Sex therapy and sensate focus

1. Introduction

Version followed: Masters and Johnson's couple-based sex therapy (Human Sexual Inadequacy, 1970) with sensate focus as later clarified by Weiner and Avery-Clark (2014 paper; 2017 illustrated manual), delivered in today's usual outpatient format (weekly sessions, exercises done at home). Dysfunction-specific techniques follow the behavioural sex therapy package as summarised by LoPiccolo and Stock (1986); PLISSIT (Annon, 1975–76) is used as the stepped-care frame. The Masters and Johnson book and the Weiner and Avery-Clark manual are not drawn on directly; their content is taken from author-written abstracts and summaries, review articles and society pages [uncertain where marked].

Sex therapy in this tradition is a brief, structured, couple-focused, behavioural-educational treatment for sexual dysfunctions (erectile difficulties, early ejaculation, delayed ejaculation, orgasm difficulties, vaginismus/penetration difficulties, low arousal or desire). Its core idea of change: dysfunction is kept going by performance anxiety, goal-directed sex and self-monitoring, so treatment removes the demand to perform (a temporary ban on intercourse and orgasm-seeking), retrains attention onto the sensations of touch, and rebuilds sexual contact in graded steps while improving couple communication. Sensate focus is designed to get attempts to make pleasure or arousal happen "out of the way" so that response can occur on its own [source: AASECT report of Weiner & Avery-Clark 2014; Wikipedia, Sensate focus; Wylie 2021]. Weiner and Avery-Clark now split the method into Sensate Focus 1 (resolving dysfunction) and Sensate Focus 2 (enhancing intimacy) and frame it as a mindfulness-based practice [source: Avery-Clark, Weiner & Adams-Clark 2019 abstract; Taylor & Francis book page].

Scope note for this guide: all touching exercises are done by the clients in private at home. The therapist never observes, demonstrates on, or touches clients; in-session work is assessment, education, instruction and debriefing [source: Wylie 2021 — original exercises done in the couple's private quarters; modern practice prescribes home tasks].

2. Framework

Original Masters and Johnson format (St Louis, 1960s–70s) [source: Wylie 2021; AASECT 2014; Duddle & Underwood 1976]

Couple treated together, never the symptomatic partner alone; careful medical and psychological screening.
Intensive two-week programme with daily sessions (weekends included), couple away from home and treated as guests in residence.
Co-therapist team: one physician and one clinician from a behavioural discipline (the team is commonly described as dual-sex; LoPiccolo & Stock refer to studies of "dual-sex cotherapy teams") [source: Wylie 2021; LoPiccolo & Stock 1986].
Days 1–2: detailed history-taking (about seven hours in total). Day 3: medical history, physical examination and laboratory tests, then a round-table session in which the co-therapists feed back their formulation to both partners.
From then on: daily debriefs, progressive sensate focus done in the couple's quarters, and dysfunction-specific techniques.

Contemporary outpatient format (version followed) [source: AASECT 2014; Wylie 2021; LoPiccolo & Stock 1986]

Weekly (or fortnightly) conjoint sessions with a single therapist; LoPiccolo & Stock report single therapists did as well as dual-sex teams in one study. Co-therapy is now mostly used in training or complex systemic cases (Wylie).
Typical length: brief and time-limited. No canonical session count is given in the sources [uncertain]. A GP adaptation used weekly 5–15 minute visits, usually no more than six, referring on cases needing more [source: Duddle & Underwood 1976]. In specialist practice, plan roughly 8–20 sessions and review at the midpoint [synthesis].
Weekly progress is slower than in the residential format because couples must create time and structure to practise [source: AASECT 2014].

