This week, you will create a PowerPoint presentation that highlights some of the basics of sex therapy. Be sure to gear this presentation toward MFT internship students that are thinking about increasing their skills and understanding of sex therapy.
Be sure to address the following key points in your PowerPoint:
Describe sex therapy.
Define at least four sex therapy models or approaches and describe how these can be applied when working with relationships.
Discuss how one MFT model could address sex therapy.
Contemporary Family Therapy (2019) 41:368–383
https://doi.org/10.1007/s10591-019-09504-x
ORIGINAL PAPER
A Hold Me Tight Workshop for Couple Attachment and Sexual Intimacy
Brianna L. Morgis1
Ruth Jampol2
· E. Stephanie Krauthamer Ewing1 · Ting Liu2 · Jaime Slaughter‑Acey3 · Kathleen Fisher1 ·
Published online: 8 August 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
There is an abundance of research demonstrating significant relationships between romantic attachment and sexual intimacy,
which in this study refers to sexual communication and sexual satisfaction. However, not many interventions specifically and
simultaneously target these two important aspects of romantic relationships. Furthermore, there are a lack of affordable and
accessible psychoeducational interventions that provide opportunities for couples to gain basic knowledge about romantic
attachment and sexual intimacy. To fill this gap, the authors of the current study took a 10-week, eight-session attachmentfocused intervention (The Hold Me Tight Program: Seven Conversations for Connection), adapted it into a 1-day workshop,
and focused on the role that attachment plays in sexual intimacy. Pilot data was collected to examine treatment feasibility,
acceptability, and knowledge acquisition. In addition, exploratory efficacy data was analyzed with respect to changes in
couple attachment patterns, sexual communication and satisfaction, and overall relationship satisfaction. Quantitative results
revealed that participating couples showed increases in perceived knowledge acquisition and actual knowledge acquisition
about concepts related to attachment and sexual intimacy. Qualitative and quantitative pilot data suggested movement in the
expected direction for improvements in couples’ romantic attachment patterns, sexual satisfaction, sexual communication,
and relationship satisfaction with a trend towards a statistically significant increase in sexual satisfaction.
Keywords Couples therapy · EFT · Romantic attachment · Hold me tight
Introduction
* Brianna L. Morgis
Blb5242@gmail.com
E. Stephanie Krauthamer Ewing
Ek469@drexel.edu
Ting Liu
Tingliu.lmft@gmail.com
Jaime Slaughter‑Acey
jslaught@umn.edu
Kathleen Fisher
Kmf43@drexel.edu
Ruth Jampol
Ruth.jampol@gmail.com
1
Drexel University, Philadelphia, USA
2
Philadelphia Center for Emotionally Focused Therapy,
Lafayette Hill, USA
3
University of Minnesota, Minneapolis, USA
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Vol:.(1234567890)
Romantic relationship satisfaction and stability are important to healthy adult functioning, but many factors can make
achieving and maintaining relationship satisfaction difficult.
Research has shown that couples report sexual satisfaction as
an indicator of relationship satisfaction, and that when they
are unhappy with their sex lives, they are unhappy in their
relationships (Soleimani et al. 2015; Štulhofer et al. 2010).
In fact, McCarthy (2003) found that unhappy couples attribute 50–70% of their relationship distress to sexual issues.
For many couples, it proves challenging to talk about sexual intimacy. Instead of openly communicating about sexual
likes, dislikes or needs, many couples rely upon stereotypes
to guide their awareness of their partners’ sexual preferences
(Byers 2011). According to MacNeil and Byers (2009), only
26% of couples have clear understanding of their partners’
concerns regarding their sexual relationships. This is problematic because effective sexual communication is a significant predictor of sexual wellbeing (Byers 2011; Khoury and
Findlay 2014). Despite the importance of sexual satisfaction
Contemporary Family Therapy (2019) 41:368–383
in romantic relationships, partners often struggle to openly
address their sexual issues with one another because of the
vulnerability, trust, emotional closeness and effective communication it requires. However, when partners are able to
develop a strong and secure romantic attachment bond with
one another, built on mutual vulnerability, emotional safety
and security they are better able to communicate their sexual
concerns and needs (Johnson and Zuccarini 2010). In turn,
they tend to have a better chance at a more satisfying sex life
and relationship as a whole.
