout this stage. With heterosexual partners, the female client gets in the astride position and is encouraged to take her partner’s penis and do the inserting. This is for three reasons: she knows when she is ready; she knows when her partner is ready; and she knows where it goes. We are fond of saying, “There are no eyes on the head of the penis so the penis does not know precisely where the vaginal opening is located and when the vagina is ready.”
The astride partner is encouraged to insert the penis slowly, a little bit at a time. The clients are both urged to attend to the tactile sensations during each stage of insertion rather than on judgments of whether or not it feels good, whether either is aroused or not, or on any other distracting thoughts. Full engorgement is not necessary to incorporate this suggestion. In cases in which arousal or engorgement is lost or diminished as the couple engages in genital-to-genital contact with the possibility of insertion, this may be framed as an excellent learning opportunity that illustrates that fears of performance and spectatoring are to be expected, that they affect sexual responsiveness, and that they can be managed through refocusing on sensations and using the code word.
Once there is full insertion, the partners focus on the sensations associated with penile containment, allowing the sensations to wash over them but without any movement. This gives partners the chance to experience the sensations of insertion without any demands for arousal or activity. We advise them that without movement, arousal may diminish. In fact, they are encouraged to stay in this position until there is loss of whatever arousal and engorgement is present if arousal and engorgement happen. Many clients report feeling very emotionally connected after this exercise and for many it is quite erotic. For men with erectile insecurity, the experience of being asked to lose their engorgement on purpose is often revolutionary.
If insertion takes place, the astride partner is encouraged to explore different types of movement. Clients may explore movement with insertion as long as this is done while focusing on sensations for self-interest and not with any expectations for arousal or pleasure. Most couples have never taken the opportunity to experience insertion in an interest-focused, non-demand fashion. Once there is insertion, many partners often think arousal and orgasm are the inevitable goal. They miss delving into sensory exploration in this position for its own sake.
While the astride partner is tending to the genital-to-genital sensations, she can also focus on touching other parts of her partner’s body, and her partner can continue to focus on the sensations wherever his hands are touching her. Once again, however, the partner on the bottom has the responsibilities of refraining from moving his hips and of leaving the genital-to-genital contact to her. As before, the astride partner is to alternate between being in the astride position, and getting off and into the mutual touching or any earlier my turn/your turn position.
Lying Next to Each Other Afterwards, and Options for Release
When the touching session ends, either partner can say “Stop.” Partners are encouraged to lie next to each other following the session (see Illustration 5.18). The couple may talk, practice mindfulness, or experience the power of being non-verbally present with the other person but without the pressure of achieving any particular goal.
Sensate Focus participants are encouraged throughout the initial Sensate Focus exercises to avoid intentionally trying to be orgasmic either during or apart from the touching sessions. This is intended to allow sexual tension to percolate over the course of treatment, taking advantage of the fact that the more sexual responsiveness is restricted, the more likely it is to occur. Clients are usually willing to accept this ban on orgasm if treatment is intensive.
However, if therapy is in a weekly outpatient setting, or takes a longer time, clients may be less likely to follow the ban. If this is the case, there are options for release. For example, if one member of the couple feels aroused even after lying quietly with the partner for a while, this client may indicate he or she would like orgasmic release. But in an effort to encourage collaboration and communication, it is suggested that the other choose one of three alternatives for providing release. The partner may: (1) inform the person asking for release that the partner prefers for that person to provide his or her own release in private; (2) lie next to and hold or touch the person asking for release while that person provides his or her own release with manual stimulation; or (3) provide manual release for the person seeking release. Oral release is discouraged because this tends to trigger expectations for a more goal-oriented, sexual or pleasuring encounter. It also may trigger prior pressure dynamics between the partners.
Couples may be reminded that they can actually do whatever they would like following the touching sessions. However, the purpose of sex therapy and Sensate Focus at this point is to build sexual tension and reduce goal-oriented pressure. Couples may not see progress with the dysfunction until and unless this tension is allowed to strengthen and they have had an opportunity to integrate the Sensate Focus skills and attitudes.
Another option for release is to propose that the couple engages in any desired sexual activity but that this is entirely separate from the Sensate Focus sessions. Otherwise, a pattern may emerge in which Sensate Focus is experienced as pressured. Sexual activity apart from Sensate Focus opportunities is often most helpful when therapy takes place once a week or less frequently, extending it over a longer period of time. An average of 14 therapy appointments is often necessary to proceed through all of the Sensate Focus 1 sessions. However, these may be scheduled less often as the couple progresses.
The Paradox of Powerful Presence
The profundity of shifting from an attitude of trying to control sexual and pleasurable responses for oneself and especially for one’s partner, to one of honoring sexual and pleasurable responses as natural functions by redirecting attention away from anxiety-producing expectations, onto present sensations in a mindful way, and for one’s own interest, cannot be overstated. It moves clients away from using Sensate Focus as a demand-oriented technique aimed at generating self and partner pleasure, an attitude that only adds to their pressures and problems. It moves clients towards reducing pressure and expectations by focusing on that over which they have control (the ability to direct attention to sensations). By focusing on these sensations, clients are guided to a powerful gateway into the very experiences for which they ultimately have sought therapy, namely, arousal, pleasure, and fostering greater intimacy.