Phases

Phase	Goals	Main content	Move on when
A. Assessment and medical screening	Rule out or treat organic causes; understand each partner's sexual and relational history; decide fit	Separate and conjoint interviews; medical/physical examination by a physician; PLISSIT level decided	Medical causes addressed or in parallel care; both partners consent to conjoint work; no contraindication (see 5) [synthesis]
B. Formulation (round table) and education	Shared, non-blaming account of what maintains the problem; correct myths	Feedback session; anatomy, physiology, response cycle including desire (Kaplan 1974)	Couple accepts the rationale and the temporary ban [synthesis]
C. Sensate Focus 1, non-genital	Reduce performance anxiety; train sensory attention	Step 1 touching, intercourse and orgasm-seeking off the table	Several repetitions over days with sustained sensory focus and tolerable anxiety [source: SMSNA — repeat over several days before advancing]
D. Sensate Focus 1, genital and breast; lotion; mutual	Include genitals without demand	Steps 2–4, hand-riding	Same criterion; no avoidance [synthesis]
E. Dysfunction-specific techniques and graded return to intercourse	Target the presenting problem	Stop-start/squeeze; partner stimulation with erection allowed to subside; directed masturbation; graded dilation; female-superior containment; sensual intercourse	Target met for that problem (e.g. intercourse usually possible; ejaculatory control acceptable to both; most intercourse pain-free) [source: Duddle & Underwood 1976 success criteria]
F. Sensate Focus 2 and consolidation	Intimacy, sharing preferences, relapse prevention	Communicating what each likes; planning for lapses	Couple maintains gains without weekly structure [synthesis]

The order of phases C–E is flexible: dysfunction-specific techniques are added gradually alongside the touching sequence, not only after it [source: Duddle & Underwood 1976 — Masters and Johnson techniques added gradually].

3. Guiding principles

The relationship is the patient. Treat the couple conjointly; no partner is the "problem". Practical: invite both from the first contact and frame difficulties as shared [source: Duddle & Underwood 1976; Wylie 2021].
Rule out the body first. Medical screening precedes or runs alongside psychological work. Practical: confirm a medical/physical check has been done before starting exercises [source: Wylie 2021; SMSNA].
Remove demand. Temporarily take intercourse and orgasm off the agenda when they generate anxiety or goal-orientation. Practical: prescribe the ban explicitly so the couple does not have to decide in the moment [source: LoPiccolo & Stock 1986; Wikipedia]. Note: Lipsius (1987) argued for sensate focus without proscribing intercourse; LoPiccolo & Stock note abstinence vs continued intercourse was untested [uncertain — Lipsius paper].
Touch for your own sensory interest, not to please. In current Weiner/Avery-Clark wording, the toucher attends to temperature, texture and pressure, not to giving or getting pleasure; earlier versions said "touch for your own pleasure", which itself became a performance goal. Practical: correct clients who say "I was trying to make it nice for her" [source: AASECT 2014].
Arousal is allowed but not pursued. Practical: if arousal comes, notice it and keep touching for sensation; do not escalate into sex [source: SMSNA].
Mindful attention. Sensate focus is presented as a mindfulness-based practice. Practical: treat distraction and spectatoring as expected, and coach returning attention to the point of contact [source: T&F book page; Avery-Clark et al. 2019 abstract citing Brotto] [synthesis for the coaching].
Graded steps. Move one step at a time and repeat a step before advancing. Practical: never jump steps to please an impatient partner [source: SMSNA; Duddle & Underwood 1976].
The therapist catalyses communication. Practical: the debrief, not the exercise, is where much of the change is consolidated [source: Wylie 2021].
Be explicit. Use plain, accurate sexual language and invite clear statements of likes and dislikes. Practical: model naming body parts and acts without euphemism [source: AASECT 2014 (Maurice)].
Permission first, then information, then suggestions, then intensive therapy. Match intensity to need; many concerns resolve at the permission or information level. Practical: ask before advising [source: Wikipedia PLISSIT; SIECCAN].
Client control, never force. Especially in penetration problems, the woman controls every insertion step; forced insertion by anyone worsens the condition. Practical: the person with the symptom sets the pace [source: LoPiccolo & Stock 1986].
Reflect on your own comfort. Ex-PLISSIT adds review and clinician self-reflection on awkwardness and bias. Practical: take discomfort to supervision [source: SIECCAN; Wikipedia PLISSIT].
Coital orgasm is not a required outcome. Practical: agree goals that do not make intercourse orgasm the definition of success [source: LoPiccolo & Stock 1986; Wikipedia — "Orgasm is never the focus."].

4. Intervention inventory

All example wording below is illustrative unless quoted and cited. The touching exercises are client homework done in private; the therapist instructs and debriefs only.