Romantic Attachment and Sexual Intimacy
Romantic attachment style has been linked to sexual intimacy, such that attachment styles influence how people
make sense of their intimate relationships (Johnson and
Zuccarini 2010; Khoury and Findlay 2014). In the scope
of this article, sexual intimacy refers specifically to both
sexual communication and sexual satisfaction. Modern
adult romantic attachment theory, heavily influenced by
John Bowlby’s theory of parent–child attachment, has been
identified as the most promising theory of adult love with
substantial empirical support (Hazan and Shaver 1987).
According to attachment theory, all human beings form
internal working models based on their early experiences
with their primary caregivers, which inform one’s self-worth
and expectations for love, care and protection in close relationships (Bowlby 1973; Verschueren et al. 1996). It is these
early experiences that influence beliefs about the availability
and responsiveness of significant others, including romantic partners, in times of distress or need (Burgess Moser
et al. 2015). Later work by Bowlby and one of his students
and colleagues, Mary Ainsworth, identified three major patterns of early childhood attachment: (1) secure, (2) insecureanxious/ambivalent, and (3) insecure-avoidant (Ainsworth
et al. 1978). While secure attachment patterns were marked
by infant expectations for caregivers to be responsive and
meet their needs, anxious/ambivalent and avoidant patterns
were not. Anxious/ambivalent infants tend to have expectations that they will receive inconsistent support from their
caregivers and will often display hyperactive expressions
of distress. Avoidant infants may be faced with caregiver
rejection, which often leads to the suppressing of emotion in
interactions with caregivers (Ainsworth et al. 1978; Burgess
Moser et al. 2015). This categorization of attachment style
was then expanded to include insecure-disorganized/disoriented attachment, which manifests as fearful, conflicted,
or disoriented behavior by infants towards their caregivers
(Main and Solomon 1986). Though there may be many reasons for infants to display disorganized/disoriented behaviors, it is often noted that these infants experience their caregivers as a source of alarm of threat.
369
In later work, Bowlby theorized that early infant-caregiver attachment patterns may impact interactions later
in development with romantic partners (Bowlby 1988). He
hypothesized that early experiences and expectations for
being cared for play a significant role in organizing positive
internal working models of self-worth and love, expectations
for care, comfort and security in close romantic relationships
later in life. Secure internal working models are thought to
help manage relationship tension and uncertainty, maintain
accurate perceptions of desired closeness, and balance closeness with independence in romantic relationships. A number of empirical studies have provided evidence for these
hypotheses (Burgess Moser et al. 2015; Greenman and Johnson 2013; Halchuk et al. 2010; Mikulincer and Shaver 2010;
Tilden and Dattilio 2005). For example, Zayas et al. (2011)
found a significant association between retrospective recollections of early insecure caregiver attachment and reports
of insecure attachment bonds with adult romantic partners.
Stemming from this body of work, Hazan and Shaver
(1987) proposed an attachment-based theory of romantic
love. They applied Ainsworth’s original three-category
attachment classification system to a study on romantic
love, and they proposed that adult lovers form attachment
bonds in similar ways that young children and caregivers
do (Hazan and Shaver 1987). Hazan and Shaver qualified
the analogy by noting that while the romantic attachment
and early attachment processes and patterns may share some
similarities, adult relationships are certainly more reciprocal
and balanced in nature compared to parent–child relationships. What they suggested, however, was that the ranges in
romantic love patterns can be theorized and conceptualized
in a similar way to the patterns developed by Ainsworth
and colleagues, in terms of secure vs. insecure expectations
for care, comfort and safety in the relationship (1978). In
sum, when a couple’s emotional attachment bond is healthy
and each partner feels safe and emotionally connected to the
other, their relationship fosters a sense of security. When
the attachment bond is weak, withdrawal, anger, anxiety,
and jealousy are commonly evoked when the relationship is
threatened (Bowlby 1988; Johnson 2004; Wood et al. 2012).
