We began Sensate Focus in Sex Therapy: The Illustrated Manual by suggesting that we know a lot more about sex than we did half a century ago when Masters and Johnson began publishing their groundbreaking work on sexual functioning and sex therapy. After researching and writing this manual, we, ourselves, know a lot more about Sensate Focus than we did when we began. We have been impressed with the extent to which practitioners and researchers from a wide variety of fields have expanded on the original work of Masters and Johnson with a wide variety of clients from all sorts of populations. Their creativity and willingness to cultivate a fertile ground for the exchange of ideas across professional specializations is remarkable. Additionally, and despite our decades of training in and working with Sensate Focus as the foundation of our sex therapy practices, we were not aware of how many clinicians use and find effective this simple yet powerful technique while helping many different kinds of people who experience sexual dysfunctions. We have been humbled and delightfully surprised! We have also been rewarded to discover how many clinicians find Sensate Focus to be as effective a therapeutic approach as we do.
Writing this manual is the fulfillment of a mission that was initiated by Masters and Johnson’s work when they promised to explain Sensate Focus in greater detail. For whatever reason, they left this promise unfulfilled, leading many people to tell us about the importance of writing the manual to clarify and codify Sensate Focus. This manual represents the first time Masters and Johnson’s foundational techniques of Sensate Focus are described in such detail and are available to everyone. We hope the additions by others and the clarifications we present will stimulate researchers in the field to do additional research and breathe fresh ideas and best practices into our field.
Writing this Illustrated Manual represents the fulfillment of several other goals. When we began we were aware that the field of sexuality had been moving in a medicalized direction in large measure because of the development and proliferation of PDE-5 inhibitors. However, we really did not appreciate to what extent this had happened. We hope that we have been able to shine the spotlight back onto the whole field of sexual healing that includes not just what physicians, nurse practitioners, and physical therapists are doing but also what psychologists, social workers, educators, relationship therapists, sociologists, spiritual leaders, and stress management counselors have to offer. We anticipate a renewal of vitality in a multidisciplinary approach in which all these professionals proactively reach out to, confer with, and cross-train one another, so that we can all better serve our clients and society with the important work we do. This is instead of merely paying lip service to what we know intellectually but so often do nothing about practically, namely, advancing the understanding that sexuality is so varied that to presume any one profession embodies everything there is to know about the field is to do the field in general, and our clients in particular, a tremendous disservice. Michael Perelman’s erudite and elegantly constructed Sexual Tipping Point® model (2009) reminds us of the dynamic interaction between the constitutionally established capacity to respond in a sexual fashion (the natural function of sexual responsiveness) and the actual elicitation of that response by different kinds of stimulation that are influenced in an ongoing way by a wide variety of psychosocial-behavioral and cultural factors.
If we do not heed this need for an ardent multidisciplinary approach to working with sexual issues, we risk the fate of professions that have become so exclusive as to render themselves arcane and eventually irrelevant as a result.
The world of intellectual possibilities has developed in unfathomable diversity. Infinitely long paths, paved with thousands of thick volumes, lead from one specialization to another. Soon no one will be able to walk down these paths anymore. And then only specialists will remain. More than ever we require … something capable of providing firm guidance.
(Jung, 2009, p. 286, fn. 135)
The firmer guidance offered by a more complex and nuanced multidisciplinary approach to sexuality parallels one of our expressed reasons for writing this manual and that is to shine the spotlight back on the whole person as well as on the whole field. We are clearly big supporters of the need to honor and address the underlying physiological, natural responses before all other dimensions. Nonetheless, it is a rare client who comes to therapy solely to address biological concerns. Clients want to learn how to manage their own anxieties better, how to communicate with their partner more intimately, how to wrestle with values that no longer serve them well, and how to cope more efficiently with stresses in their daily lives. This is all in service to resolving sexual dysfunctions and improving sexual relationships. Addressing one or a couple of these aspects without respecting the influence of the others is like the blind touching the proverbial elephant: an appreciation for the entirety is forsaken in favor of a rigid adherence to myopic perspectives that lead to conflict and, in the case of sexologists, disservice to our clients.
As we worked on this manual, we were perplexed to discover that there are some who suggest that sex therapy, and Sensate Focus along with it, has little to offer as a unique specialty and that they are considered essentially passé. Needless to say, we would respectfully disagree. This puzzling perspective seems to parallel the movement of increasing medicalization of the field of sexuality. However, as is so often the case, there is strong evidence that the pendulum may be starting to swing the other way. There is an increasing awareness in the mental health and possibly even in the medical fields of the unique contributions made by sex therapists and clinicians who are comfortable providing sex education, information, and strategic interventions such as Sensate Focus.