4.1 Sexual history and assessment (separate and conjoint)

Purpose / when: First 1–3 sessions; establishes the problem, its course, maintaining factors and medical contributors. Masters and Johnson spent about seven hours over two days on history, then examination and tests on day 3 [source: Wylie 2021].
Steps: (1) See the couple together briefly to explain the process and confidentiality rules (agree in advance how individually disclosed information will be handled) [synthesis]. (2) Interview each partner alone: onset (lifelong/acquired), situational vs generalised, solo vs partnered function, desire, arousal, orgasm, pain, sexual learning and attitudes, trauma, relationship satisfaction, health, medication and substances. (3) See them together again to hear each person's account of a typical recent sexual encounter. (4) Arrange medical/physical assessment by a physician, including genital examination where relevant (the GP adaptation valued vaginal examination) [source: Duddle & Underwood 1976 — 30–50 min assessment, each partner seen separately then together]. (5) Screen for contraindications to conjoint touching work (section 5).
Example language (illustrative): "I'll ask you both some very direct questions about sex. There are no right answers; the more specific you can be, the more useful this is." / "Walk me through the last time you tried to make love — what happened, and what was going through your mind?"
Watch for: spectatoring and performance fears in the narrative; avoidance patterns; one partner speaking for the other; undisclosed affairs, violence or coercion; medical red flags needing referral before behavioural work [synthesis].

4.2 Round-table formulation session

Purpose / when: After assessment; gives a shared, non-blaming formulation and the rationale for treatment [source: Wylie 2021 — both partners and co-therapists review findings; therapists summarise causes and effects, often confirming what the couple already suspected].
Steps: (1) Summarise the medical findings. (2) Describe how the problem started and what keeps it going (e.g. one failed erection → worry → watching oneself → more difficulty → avoidance). (3) Show how each partner's reactions fit the cycle without blame. (4) Present the plan: education, a temporary ban on intercourse, graded sensate focus, problem-specific techniques. (5) Ask each partner what fits and what doesn't; agree goals [synthesis for step detail].
Example language (illustrative): "Neither of you caused this. What's keeping it going now is that sex has become a test. The first thing we'll do is take the test away."
Watch for: relief and engagement vs. one partner rejecting the formulation; a partner who wants the other "fixed" (return to the shared frame).

4.3 Sex education

Purpose / when: Throughout, especially early; corrects myths that fuel anxiety [source: LoPiccolo & Stock 1986 — education on anatomy and physiology is a core component, often with self-help books].
Steps: (1) Ask what each already knows (open questions) [source: SIECCAN]. (2) Cover genital anatomy, the sexual response cycle including the desire phase Kaplan added (1974) [source: Wylie 2021], normal variability, that erections and lubrication come and go, and that many women need direct clitoral stimulation. (3) Recommend vetted reading. (4) Check understanding.
Example language (illustrative): "Erections naturally rise and fall during a long sexual encounter. Losing one doesn't mean it's gone."
Watch for: shame or disgust reactions; a partner surprised by basic facts (often a sign of narrow sexual scripts) [synthesis].

4.4 PLISSIT / Ex-PLISSIT stepped response

Purpose / when: Frame for any clinician meeting a sexual concern; decides how much intervention is needed and when to refer [source: Wikipedia PLISSIT; SIECCAN].
Steps: (1) Permission: invite the topic, listen non-judgementally, confirm the concern is speakable and often normal. (2) Limited information: ask what they know; give brief, accurate information and resources. (3) Specific suggestions: tailored, problem-solving advice (e.g. lubricant vs moisturiser for dryness, position changes for joint pain, outlining options for early ejaculation). (4) Intensive therapy: refer to a sex therapist or sexual-medicine provider when causes are multifactorial or there is significant psychological comorbidity. (5) Ex-PLISSIT: keep offering permission at every level; review ("How have things been since we talked?") and reflect on your own comfort and assumptions [source: SIECCAN; Wikipedia PLISSIT, citing Davis & Taylor 2006].
Example language (illustrative): "Many people with this condition notice changes in their sex life. Is that something you'd like to talk about?"
Watch for: skipping straight to a leaflet without permission-giving (the problem Ex-PLISSIT was designed to fix).