Recent studies have also explored the connection between
romantic attachment and sexual intimacy. For example, studies have found that partners with weak or insecure attachment bonds often struggle to effectively communicate and
express their needs for emotional and sexual closeness (Banmen and Vogel 1985; Susan Johnson and Zuccarini 2010;
Soleimani et al. 2015; Theiss 2011). This leads to greater
disconnection and dissatisfaction in the relationship and
ultimately further bolsters the patterns of insecure attachment in the dyad (Susan Johnson and Zuccarini 2010). On
the other hand, secure attachment between partners often
fosters successful communication regarding sexual matters.
This pattern of communication can help partners better
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370
understand one another’s likes and dislikes, resulting in the
couple engaging “in a sexual script that includes more pleasing and fewer displeasing activities” (Byers 2011, p. 22).
Butzer and Campbell (2008) support this association
between better attachment and improved sexual satisfaction and communication. In their study of 116 married
couples, they used the Experiences in Close Relationships
Questionnaire-Revised (Fraley and Shaver 2000) to measure attachment avoidance and anxiety, the ENRICH Sexual
Relationship Subscale (Fournier et al. 1983) to measure sexual satisfaction related particularly to communication and
behavior, the Relationship Assessment Scale (Hendrick et al.
1998) and the Index of Sexual Satisfaction (Hudson et al.
1981) also to measure sexual satisfaction. They explored
how attachment is linked to sexual satisfaction and how
people in long term relationships view their sexual relationships as a whole. As predicted, based on attachment theory,
partners with more insecure attachment bonds (manifested
as either anxiety or avoidance) reported lower sexual satisfaction. Furthermore, participants with avoidant partners
reported that they were often less satisfied with their sexual
relationship. “Partner effects suggest that having a spouse
who is emotionally distant and uncomfortable with expressions of closeness relates to lower feelings of satisfaction
with one’s sexual relationship” (Butzer and Campbell 2008,
p. 150). Another similar study with a larger sample size
(N = 1989), showed significant associations between insecure attachment and poorer sexual satisfaction, with attachment avoidance relating most strongly to poor physical sexual satisfaction, and anxiety showing a stronger relationship
to poor emotional sexual satisfaction (Davis et al. 2006).
Couples Therapy and Evidence Based Models
For couples experiencing distress and relationship deterioration, couples therapy can help. In fact, systematic reviews
of couples therapy suggest that 70% of couples benefit, at
least somewhat, from participating in therapy (Carr 2014;
Lebow et al. 2012; Shadish and Baldwin 2003). Emotionally Focused Couples Therapy (EFT), a model developed by
Susan Johnson and Leslie Greenberg in the 1980’s, focuses
heavily on couple attachment patterns and the quality of the
couple’s emotional bond. EFT draws from both humanistic
and systems approaches, in particular attachment theory.
Specifically, EFT aims to improve relationship functioning
through the creation of secure attachment patterns between
partners, where “couples are encouraged to explore hereand-now emotional experiencing, uncovering primary
emotions that are often blocked from awareness by reactive surface emotions and responses, and share these with
their partner in session” (Wiebe and Johnson 2016, p. 1).
EFT has been described as the most empirically supported
treatment for couple relationship discord with high success
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Contemporary Family Therapy (2019) 41:368–383
rates (Dalgleish et al. 2015; Fitzgerald and Thomas 2012;
Greenman and Johnson 2013; Halchuk et al. 2010; Johnson
2004; Johnson and Greenberg 1985a, b). Many recent studies have highlighted the success of EFT and its ability to
target couples’ romantic attachment and even sexual satisfaction. For example, Burgess Moser et al. (2015) found that
couples that participated in EFT experienced a significant
increase in secure relationship-specific attachment behavior
and decreases in both avoidance and anxiety. Interestingly,
they found that some partners experienced decreases in their
tendency to use blaming tactics during conflict (referred to
as blamer-softening), a key change event in which the more
critical partner softens and becomes vulnerable towards the
more withdrawn partner (Bradley and Furrow 2004). For
these partners, there was a significant decrease in attachment
anxiety. Regarding sexual satisfaction, a recent study conducted with couples facing infertility found that both marital adjustment and sexual satisfaction improved for couples
who received EFT compared to those in a control group
(Soleimani et al. 2015).