We hope that this Illustrated Manual will stimulate a rebirth of interest in and appreciation for sex therapy in general and Sensate Focus in particular. Our hope dovetails with questions about the unique purview of sex therapy and Sensate Focus in that both have the potential for stimulating more evidence-based research in these areas, research that is sorely needed. For example, where is significant evidence to suggest who uses sex therapy and Sensate Focus? If professionals trained in only one health or mental health specialty represent the great majority of sex therapists and professionals who use Sensate Focus then maybe both health and mental health professionals can be subsumed under some one specialty and do not have much to offer in the way of unique therapy. Our experience has been quite different. We have been impressed with the fact that sex therapists and clinicians who use Sensate Focus come from divergent backgrounds including psychologists, social workers, psychiatrists, mental health counselors, marriage and family therapists, health personnel, physicians, nurse practitioners, physical therapists, and religious and spiritual counselors, to name some. This would suggest that there is something special that sex therapy and Sensate Focus have to offer that is not included in the training of a diverse number of health and mental health professions. Nonetheless, there is little in the way of evidence-based investigations to provide a firmer objective foundation for our experience.
Another rich area for research has to do with contentions we have often made throughout this manual. These include our claims that the specific way in which Sensate Focus rationale and instructions are presented, and the specific questions asked of clients in order to process Sensate Focus during the therapy sessions, have significant bearing on how well clients understand the concepts of Sensate Focus. We also contend that these have considerable influence on how willing clients are to carry out the suggestions, and how effectively they cultivate the attitudes and skills that are most productive for implementing it. But are these empirically the case? Precise data has yet to be gathered. We think it would be interesting and invaluable for significant investigations to be initiated to objectively assess these claims.
Yet one other fertile field of inquiry would be evaluating the modifications suggested for Sensate Focus with a diversity of populations. There is a dearth of methodologically sound research on this. Do the changes in Sensate Focus that we encourage and that have been suggested by other clinicians actually make a significant difference beyond these clinicians’ reports? What precisely are the modifications to Sensate Focus that work best with different populations, and what new modifications are needed and can be created?
The whole question of the objective effectiveness of Sensate Focus in general continues to intrigue us. There have been few systematic studies into how well Sensate Focus works beyond experiential, anecdotal reports. What is the operationally defined effectiveness of Sensate Focus in the short term? How about in the long term?
These are but a few of the investigative questions that we hope readers will consider as the field of sex therapy and Sensate Focus develops even more creatively, productively, and inclusively. Our wish is that this expansion in research spearheads a more general resurgence of interest in, and appreciation for, sex therapy and Sensate Focus stimulated by this manual.
Two other points deserve emphasis. Throughout the preparation for and writing of this manual, we have been humbled repeatedly by the primalness and power of touch. We noted at the beginning that touch is the first sensory system to develop and arguably the most compelling. Recently there was a video posted in which a woman went into premature labor with twins, and was informed that the male twin had not lived through the delivery.
I just grabbed the baby from the doctor, and unwrapped him, and ordered [my husband] to get his clothes off because I wanted him to get in bed with me because I wanted as much body heat around this baby as possible because he was cold and I wanted him to be warm and alive. We put his skin against my skin, and I just held him close to my heart. I moved his head so he would be able to hear my heart beating. And cried. And cried … So we are balling our eyes out and holding him, and then he started to move. We thought, “What? What’s happening?” … We said, “Look, he’s moving,” and they said, “He’s dying” … And we never let go of him. His skin was against mine for the entire time. And then he opened his eyes … and he grabbed [his father’s] finger … He laid his head back down on my chest … And we realized it was because we had held him and he had the body heat … and that soft cocooning warmth … That’s what had brought him back and had given him the time … to live!
(Diamond, n.d., 1:10–3:13)
What more powerful testament to the life-giving energy of touch can there be? It is this energy that Sensate Focus harnesses, and the healing effect it can have on sexual responsivity in particular, and feelings of wellbeing and life in general, is remarkable.
Finally, perhaps the most professionally and personally meaningful reason we undertook publishing Sensate Focus in Sex Therapy: The Illustrated Manual (1975; 1987) is to remind all of us that fundamental to sex therapy and Sensate Focus is the beauty and humanity of sex. Helen Singer Kaplan did this some four decades ago by including illustrations in her Illustrated Manual of Sex Therapy (1975; 1987). We hope the drawings laced among the pages of this book will inspire and remind us why we do this work.
Sexuality is the great mystery of our being, sensuality the first cog in our machinery. It stirs our whole being and makes it alive and joyful. All our dreams of beauty and nobility have their source here. Sensuality and sexuality constitute the essence of music, of painting, and of all the arts. All the desires of mankind revolve round this centre like moths round a flame. The sense of beauty and artistic feeling are only other dialects, other expressions. They signify nothing more than the sexual urge of mankind.
(Jung, 1990, para. 332n)