The History of Sensate Focus, and How We Self-Educate When It Comes to Evolving Therapeutic Techniques

AASECT members Linda Weiner, MSW, LCSW and Constance Avery-Clark, PhD recently published a paper titled "Sensate Focus: clarifying the Masters and Johnson's model" in the Routledge-published journal Sexual and Relationship Therapy. The paper addressed persistent confusion over the definition of the sensate focus technique by delving into the history of its development and drilling down into the various reasons for misunderstanding and misuse over the years.

One of the interesting things about sensate focus is that — despite its effectiveness in opening up a dialogue about sex and sensation — written records of the technique itself are hard to come by. In pondering this, one could see parallels between this and the teachings of other therapeutic techniques. How can we avoid losing our grasp on the legacy our professional predecessors have left us? And how can we most effectively continue to educate ourselves on best practices and techniques?

The History of Sensate Focus and How It Has Evolved Over Time

Weiner and Avery-Clark worked at the Masters & Johnson Institute in the mid- to late-1980s, as Research and Clinical Associates. During their time there, they were able to observe the continued development of the sensate focus technique, and the ways in which it evolved in response to criticism and client need.

"As most sex therapists know," says Avery-Clark, "sensate focus was originally incorporated into two-week treatment for sexual concerns during which clients were seen every day for two weeks, including weekends. This intensive format required social isolation to afford the opportunity for rapid progress."

Understandably, the financial and personal time commitments required to participate in such a process weren't ideal for a large number of clients. "One of the most significant developments in the evolution of sex therapy has been the use of sensate focus in contexts other than this intensive one," says Avery-Clark. 

She elaborates, saying, "the advantage of sensate focus being utilized in the more common therapeutic format... is that it can be more easily worked into the routine of couples' daily lives, as opposed to the difficulties that often confronted couples doing just this when returning from two weeks of intensive and socially isolated therapy. The disadvantage is that progress may be slower because it is problematic for many clients to find the time or assert the structure that is required to regularly practice the skills."

Weiner chimes in, providing additional context for the changes made to the original sensate focus model. "The Masters & Johnson model of sex therapy," she says, "like any model, continued to evolve organically as more than 25 years of experience, new information, and professionals with varied clinical training and experience morphed the original core research-based psycho-educational model with sensate focus as the primary diagnostic and therapeutic intervention." 

Weiner tells of how, early on in the development process, Dr. Emily Mudd, founder of the Philadelphia Marriage Council and a pioneer in the emerging field of marital counseling, consulted with Masters & Johnson for one week a month over a two-year period, likely providing concepts related to interpersonal relationships and helping to expand their model to provide a more sophisticated approach to couples counseling. Unfortunately, the bulk of their work together was never published by Masters and Johnson in any detail, and critics of the technique bemoaned a lack of attention to couple dynamics and relationship skills.

An even greater change to the sensate focus technique was in regard to its instructions. In 1980, Masters & Johnson instructed partners to touch for one's own pleasure without regard to physical or sexual arousal. The beauty of this was that it resulted in a reduction in performance anxiety. Still, it missed the point that performance pressure was naturally inherent in the instruction to touch for pleasure at all, one's own or one's partner's. 

These suggestions were eventually modified, and patients were instructed — in the initial stages of sensate focus — to touch for whatever they themselves experienced sensorally (temperature, texture of skin and hair, and variations in the feelings of pressure), rather than in pursuit of pleasing their partner, or even in pursuing pleasure for themselves. In later stages, couples were encouraged to share information about pleasurable touch once the dysfunction they had initially sought out help for was being managed.

Weiner acknowledged that these changes to the sensate focus model were transmitted to participants in Masters & Johnson's six-month training program, and at their week-long seminars, but were not effectively disseminated to other sexologists.

How Confusion Over Sensate Focus So Easily Spread

Over the years, this lack of effectual dissemination has led to many misuses of the technique, and a mislabeling of other types of erotic touch exercises as sensate focus.

Heather Raznick, MSW, LCSW, the most recent assistant to William Masters before his retirement, speaks to this in her own experience. "I'm fortunate in that I was trained by the originator of [sensate focus]," she says. "Over the years, it's been misrepresented as something that can be utilized in traditional marital therapy to increase pleasure and arousal. It's been watered down... misunderstood." Similarly to what was covered in Weiner and Avery-Clark's paper, she explains how people have confused the concept of touching for one's own interest vs. touching for pleasure.

But this particular area of confusion isn't the only cause of misinterpretation. "Another part of the problem is that it's very difficult to find a specific script to be able to model exactly what you're supposed to say and how you're supposed to say it."

She also mentions clients' resistance to working with a technique that requires such a huge time commitment and such a regularity of use, rather than providing a quick fix. "When they're coming to you for sexual dysfunction — or looking for ways to promote intimacy and connection — and the assignment is not romantic," says Raznick, "they look at you like you're crazy. There's an expectation that if there's not a pill, you have to have a technique." She constantly has to remind clients that this exercise is supposed to focus on non-demand touching. There should be no expectations. Clients should only be focusing on sensation.

Still, she admits that the confusion between sensate focus exercises and erotic touch exercises is easy to understand. "I trained with him and I had that same experience," she says. "It's very difficult until you're in practice and understanding what the intention is. Until you have a chance to sit with people and do this work, to understand the nuances, to really know the difference between touching for one's own interest vs. pleasure... it wouldn't make sense until you were clinically able to apply it. It is confusing."