The Role of Psychoeducation in Helping Couples
While EFT studies have provided a wealth of evidence to
support the efficacy of the model, many couples do not
seek treatment until their distress has become clinically significant, making it more difficult to treat (Cummings et al.
2008). Treatment length and intensity may be a potential
barrier for some couples, and brief-psychoeducational programs may be an important prevention and treatment option.
Brief psychoeducation programs are promising interventions for helping to improve marital conflict with couples
experiencing mild distress (Cummings et al. 2008; Cohen
et al. 2014.) In contrast to intensive traditional therapy models, psychoeducation programs often take place in more costeffective group settings, are less intensive in nature, are less
time consuming, and do not include as much one-on-one
time between partners or with the therapist on specific personal issues (Hawkins et al. 2008). Some couples may be
more willing to seek relationship help in this format (Cummings et al. 2008; Hawkins et al. 2008).
The Hold Me Tight Program: Seven Conversations for
Connection (Johnson 2010) was developed, along with a
self-help book for couples by the same name, as an effort
to utilize the principles of EFT in an eight-session psychoeducational group for couples. The group-based psychoeducation program is designed to supplement the book
through didactic presentations, group discussions between
couples, video clips, in-session activities, and homework
assignments (Fisher et al. 2014; Johnson 2010). Two studies have provided preliminary data indicating that both
the self-help book and adaptations of the psychoeducation program may provide benefits for couples, in terms
Contemporary Family Therapy (2019) 41:368–383
371
of improved relationship satisfaction and reduced distress.
Furthermore, positive participant feedback and high retention rates suggest good treatment acceptability and feasibility (Fisher et al. 2014; Lynch 2015).
The potential value of different levels of treatment
(e.g. therapy, psychoeducation groups, self-help books) in
achieving strong romantic attachment and sexual satisfaction can be thought of as a sequential process. A theoretical model, created by the study investigators, frames the
process as a series of three levels (Fig. 1).
Level One describes the beginning or foundational
stage in which couples may be provided general psychoeducation, often in a group format, around the correlation
between attachment and sexual intimacy (specifically communication and satisfaction). It is in this stage that they
can begin discussions that help lead them to identify areas
specific to their own emotional and sexual relationship that
may need improvement. This level is less time-consuming,
less financially straining, and tends to be less threatening in nature as it does not necessarily require couples to
discuss their issues on a deeper level as does longer-term
therapy.
Once couples have gained the necessary knowledge and
understanding of their own attachment-based issues affecting
their sexual relationship, they then can proceed to the second
level and begin to address these issues as well as develop
and practice new skills for working through their problems.
While some couples may seek out more intensive treatment
at this stage (i.e. longer-term couples therapy), other couples
at this stage may look to self-help books or other relationship
education resources to continue to learn new relationship
skills. As they begin to learn new skills, they actively begin
applying changes within their relationship.
When couples feel confident and can integrate the knowledge and skills from the previous levels into their relationship and successfully solve conflicts independently outside
of therapy, they have reached Level Three, the highest level
of strengthening romantic attachment and sexual intimacy.
Thus, the gap the investigators seek to close is the lack of
opportunity for couples to address Level One—gaining
introductory knowledge, understanding, and recognition of
attachment-based and sexual concerns.
More work is needed to replicate and extend findings
regarding the value of psychoeducation for couples around
EFT related principles. In addition, while the 8-session Hold
Me Tight program may be more accessible for some couples,
the time commitment is still likely burdensome for many,
particularly those who are not experiencing clinical levels
of distress.
The Current Study
The aims of the current study were to: (1) condense and
adapt the original eight-session Hold Me Tight treatment
manual into a 1-day workshop integrating content specific
to both couple attachment and sexual intimacy; (2) pilot the
adapted protocol to assess treatment feasibility and acceptability, and improvements in participants knowledge of
EFT/HMT principles; and (3) explore pilot data for potential changes in participants reported romantic attachment,
sexual communication, and sexual intimacy.