4.5 Temporary ban on intercourse and orgasm-seeking

Purpose / when: Before sensate focus; removes performance demand [source: LoPiccolo & Stock 1986; Wikipedia; Duddle & Underwood 1976 — any attempt to produce orgasm or ejaculation barred].
Steps: (1) Explain the rationale (section 4.2). (2) Prescribe clearly: no intercourse, no attempts at orgasm with each other, and genitals and breasts off-limits until the therapist adds them. (3) Agree that the ban is lifted by the therapist step by step, not by the couple mid-exercise. (4) Clarify what remains allowed (affection, talking) [synthesis for (3)–(4)].
Example language (illustrative): "For now, intercourse is off the menu — not as a punishment, but so neither of you has to wonder whether tonight is the night."
Watch for: relief (common) or covert breaking of the ban (see 5); some therapists adapt by not proscribing intercourse (Lipsius 1987) [uncertain].

4.6 Sensate Focus 1, Step 1: non-genital touching

Purpose / when: First touching assignment; trains sensory attention and lowers anxiety [source: SMSNA; Wikipedia; AASECT 2014].
Steps (as given to the couple): (1) Choose a private time when both are rested; be clean, unclothed or in loose clothing, in a comfortable warm room. (2) One partner is toucher, the other receiver; swap halfway (SMSNA suggests about 15 minutes each and swapping before boredom or fatigue). (3) The receiver lies down; the toucher touches anywhere except breasts and genitals, varying pressure and rhythm, fingertips and whole hand. (4) The toucher focuses on what they feel — temperature, texture of skin and hair, pressure — touching for their own interest, not to please the partner [source: AASECT 2014]. (5) The receiver attends to sensation, does not direct, and speaks up only if something is uncomfortable. (6) When the mind wanders or starts evaluating, return attention to the point of contact [synthesis consistent with mindfulness framing]. (7) Repeat on several occasions over days before advancing [source: SMSNA]. (8) Afterwards, each makes brief notes on what they noticed [synthesis].
Example language (illustrative): "When you're touching, be curious: is this spot warm or cool, smooth or rough? You're not trying to make your partner feel anything." / "If you notice you're judging how it's going, that's normal. Just bring your attention back to your fingertips."
Watch for: reports of "giving a massage" or trying to arouse (re-explain touching for self); avoidance of scheduled sessions; working: clients describe specific sensations and report less anxiety.

4.7 Sensate Focus 1, Step 2: genital and breast touching; hand-riding

Purpose / when: After Step 1 is comfortable; includes genitals without demand [source: SMSNA; Wikipedia].
Steps: (1) Same structure; breasts and genitals now included but given no more and no less time than other areas. (2) Introduce hand-riding: the receiver places a hand over the toucher's hand to show pace and pressure non-verbally [source: SMSNA; Wikipedia]. (3) A suggested position is the receiver sitting between the toucher's legs [source: SMSNA]. (4) Arousal may come and go; neither pursues it. Intercourse remains off-limits. Some versions add breasts before genitals as a separate stage [source: Wikipedia].
Example language (illustrative): "Touch the genitals the way you touch an arm — for what it feels like, not to get a reaction."
Watch for: concentrating on genitals, renewed spectatoring ("Is he getting hard?"), or freezing; step back to Step 1 if anxiety spikes [synthesis].

4.8 Sensate Focus 1, Step 3: adding lotion or lubricant

Purpose / when: Adds a new sensory dimension and changes texture [source: SMSNA].
Steps: Use lotion or oil on the body and lubricant on genitals; warm it first in the hand or by standing the container in warm water. Check for latex compatibility and skin sensitivity [synthesis].
Example language (illustrative): "Notice how the same touch feels different once there's lotion."
Watch for: aversion to wetness or mess (explore; may link to body image or disgust).

4.9 Sensate Focus 1, Step 4: mutual touching

Purpose / when: Both touch simultaneously; brings the exercise closer to natural sexual contact while still without arousal goals [source: SMSNA].
Steps: Partners touch each other at once, keeping focus on own sensations; SMSNA says lips and tongue may be used but kissing and oral sex are avoided at this stage.
Example language (illustrative): "Now you're both touching at the same time. The trick is to keep your attention on what you feel, even while being touched."
Watch for: one partner taking over or reverting to a habitual sexual routine.

