Chapter 8:Common Problems and Their Management in Sensate Focus
Now we will move away from the changes to Sensate Focus that help clients with specific dysfunctions and with dysfunctions in specific types of relationship. We are going to take a look at common problems that surface when implementing Sensate Focus with couples from all types of populations. Some or all of these problems are to be expected to some degree at the beginning of Sensate Focus. However, if they persist beyond the initial sets of instructions, this may be indicative of the need for other types of interventions either before or during sex therapy and Sensate Focus.
While being aware of the common problems is important, understanding how to address them is perhaps even more so. In training and supervising other clinicians, it has been our experience that they frequently report finding Sensate Focus ineffective when encountering these problems. Our approach is that it is the very fact that Sensate Focus elicits these problems that suggests its value and importance. When these problems arise it is not the time to do away with Sensate Focus but to reframe the problems as precisely the reasons clients are in therapy and then to continue with sex therapy and Sensate Focus as a way to manage and ultimately resolve them.
Delaying the Touching Sessions
Despite the fact that clients are told that they do not need to have any particular emotion prior to doing the touching sessions, especially pleasant anticipation, one of the most common problems is delaying/avoiding the touching sessions until late at night or right before coming in for therapy. Delaying often takes two forms. With both types, resistance may be handled by encouraging couples to formally schedule the touching sessions. It may also respond to partners developing a plan as to how to deal with the resistance.
More specifically, in the first type of delay, one partner (often the one without the identified problem) may be looking forward to the touching but the other fails to initiate until the last minute and is clearly doing it without enthusiasm or without what the partner perceives as an expectation of positive results. This frequently results in disappointment on the part of the partner eagerly anticipating the sessions, and these couples often arrive at the therapy sessions frustrated or angry at each other. This common scenario is handled by reminding the clients that they are not expected to look forward to the touching sessions, and that whatever happens before and during them is a snapshot of the dynamics that have brought them to therapy in the first place. The primary dynamic may be, for example, that one partner pressures and the other resists, and then this partner complies in a service organization mode in order to minimize the overt or even covert conflict.
A review of methods to address the anxiety that might, in this case, be getting in the way of initiation, and how to utilize the partner to help manage this anxiety, is offered. For example, the hesitant client may say,
I have thought about initiating the session for three days now without mentioning it. I think the best way to handle this is to tell you about my struggle and ask you to hold me for a few minutes before we begin.
The proactive partner is now hesitant to say something for fear of being perceived as pressuring or interfering with the other client’s initiation. He or she is also growing frustrated and anxious that the touching may not happen. This partner is encouraged to say something like,
I’m anxious about doing the touching before our next session but know you are to initiate and I don’t want to pressure you. But it would be helpful to me to know what you are thinking about this and what, if anything, I might do to help.
This interchange involves relationship and communication skills that are self-responsible, non-blaming, authentic, and focused on the couple as a team rather than as competitors. Besides a focus on communication, problem-solving, and managing feelings that get in the way, the couple might be encouraged to formally schedule their touching sessions, always with the caveat that a renegotiation is possible.
In the second type of delaying, partners may collude in postponing the touching, often citing busy schedules and associated fatigue. They may have developed a pattern of protecting themselves and each other from the anxiety, the fear of rejection, and the anticipated failure associated with trying. A common barrier is the unspoken belief that, “If we don’t try we cannot fail.” Once again this is best addressed by identifying the pattern, normalizing the resistance and offering the couple tools to communicate, address the feelings, and move ahead.
Among the most common difficulties with Sensate Focus suggestions is clients’ failure to do the touching exercises at all, or failure to do them as suggested. Sometimes the couple has avoided the Sensate Focus suggestions completely. Not infrequently this may represent pressuring dynamics from the partner who continues to push the envelope. Sometimes the couple has begun Sensate Focus but it devolves into their engaging in old patterns of sexual interaction and even intercourse instead of continuing with the touching sessions. It may seem as if the couple is denying the existence of the sexual problem by engaging in what therapists refer to as a flight into health. This is especially true when partners have gone without physical contact for a long time. Sometimes it is the very instruction that nothing has to happen that frees them momentarily from their fears of performance and allows them to function in this flight into health fashion. It may be helpful to reiterate that the goal is to have them function in a more secure way sexually for a long time and not just for the moment. The Sensate Focus skills may help them understand what they can do differently from this point forward, for the duration of their relationship, if they slip back into old patterns. It is as if the therapist is suggesting, “I don’t promise you will never again fail to get and keep an erection, but you will know exactly what happened and what you might remember to do next time. It will not be such a mystery any longer.”