Our hypotheses were as follows: (1) the adapted protocol would demonstrate adequate treatment feasibility and
fidelity with therapists while also showing adequate treatment acceptability with participating couples (Credibility
and Expectancy Questionnaire; Narrative feedback); (2)
Fig. 1 Theoretical model of
strengthening romantic attachment, sexual communication
and satisfaction
Level Three: Integrating
Knowledge and Skills
Level Two: Skill Building
Level One: Learning
Target Constructs: Acceptability,
Feasibility, Perceived
Knowledgeability & Knowledge
Acquisition
Goal 1: Gain knowledge,
understanding, and recognition of
how attachment and sexual
satisfaction are connected and the
role they play in romantic
relationships
Target Constructs: Romantic
Attachment, Sexual Communication,
Sexual Satisfaction, & Relationship
Satisfaction
Goal: Address the specific issues or
concerns in the couple’s relationship
and learn skills to improve them (e.g.
self-help book, more
psychoeducation, therapy)
Target Constructs: Romantic
Attachment, Sexual Communication,
Sexual Satisfaction, & Relationship
Satisfaction
Goal: Couples can integrate the
knowledge and skills gained from
Levels One and Two into
relationship and have the ability to
solve issues on their own
Goal 2: Begin discussion about
specific issues that need addressing
13
372
participating couples would show improvement in perceived
knowledgeability of program principles (Learning Measure
1), and actual learned knowledge (Learning Measure 2); and
(3) participating couples would show improvement in couple attachment (BARE), sexual satisfaction (PROMIS 2.0),
sexual communication (DCS), and relationship satisfaction
(R-DAS).
Method
Research Design
This mixed-methods pilot study aimed at testing the feasibility and acceptability of the Hold Me Tight (HMT) protocol, which was adapted to include specific components
of romantic couple attachment and sexual intimacy. Phase
one of the study included modification of the manual with
a panel of five experts in Emotionally Focused Couples
Therapy (EFT). In phase two of the study, we pilot tested
the adapted manual with 15 couples participating in a 1-day
workshop led by three trained group facilitators. We utilized
a one-group pre-test post-test design. The fifteen couples
were divided into two one-day workshops that were identical
in content. The first one-day workshop included eleven couples. The second one-day workshop included the remaining
four couples. Based on a power analysis, our study required
a minimum of 10 couples. Upon recruiting our couples, we
offered two different group dates to meet the needs of interested and eligible couples. The groups were split up based
on couples’ availability.
Participants
Fifteen couples from the northeast region of Pennsylvania
were recruited for this pilot study via fliers and brochures
distributed to local therapy clinics, primary care offices,
several local family therapy graduate programs, and universities. Interested couples contacted the study coordinator and were screened for eligibility. Couples met inclusion
criteria if they were: (1) partnered in a committed romantic
relationship for at least a year; (2) at least 18 years of age,
(3) at least one partner in the relationship reporting mild
to moderately weak couple attachment as measured on the
Brief Accessibility, Responsiveness, and Engagement Scale
(BARE) (Sandberg et al. 2012), and (4) able to understand
and speak English. Prior participation in a Hold Me Tight
couples workshop or having previously read the Hold Me
Tight book was the only exclusion criterion. Eligible participants were invited to participate in the one-day workshop
and completed informed consent.
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Contemporary Family Therapy (2019) 41:368–383
Procedure
Step I: Adaptation of the Manual
The primary investigator joined an expert panel of certified
EFT therapists and trainers to help with the adaptation of
the Hold Me Tight manual for this study. Along with their
clinical expertise, the team discussed and reviewed literature
connecting attachment, communication, and sexual satisfaction to determine which of the eight original HMT sessions
were selected to be included in the adapted manual. Consultation with these experts also determined the length of the
program (number of hours), which video clips and in-class
activities were used, and the number of therapists needed
to successfully facilitate the groups based on the number
of couples.