4.10 Sensate Focus 1, Step 5: genital contact and sensual intercourse (containment)

Purpose / when: Final graded step; returns to intercourse with the same sensory focus [source: SMSNA; Wikipedia — genital touching and then intercourse gradually reintroduced].
Steps: (1) Genital-to-genital contact without insertion [uncertain — a separate non-insertive genital-contact step is not described in the sources; the SMSNA page goes straight from mutual touching to sensual intercourse]. (2) Slow insertion (fingers or penis) and withdrawal several times before any thrusting; attention stays on sensation, not orgasm; varying breathing is suggested [source: SMSNA]. (3) The partner with the penetration-related concern usually controls insertion (often from a female-superior position; see 4.15) [source: Duddle & Underwood 1976; McConaghy 2005].
Example language (illustrative): "This is still a sensate focus exercise. If it stops feeling like sensation and starts feeling like a test, slow down or go back a step."
Watch for: rushing to orgasm; anxiety returning at penetration (go back a step).

4.11 Sensate Focus 2: sharing preferences and enhancing intimacy

Purpose / when: Once the presenting dysfunction is managed; partners now share what touch they find pleasurable [source: AASECT 2014 — later stages; Avery-Clark et al. 2019 abstract — Sensate Focus 2 for optimising intimacy].
Steps (procedural detail not drawn on; outline only): (1) Touching sessions in which the receiver now communicates preferences, verbally or by hand-riding. (2) Partners practise explicit statements about likes and dislikes [source: AASECT 2014 (Maurice)]. (3) Gradually integrate into the couple's ordinary sex life [synthesis]. The detailed Sensate Focus 2 instructions are in Weiner & Avery-Clark 2017 [uncertain].
Example language (illustrative): "This week the receiver's job changes: let your partner know, with words or your hand, what you'd like more of."
Watch for: the receiver feeling they must please the toucher with feedback.

4.12 Debriefing the homework (in-session processing)

Purpose / when: Every session; where learning is consolidated and the next step set [source: Duddle & Underwood 1976 — couples report in detail how they acted and felt, then get specific instructions for the next week; Wylie 2021 — therapist as catalyst to communication].
Steps: (1) Ask each partner in turn for a concrete account: when, how long, who initiated, what they noticed, thoughts and feelings. (2) Distinguish sensations from evaluations. (3) Identify departures from instructions without blame. (4) Decide: repeat, step back, or advance. (5) Give the next assignment in writing [synthesis for (2), (3), (5)].
Example language (illustrative): "Before you tell me whether it 'went well', tell me one thing you physically noticed."
Watch for: vague reports ("It was fine") signal avoidance or the exercise not being done.

4.13 Stop-start (pause) technique for early ejaculation

Purpose / when: Early (premature) ejaculation; trains awareness of arousal level and control. Based on Semans (1956), adopted by Masters and Johnson [source: LoPiccolo & Stock 1986; Duddle & Underwood 1976].
Steps: (1) Begin once non-demand touching is established. (2) Partner stimulates the penis manually (or the man stimulates himself if solo). (3) The man attends to his arousal and signals when ejaculation is approaching but not yet inevitable. (4) Stimulation stops until the urgency passes. (5) Resume; repeat the cycle two or three times before ejaculation is allowed [source: Duddle & Underwood 1976]. (6) Progress from dry hand to lubricated hand, then to containment without movement and then with movement (4.15) [synthesis for the lubrication step].
Example language (illustrative): "Your job is to notice your arousal like a dial from 1 to 10 and call 'stop' at about 7 — before the point of no return."
Watch for: stopping too late (ejaculation occurs: treat as information, not failure); the partner feeling like a technician (attend to their experience in the debrief). Working: longer intervals before signalling, more confidence. LoPiccolo & Stock note high short-term success but limited long-term follow-up; McConaghy notes high relapse and that effects may be partly non-specific [source].