Regardless of the reason, failure to do the touching or going beyond suggestions is processed in therapy by addressing the fear, confusion, guilt, anxiety, expectations, discomfort, pressure, and problematic relational dynamics associated with it. At no point are clients chastised for non-compliance, and their understandable difficulties are normalized. In fact, their non-compliance can be interpreted positively as helping the therapist clearly identify the roadblocks that get in the way of working on the sexual dysfunction, and provides the opportunity for offering therapeutic strategies for managing these roadblocks that may include, but are not limited to, the following:
1.Reviewing the purpose of Sensate Focus;
2.Clarifying expectations;
3.Formally scheduling touching time and setting reminders;
4.Scheduling touching daily at a certain time so both head to the bedroom at that time;
5.Changing who initiates and who touches first; and
6.Identifying, communicating, and managing the anxieties alone or with the partner’s assistance.
It is often helpful to discuss the fact that couple’s anticipation of the touching is often more anxiety provoking than the touching itself. Clients often confirm this subsequently and report feeling relieved, cared for, and more intimately connected to their partners once they have completed the touching sessions (“That wasn’t so bad!”). This sense of emotional closeness and relief from pressure for any particular outcome helps to lessen their worries. Nonetheless, problems with non-compliance can re-emerge with each new Sensate Focus suggestion.
One of the most common therapist contributions to non-compliance is failure to explain the rationale for using Sensate Focus. This is where Masters and Johnson’s data on the characteristics of sexually functional people may be valuable. As we have noted, Masters and Johnson discovered that there are three techniques these highly sexually functional people shared, and they are: focusing on sensations for one’s interest; focusing on one’s own experience rather than on the partner’s; and returning the focus of attention to sensations if distracted by anything else. These strategies are the foundation of their therapy and the portal into natural sexual responsiveness. In offering Sensate Focus suggestions, clients are told that the purpose of the exercise is to practice these skills in order to build the foundation of the house they want constructed.
Another inadvertent therapeutic contribution to non-compliance is making the mistake of giving up too quickly when clients appear unwilling to follow through with Sensate Focus. It is helpful for clinicians to see non-compliance as a resistance, like any other resistance, that needs to be understood and addressed.
Dislike Touching: Boring, Constraining, and Non-Spontaneous
It is not uncommon for clients to report feeling bored with or limited by the touching exercises. They often yearn for spontaneity and freedom. Although couples come to sex therapists for direction, they may chafe at first at the highly structured approach.
When clients report boredom or lack of spontaneity they are sometimes still steeped in demand expectations for enjoying, being excited by, responding sexually to the touching exercises, and/or expressing disappointment that they must begin where they are. It may be helpful to remind them that if they could make sexual responsiveness occur on demand they would already have done so. Their discontent with the touching suggestions has to be balanced with the necessity of taking small steps. Again, it may be helpful to characterize Sensate Focus as the foundation of therapy that must be built before the walls and roof of other techniques can be included.
At times it is the therapist who needs to be creative if Sensate Focus is not proceeding quickly enough. This can be done by suggesting alterations such as the use of lotion to vary the sensations or other modifications to help clients learn the skills they need before they can proceed.
Because ticklishness is a reflexive reaction, it is often experienced as a challenge during initial sessions. Clients are reminded that ticklishness is a response we can rarely directly produce ourselves, and may be triggered by understandable anxiety when being touched by the partner. They are reassured that it is nothing to be embarrassed about and that it will diminish with Sensate Focus experience. Ticklishness that continues across touching opportunities can also suggest more complex and significant anxieties. Sometimes these can be severe and distressing, and may be associated with a history of relentlessly and even forcefully and relentlessly being tickled as a child.
The most frequent suggestion is to employ handriding, either removing the partner’s hand or placing the ticklish person’s hand under or over the partner’s hand and move the Toucher’s hand away in a more specific fashion in order to gain a greater sense of control. In some instances, such as feet ticklishness, the Toucher is asked to avoid that body area with the possibility of returning at a later time.
Not infrequently, clients will return from Sensate Focus sessions reporting that they felt nothing. Just as with feeling bored with or constrained by Sensate Focus, this often means that they are still expecting to feel aroused and responsive, despite therapists’ assurance that this is not the goal. This becomes diagnostic of a performance-oriented approach and serves as a teaching opportunity.