The team then reviewed the eight original sessions (or
“conversations”) of the Hold Me Tight psychoeducational
program and the activities that supplemented them, narrowed down the four that seemed to fit best with the aims
of the proposed adaptation, and finalized the order of these
conversations. These included: (1) Recognizing demon dialogues, (2) Finding the raw spots, (3) Hold me tight: Becoming open and responsive, and (4) Tender touch and synchrony sex: Bonding through sex and touch (Johnson 2010).
These four specific conversations highlight attachment, how
partners’ style of attachment impacts their romantic relationship, and how hindered attachment affects sexual intimacy.
The final structure of the workshop was as follows: (a)
introductions of couples and facilitators, (b) lesson on
attachment, (c) recognizing demon dialogues conversation
and brief connection to raw spots, (d) lunch break, (e) hold
me tight: becoming open and responsive conversation, (f)
tender touch and synchrony sex: bonding through sex and
touch conversation, and (g) wrap-up. Short 5 to 10-min
breaks were also implemented throughout the day.
Step 2: Training Therapists
Upon conclusion of manual adaptation, three therapists were
recruited and trained as group facilitators with the adapted
protocol. Selected therapists were diverse in race and age,
included two Masters level family therapists and one doctoral student in couple and family therapy. All selected therapists had previously completed introductory and advanced
EFT courses with a certified EFT trainer. The training consisted of a 3-h consultation meeting with a certified EFT
therapist and trainer along with the study investigator who
was also trained in EFT. During this training, the therapists
were given copies of the adapted manual, reviewed the main
lessons, and discussed which therapists would be leading
each conversation. They were then asked to practice their
Contemporary Family Therapy (2019) 41:368–383
facilitation, and a follow-up consultation with the investigator was held 1 week prior to the workshop.
Step 3: Piloting the Program
Eligible participants were invited to participate in the
adapted HMT workshop. All pre-test measures were electronically distributed to participants via Qualtrics 1 week
before the Hold Me Tight workshop. Similarly, post-test
measures and structured narrative questions were administered through Qualtrics 2 weeks after the workshop, and
follow-up measures were completed 6 weeks after the oneday workshop electronically through Qualtrics.
Measures
Demographics
All couples completed surveys for demographic data (e.g.
gender, age, race, ethnicity, SES, sexual orientation, length
of relationship, participation in other couples’ therapy).
Treatment Fidelity
373
qualitative data from the facilitators, the investigative team
used content analysis to develop overall patterns and themes
of the facilitators’ experiences (Elo and Kyngäs 2007; Vaismoradi et al. 2013).
Acceptability‑ Qualitative Data from Participants
To examine treatment acceptability, investigators provided
couples with workshop-specific structured questions to
collect qualitative data describing the couples’ experience
with the program. The investigator developed the questions
with the help of the EFT consultation team and an outside
researcher to ensure that the questions were targeting the
correct constructs and that they were specific to the Hold Me
Tight program. Example questions included: “What aspect
of your relationship has changed the most since attending
the HMT workshop?”, Describe how attending the workshop has changed your romantic attachment bond.”, and “Is
there anything you would change about the HMT workshop?
If so, please describe”. The investigators then again conducted content analysis to specify themes in the participant
feedback.
A fidelity checklist was created by the lead investigator
and the HMT consultation team which was inspired by the
original Emotion Focused Therapy-Therapist Fidelity Scale
(EFT-TFS), which was designed to measure therapists’
adherence to the EFT model (Denton et al. 2009). Since
the HMT intervention was only a 1-day psychoeducational
workshop, the scale that was created focused on whether the
therapists covered the material as intended. The investigator
and two research assistants completed the fidelity checklist
by videotaping the workshop and watching it live from the
research lab. This enabled them to observe the facilitation
of the workshop step-by-step and ensure that the therapists
followed the protocol correctly. All participants were aware
that the workshop was being videotaped and had completed
written consent prior to the start of the program.