Which is why Weiner and Avery-Clark have been making proper education of this technique such a primary focus in their careers lately. "Linda Weiner and I are making a concerted effort to clarify the true intent of sensate focus," says Avery-Clark. "It has little to do with pleasuring or arousing either one's partner or one's self; instead, it is about getting attempts to make pleasure or arousal happen out of the way so that Mother Nature can let them happen on their own!"

The Beauty of the Sensate Focus Model, and the Benefits of Training with Its Originators

Still, it seems you just can't beat the actual experience of having trained at the Masters & Johnson Institute. William Maurice, MD credits his experience at the Institute with his ability to more effectively communicate with clients. When Maurice decided to take the plunge into psychiatry, he went to Washington University in St. Louis, where the Masters & Johnson Institute was located. He did a rotation in their clinic at that time, as part of his psychiatry residency.

"When I was a first-year resident in psychiatry," he says, "there were two things I had trouble talking to patients about: one was money and the other was sex. I was told: oh, it will come in time. But it never came." Finally, as a senior resident, Maurice opted to take a rotation at the Institute, where he saw couples while being supervised by Masters and Johnson. Maurice's observations at the Institute helped him discover that sex was actually a pretty easy thing to talk to people about. "I'd never observed someone talking in that amount of detail on sexual matters," he said, "until then. The whole process of interviewing and history-taking became a central focus to me."

That focus is something he stuck with throughout his career, even covering it extensively in his book Sexual Medicine in Primary Care (available free as an e-book both here and here). As he writes in the preface for that book: 

"Those who are professionally engaged in talking to individuals about these difficulties know that when the inhibitions lift, they are often told of private thoughts, experiences, and fantasies that have never been revealed to anyone else, not even a loved sexual partner. Ironically, two people may engage in what is almost universally acknowledged as potentially the most intimate of human connections, and at the same time, have trouble talking about what just occurred. As curious as it might seem, it often seems easier to talk about sexual difficulties with a stranger, such as a health professional. Whatever the reasons (e.g., trust and no expectation of being judged), health professionals are in a particularly advantageous position to hear about those troubles."

In talking about sensate focus in particular, Maurice says, "I see it pretty strongly and clearly as a communication device. He explains further that it can be a way for partners to tell each other what they did and didn't like. "That's certainly how I used it over the years. One could encourage people to be explicit about what they like and don't like." 

After all, Maurice says, he used to ask clients with, for example, erectile or orgasmic dysfunction: has he ever told you which part of his penis he enjoys having touched? or has she ever told you how she likes to stimulate herself? Has she ever taken your hand and shown you what she likes? "And the response was usually no." Because of this, he saw the sensate focus technique as a tool of education for his clients.

Raznick also credits her time at the Masters & Johnson Institute as a period of essential learning. "From a very early age," she says, "I knew I wanted to be a sex therapist. One of the first books I received from my mom was Our Bodies, Ourselves. I devoured it." 

Raznick wanted very badly to work with Dr. Masters, mentioned prominently in the book, so she called the Masters & Johnson Institute and asked if she could meet the man and discuss possible internship opportunities. She told the clinical director, who informed her they were looking for more men at that time: "I will do whatever I have to do to work with Dr. Masters. I will cut my hair and wear a hat." 

Later, after speaking to Dr. Masters himself, he gave her the chance she was looking for, allowing her to act as co-therapist... student... assistant... whatever was needed. "He loved to teach and was looking for someone he could continue to teach. I sat in his office and listened to him talk about his cases. He shared his clinical expertise with me, and stories of his experiences."

Conferences as a Form of Self-Education:

As the AASECT conference approaches, it's natural to wonder how effective and/or essential professional conferences can actually be in educating industry professionals on the evolution of various sex therapy interventions, sensate focus and otherwise.

Raznick believes it is "imperative" to seek out these continuing education opportunities. But she feels that, at many of the conferences she goes to, it's rare to find offerings that teach about specific techniques and interventions in a theoretical way while also getting into the nitty-gritty of how you go about incorporating them into your practice. "That's the stuff we need to know. To be able to see it and understand it. A case where you could hear someone give the specific instructions... have them model the technique... that would be very helpful." 

"My hope for Linda and Constance," she says, "is that they turn this information into a training manual that might even be used in the certification process. That's what we need."

Maurice has a similar mindset. "I don't recall hearing anybody talk in detail about sensate focus," he says. "People use the term as if everybody understands what it means." 

He mentions that this is the case for a variety of issues in the field of sexuality. "Colleagues will often use words like 'sexual abuse,'" he says, "but not really explain what they mean by it. It can mean being flashed on a street corner or it can mean a father sleeping with his daughter for 10 years... or any number of other things. I see a lot of assumptions being made when people speak about certain topics."

Maurice finds it interesting that clinicians were talking about sensate focus in the '60s and, here we are, 40 - 50 years later, still wondering what they're talking about. He reflects on what it would mean to create a truly effective conference workshop. He imagines it would require seeing demonstrations from people who learned directly from Masters and Johnson.

"Education and conference programs are crucial for promulgating new ideas," says Avery-Clark. "Education and meetings of sex therapists are also necessary for correcting well-intended but inaccurate interpretations of techniques like sensate focus, techniques that represent the core of sex therapy."

Weiner adds, "Most everyone assumes that sex educators and sex therapists already know how to take a sex history or give and process sensate focus homework."

Unfortunately, these assumptions only perpetuate the confusion.

(image via)