Feeling nothing may also be an indication of possible sexual trauma and dissociation, or it can point to other concerns such as damaged nerve conduction from illness, medication, or treatment. Additionally, it can signify a client’s coming to therapy not to actually improve the sexual relationship. Instead, the client may be coming for therapy with a motivation to prove the sexual relationship is toxic or irretrievably broken, or there may be an ongoing affair or alternative sexual interest. Although every effort is made to identify these barriers during initial sessions, it is sometimes possible to do so only as problems surface in association with Sensate Focus suggestions.
The feeling nothing assertion is often best handled by asking the client to describe the sensation of their hands on the chair or their buttocks on the couch on which they are sitting. When they answer along the lines of, “It feels hard,” the therapist reiterates that this is exactly the non-evaluative, sensory-oriented attitude that is being sought in the Sensate Focus experiences.
Masters and Johnson’s original suggestion that couples refrain from sexual release both during and apart from Sensate Focus sessions, and also that they not self-stimulate to orgasm, was aimed at allowing sexual tension to build in a non-demand way. It takes advantage of the principle that sex is a natural function and, therefore, the more that desire or arousal is not the goal, the more likely it is to occur. However, as the complexity of the Sensate Focus suggestions increases and begins to involve additional parts of the body, the sexual tension may also increase, and this may become a significant distraction.
Couples are encouraged to allow arousal to develop as any other emotion, and to lie next to each other for several minutes after the Sensate Focus session ends to see if the arousal will dissipate. If it does not, one or both clients may indicate their desire for physical release. However, this follows Sensate Focus and a period of time of lying next to each other or taking a break. As suggested previously, while one of the options is for the partner to provide manual release, the other two involve the person’s requesting release to self-stimulate either by him or herself, or to self-stimulate in the presence of the partner while the partner holds the person seeking release. In any case, it is the partner who makes the decision about how the release takes place. A simple technique for handling release if both partners request it is to first provide release for the person who asked first, and then provide release for the person who asked subsequently.
The partner’s choosing the type of release as the couple lies next to each other after Sensate Focus is particularly helpful when therapy takes place in a less intensive format. When Sensate Focus is associated with a longer-term outpatient format, it may also be productive to suggest clients engage in sexual activities if they feel the need as long as: these activities take place at an entirely different time, separate from the Sensate Focus opportunities; the partners are clear about the intent; and they are realistic about progress. Clients are still enjoined to have release apart from the touching sessions as infrequently as possible in order to foster higher levels of sexual tension.
Confusion About, and Difficulties With, Concepts and Instructions
Many of the attitudes and concepts of Sensate Focus are so different from the cultural scripts with which clients are raised, that confusions are likely. Sex as a natural function is a concept that is particularly difficult for many clients to apply especially when it comes to the notion that sexual responsiveness cannot be consciously produced. Often they have succeeded in most aspects of their lives by pouring conscious effort into whatever they have done. It may be difficult for them to embrace the idea that working hard at sexual response never works.
It may also be helpful to follow up verbal Sensate Focus instructions with a demonstration in the therapy office of the way in which to touch, especially for anxious clients. This is especially true for anxious clients. This is accomplished by having them use their hands to touch the chair or couch on which they are sitting and reporting about the touch sensations they experience. The instructions and touch demonstration can also be followed by giving clients a written instruction guide (see Appendix B).
When these strategies fail, ongoing confusion about the concepts and instructions may represent individual or partner dynamics of a more severe psychological nature. These may require additional professional expertise such as separate and intensive individual or couples therapy or a medication consultation as in the case of a client with obsessive-compulsive disorder.
Going Further Than Suggested on a Regular Basis
It is to be expected that clients who have experienced the build-up of sexual tension from repeated Sensate Focus may be spontaneously orgasmic during the touching as part and parcel of natural, sexual functioning. However, there are some couples that repeatedly and seemingly intentionally go beyond the current suggestions for Sensate Focus. They may even seek orgasmic release on a regular basis and as each successive touching opportunity is introduced, or may move on to intercourse repeatedly before this is encouraged. The usual intervention is to reiterate the concern about returning to goal-oriented expectations, a return which may reduce the opportunity for success in treatment. Sometimes the push for intercourse or orgasm is diagnostic of one partner’s pressuring the other, of sexual compulsivity, of a personality disorder, or of a lack of sufficient education. All this is grist for the therapeutic mill.