Acceptability Credibility and Expectancy Questionnaire
(Borkovec and Nau 1972, α = .91)
Treatment Feasibility
The study’s investigative team worked together to develop
questions that measured participants’ perceived and actual
learned knowledge regarding Hold Me Tight concepts of
attachment and sexual satisfaction. Learning Measure One:
Perceived Knowledgeability is a five-question self-report
measure that gave participants the opportunity to rate how
knowledgeable they felt by selecting either “not at all”,
“somewhat”, “more than not”, or “very”. Scores range from
five to 20, with higher scores interpreted as higher perceived
knowledgeability. Learning Measure Two: Knowledge
Acquisition included 10 multiple choice test questions in
order to measure how much information participants learned
and remembered at each time-point. Total scores range from
Treatment feasibility was assessed through participant attrition rates as well as qualitative data collected from the facilitators of the Hold Me Tight groups in the form of answers
to structured questions, developed by the investigators and
consultation team. Examples of questions included: “Which
HMT lessons were easy and difficult for you to facilitate
and why?” and “Were there any aspects of the HMT workshop that you felt you were unprepared for?”. In addition, at
the completion of the workshops, the investigator debriefed
with the therapists to gather information regarding their
initial impressions of running the program. To analyze the
Treatment acceptability was also assessed by administering
the Credibility and Expectancy Questionnaire, which is the
most frequently used credibility and expectancy measure in
therapy research (Devilly and Borkovec 2000). According
to Devilly and Borkovec (2000), this questionnaire assesses
two factors—a treatment credibility factor and a treatment expectancy factor (cognitively based credibility and
relatively more affectively based expectancy). Total scores
range from four to 56, with higher scores meaning higher
acceptability.
Hold Me Tight Learning Measures (α = .74)
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374
zero to 10, with higher scores translating to higher knowledge acquisition.
Brief Accessibility, Responsiveness, and Engagement Scale
(BARE; Sandberg et al. 2012, α = .88)
In order to assess couples’ romantic attachment, participants
were given the Brief Accessibility, Responsiveness, and
Engagement Scale, a “short, systemic, self-report measure
of attachment behaviors in couple relationships” (Sandberg
et al. 2012, p. 512). This 12-item measure identifies behaviors that promote and maintain attachment at the dyadic level
rather than at the individual level. This allows researchers to
gather information regarding systemic experiences between
partners (Sandberg et al. 2012). For scoring purposes, total
scores on the measure are broken down into low, medium,
and high attachment quality benchmarks. The low-quality
benchmark total score is 37, medium benchmark is 45, and
high-quality benchmark is 52. The lowest possible score is
12, and the highest possible score is 60.
Patient Reported Outcomes Measurement Information
System (PROMIS 2.0; Weinfurt et al. 2015, α = .93)
Sexual satisfaction was measured using the satisfaction
subscale of the second version of the Patient Reported
Outcomes Measurement Information System (PROMIS
2.0) assessment. This scale includes five Likert-scale items
ranging from 0 to 5 (with 5 indicating high satisfaction).
Preliminary evidence for the PROMIS, specifically for the
satisfaction and function subscales, was reported by Weinfurt et al. (2015).
Dyadic Sexual Communication Scale (DCS; Catania 1998,
α = .90)
Couples’ sexual communication was assessed using the
Dyadic Sexual Communication Scale, a 13-item Likert-type
scale assessing participants’ perceptions of the communication process within their sexual relationships. Higher scores
indicate better dyadic sexual communication. Previous studies also show that this assessment was significantly able to
discriminate between participants who fell into the “sexual
problems” group and the “no sexual problems” group.
Revised Dyadic Adjustment Scale (R‑DAS; Busby et al. 1995,
α = .91)
Relationship satisfaction was measured through use of the
R-DAS, a 14-item self-report assessment that includes three
scales: (1) “consensus,” or level of agreement between partners in different areas of their relationship (e.g. affection,
sex, and decision-making); (2) relationship satisfaction; and
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Contemporary Family Therapy (2019) 41:368–383
(3) relationship cohesion, which includes questions regarding how often couples participate in activities together or
engage in communication. Scores on the R-DAS range from
0 to 69, with higher scores meaning higher relationship satisfaction. Busby et al. (1995) describes the following clinical
cut-off scores: > 45 indicate non-distressed, 32–45 indicate
moderate distress, and < 32 indicate severely distressed.