4.14 Squeeze technique

Purpose / when: Modification of stop-start for early ejaculation; usually combined with the pause [source: McConaghy 2005; LoPiccolo & Stock 1986].
Steps: (1) Partner sits facing the man, between his legs, and stimulates him manually. (2) He signals when close to ejaculation. (3) Partner stops and squeezes firmly but not painfully near the head of the penis, thumb on the underside and two fingers on the upper side just above and below the ridge; a diagram helps teach this. The squeeze inhibits the urge and often reduces the erection. (4) Resume stimulation; repeat. (5) When he can keep an erection for several minutes without nearing ejaculation, move to intercourse in the female-superior position (4.15); if close, the partner lifts off and squeezes, or stays still while he squeezes the base of the penis. (6) Solo version: men without partners can apply stop-start or squeeze during self-stimulation [source: McConaghy 2005; Duddle & Underwood 1976].
Example language (illustrative): "Firm, not painful — if it hurts, ease off. It should take the edge off the urge within a few seconds."
Watch for: pain, embarrassment of the partner at handling the penis, or the partner feeling responsible for his control.

4.15 Female-superior containment without movement ("non-demand" intercourse)

Purpose / when: Transition back to intercourse for early ejaculation, erectile anxiety and penetration difficulties; puts the partner who has the concern, or the woman, in control [source: McConaghy 2005; Duddle & Underwood 1976].
Steps: (1) He lies on his back and does not thrust. (2) She kneels astride, guides the penis in, and stays still at first, attending to sensation. (3) Movement is introduced gradually, first by her, then by him. (4) Stop and lift off (or squeeze) if ejaculation approaches. (5) If this position is unsuitable (e.g. joint pain, weight, preference), use side-by-side positions [source: Duddle & Underwood 1976]. Duddle and Underwood also gave no direct instruction to attempt intercourse, leaving it to emerge from the sequence.
Example language (illustrative): "This isn't sex yet; it's another way of noticing sensation. Stay still and just feel."
Watch for: reverting to the habitual position and pace; anxiety at the moment of insertion.

4.16 Erectile difficulties: allowing erections to come and go

Purpose / when: Psychogenic or mixed erectile difficulty; disconfirms the fear that a lost erection cannot return [source: Duddle & Underwood 1976; Wikipedia — refocus from the penis to the whole body].
Steps: (1) Continue sensate focus with genitals included and the intercourse ban in place. (2) Partner stimulates him to erection, then stops and lets the erection subside fully. (3) Resume and let it return; repeat. (4) Only later, insertion from the female-superior position without thrusting (4.15) [source: Duddle & Underwood 1976]. Names such as "teasing" or "waxing and waning" are used for this in the literature but are not confirmed in the sources [uncertain].
Example language (illustrative): "This week, losing the erection is part of the exercise. Let it go, and notice that it can come back."
Watch for: spectatoring ("Is it working?"); medical contributors — a mild organic impairment may still allow erections once anxiety and behaviour are addressed [source: LoPiccolo & Stock 1986]. Coordinate with the prescriber if medication is used (no dosing here).

4.17 Directed masturbation (LoPiccolo & Lobitz, 1972)

Purpose / when: Lifelong (primary) orgasm difficulty in women; also adapted for secondary orgasm difficulty and for delayed ejaculation [source: LoPiccolo & Stock 1986].
Steps (nine-step programme, outlined in own words): (1) Education. (2) Visual self-exploration of the body and genitals (e.g. with a mirror). (3) Tactile self-exploration. (4) Locating pleasurable areas. (5) Focused self-stimulation of those areas, building duration. (6) Adding sexual fantasy and, if needed, a vibrator; using "orgasm triggers" (behaviours that can tip high arousal into orgasm). (7) Self-stimulation with the partner present (sensate focus alone, then with the partner). (8) Showing the partner effective techniques; partner stimulation. (9) Partner stimulation during intercourse if the couple wishes; coital orgasm is not a required goal [source: LoPiccolo & Stock 1986; step boundaries paraphrased and partly inferred — uncertain]. A self-help version (book Becoming Orgasmic) with limited therapist contact did as well as therapist-delivered treatment in one study [source: LoPiccolo & Stock 1986].
Example language (illustrative): "This week is just getting to know your own body, with no goal of arousal. Look, touch, and notice."
Watch for: shame, religious or cultural objections to self-touch (explore and respect; adapt or stop); narrow stimulation habits in secondary orgasm difficulty, which may need unlearning [source: LoPiccolo & Stock 1986].

4.18 Role-play of exaggerated orgasm (and vibrator use)

Purpose / when: Inhibition of letting go at high arousal; described for women in the orgasm programme and borrowed for delayed (inhibited) ejaculation [source: LoPiccolo & Stock 1986].
Steps: (1) Alone first, the client deliberately acts out an exaggerated, theatrical orgasm (sounds, movement) to reduce fear of loss of control or looking foolish. (2) Later, during high arousal, the same behaviours are used as triggers. (3) For delayed ejaculation, combine with stronger physical stimulation (e.g. a vibrator) and performance-anxiety reduction [source: LoPiccolo & Stock 1986; step detail synthesis].
Example language (illustrative): "It may feel silly — that's the point. You're practising letting go."
Watch for: embarrassment preventing practice; respect refusal.

4.19 Graded insertion for vaginismus / penetration difficulty

Purpose / when: Involuntary pelvic floor tightening that prevents or pains penetration, after medical assessment for pain conditions [source: LoPiccolo & Stock 1986; Duddle & Underwood 1976].
Steps: (1) Assess for dyspareunia and pain causes first; address trauma history and couple issues before starting [source: LoPiccolo & Stock 1986]. (2) Teach relaxation. (3) The woman inserts graded dilators herself, smallest first, staying with each size until it is comfortable, then advances; tampons during menstruation can be a step [source: Duddle & Underwood 1976]. (4) Then her own finger, then the partner's finger under her guidance [synthesis on order]. (5) Then penile insertion from the female-superior position with her in control, using the penis as a dilator [source: Duddle & Underwood 1976]. (6) Never rush sizes or allow forced insertion by anyone; forced insertion worsens the condition [source: LoPiccolo & Stock 1986].
Example language (illustrative): "You're in charge of every step. If your body says no, that's information, and we wait."
Watch for: panic, dissociation or trauma memories (stop, ground, re-plan); partner pressure. Working: comfortable insertion at a given size on several occasions.

4.20 Adjunct components

Purpose / when: Added to the core package as indicated [source: LoPiccolo & Stock 1986].
Components: couple communication training; systematic desensitisation for anxiety about specific sexual situations; body-image work; sexual technique training; assertion training; modelling and behavioural rehearsal; group formats for suitable clients (one group held a separate meeting with all male partners to address their anxieties) [source: LoPiccolo & Stock 1986]. Procedural detail for each is not given in the sources; deliver them using standard CBT methods [synthesis].
Watch for: relationship distress severe enough that couple therapy should come first [synthesis].

4.21 Adaptations for specific populations

The Weiner & Avery-Clark manual describes modifications for LGBTQ clients, older adults, disabled people, trauma survivors, and people with autism, anxiety or depression, and suggestions for avoidance, confusion and goal-directed attitudes [source: Taylor & Francis book page]. Detail not drawn on here [uncertain].
Practical adaptations [synthesis]: use the client's own words for bodies and acts; for same-sex couples drop heterosexual intercourse as the endpoint and let the couple define the final step; for single clients use solo sensate focus and self-touch versions of the exercises; for disability, adapt positions and supports and coordinate with the medical team; for trauma survivors, give the receiver an explicit stop signal, keep clothing options open and move more slowly.

5. Handling problems

The Weiner & Avery-Clark manual addresses avoidance, confusion and goal-directed attitudes [source: Taylor & Francis book page], but its specific responses are not drawn on here. Unless a source is tagged, the guidance below is [synthesis].

Exercises not done (avoidance, "no time"). The outpatient format depends on the couple making time [source: AASECT 2014]. Response: schedule specific slots in session, shorten sessions (e.g. 10 minutes each), explore what the avoidance protects (fear of failure, resentment, disgust, trauma), and step back to an easier step rather than pushing on. Treat repeated avoidance as data about the formulation.
Ban broken (couple has intercourse or pursues orgasm). Explore without scolding: who initiated, what happened, how each felt. Often it reflects one partner's anxiety that the ban means abandonment of sex, or the other's sense of duty. Restate the rationale and keep the ban; some clinicians instead allow intercourse alongside sensate focus [uncertain — Lipsius 1987].
Goal-directed touching ("I was trying to turn her on"). Re-explain touching for one's own sensory interest; ask the toucher to describe three sensations next time [source for the principle: AASECT 2014].
Distraction, spectatoring, intrusive evaluative thoughts. Normalise; coach repeated return of attention to the point of contact; consider brief mindfulness practice between sessions [source: mindfulness framing in T&F book page and Avery-Clark et al. 2019 abstract; the coaching is synthesis].
Overwhelm, panic, dissociation or trauma memories during exercises. Agree a stop signal before any exercise; the receiver may stop at any time; return to an earlier step, partial clothing or shorter time; add grounding skills; if trauma symptoms dominate, treat trauma first and resume later. For penetration difficulties, assess and address trauma before graded insertion [source: LoPiccolo & Stock 1986].
Boredom or loss of interest in the exercises. Swap roles before fatigue sets in [source: SMSNA]; vary setting, time of day, textures (lotion step).
One partner complying under pressure / coercion / intimate partner violence. Screen individually. Conjoint touching homework is contraindicated where there is coercion, violence or fear; do individual safety work first. Every touch exercise requires both partners' ongoing, freely given consent.
Partner resistance as the symptomatic partner improves. LoPiccolo & Stock describe partners resisting when women in group treatment became more assertive, managed by a meeting for the male partners [source]. Response: anticipate this; give the partner a role and voice; explore the meaning of change for the relationship.
Severe relationship distress, affairs, contempt. Sexual work rarely progresses; move to couple therapy first and return to sex therapy later [synthesis; LoPiccolo & Stock 1986 note group formats suit clients without major relationship distress].
Organic factors and medication. Keep the physician involved; a mild organic impairment may still respond once anxiety and behaviour are addressed [source: LoPiccolo & Stock 1986]. Do not give medication advice beyond referral.
Lapses after progress (e.g. one failed erection). Predict lapses in advance; frame as normal variability; return briefly to an earlier step for a week.
Desire discrepancy or low desire. Standard sex therapy often fails to raise desire, and low desire may be secondary to another dysfunction [source: LoPiccolo & Stock 1986]. Response: treat the primary dysfunction, address relational and individual factors, and consider more comprehensive cognitive-behavioural work; refer on (PLISSIT intensive level) if outside competence.
Single clients or a partner who will not attend. Use solo versions (self-touch sensate focus, stop-start alone, directed masturbation) [source: McConaghy 2005 for solo stop-start/squeeze; LoPiccolo & Stock 1986 for directed masturbation].
Cultural or religious objections to self-touch, nudity or specific acts. Ask what is acceptable; adapt (clothing, excluding masturbation-based steps) rather than persuade; consider consultation with someone the client trusts.
Ruptures with the therapist (shame, feeling judged, embarrassment). Name the awkwardness, apologise for missteps, slow down, re-establish permission (Ex-PLISSIT ongoing permission and review) [source: SIECCAN for the review step]. Use supervision for your own discomfort [source: SIECCAN].
Boundaries. The therapist never touches, examines, observes or demonstrates sexual activity with clients; physical examination is done by a physician in a medical context. Sexological bodywork and any practitioner sexual touch are outside this method and outside psychotherapy ethics; do not refer on that basis.
Sexual orientation. Do not use sex therapy to change sexual orientation. Wylie (2021) notes that Masters and Johnson's later programme for gay and lesbian clients included conversion attempts, a practice now universally condemned [source: Wylie 2021]. Work affirmatively with LGBTQ clients and adapt the endpoint (see 4.21).
Suicidal ideation or severe depression emerging. Pause the sexual work, assess risk using standard practice, and treat or refer for the mood disorder first.

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Further reading (not drawn on): Weiner, Cannon & Avery-Clark (2014) "Reclaiming the lost art of Sensate Focus", Family Therapy Magazine (ISRTT PDF); Springer Medicine full text of the 2019 review.