Target Constructs and the Theoretical Model of Building
Strong Romantic Attachment and Sexual Intimacy
Both learning constructs (perceived knowledgeability and
knowledge acquisition) target the first level of our theoretical process of change model because of their focus on
knowledge and understanding the concepts of the workshop.
In contrast, romantic attachment, sexual communication,
sexual satisfaction, and relationship satisfaction are more
appropriately aligned with levels two and three of the model
due to their complexity and need for the development and
practice of relationship skills between partners.
Results
Demographics
Participants included 15 heterosexual couples with a total
sample size of 30 participants. Sixty-three percent of participants were white (N = 19), 20% identified as Black or
African American (N = 6), 13% identified as Asian (N = 4),
and 3% identified themselves as “other” (N = 1). The majority of participants were married (N = 24), and 20% were not
married but identified as being in a committed romantic
relationship for at least 1 year (N = 6). Most of the sample
were employed at least part-time (N = 26). Seventy-three
percent reported having had received at least a Bachelor’s
degree (N = 22), and 67% reported a household income over
$80,000 per year (N = 20).
Descriptive Statistics
Table 1 presents means and standard deviations for all study
variables at pre-treatment, post-treatment and follow-up.
Hypothesis 1: Feasibility and Acceptability
To examine hypothesis one, that the adapted HMT protocol
would be implemented and demonstrate adequate treatment
feasibility and acceptability, the following domains were
examined: participant interest and attrition, treatment fidelity, and qualitative and quantitative data about feasibility and
acceptability from therapists and participants. Figure 2 presents a CONSORT table describing attrition of participants.
Contemporary Family Therapy (2019) 41:368–383
Table 1 Descriptive statistics of
all study variables
Variable
RDAS
BARE
PROMIS 2.0
DSCS
BDI-II
LM1
LM2
CEQ
375
Time 1
Time 2
Time 3
M
SD
M
SD
M
SD
42.0667
42.533
13.067
48.468
9.8067
8.367
6.10
–
10.576
7.956
6.017
11.079
7.845
2.566
1.729
–
43.4286
42.828
14.655
49.138
8.266
12.643
7.464
39.157
12.312
9.871
5.684
12.538
9.202
3.832
1.774
10.777
43.0714
43.00
13.25
48.143
8.462
12.286
7.321
–
13.095
11.467
7.059
12.328
10.146
3.999
2.278
–
Relationship satisfaction means and standard deviations on the R-DAS at pre-, post-, and follow-up, Couple Attachment means and standard deviations on the BARE at pre-, post-, and follow-up, Sexual Satisfaction means and standard deviations on the PROMIS 2.0 at pre-, post-, and follow-up, Sexual Communication means and standard deviations on the DSCS at pre-, post-, and follow-up, Depression means and
standard deviations on the BDI-II at pre-, post-, and follow-up, Perceived Knowledgeability means and
standard deviations on the Learning Measure 1 at pre-, post-, and follow-up, Actual Knowledge means and
standard deviations on the Learning Measure 2 at pre-, post-, and follow-up, Credibility & Expectancy
means and standard deviations on the CEQ at post-test
Fig. 2 CONSORT diagram of
recruitment
Enrollment
Assessed for eligibility (n= 28
couples)
Excluded (n= 13 couples)
Not meeting inclusion criteria (n=4
couples)
Declined to participate (n=9 couples)
Due to date unavailability, not
being able to find child care, or not
returning recruiter phone calls
Allocation
Follow-Up
Allocated to intervention (n= 15 couples)
Received allocated intervention (n=15
couples)
Lost to follow-up (n= 1 couple)
One couple declined communication
following the HMT workshop for unknown
reasons.
Analysis
Analyzed (n= 15)
Regarding fidelity, the researcher and two research assistants
completed the fidelity checklist for each therapist in each
group and found that all three therapists facilitated the workshop as intended with 100% fidelity ratings.
In terms of treatment feasibility, investigators collected
qualitative data from the three facilitators and conducted
content analysis to identify themes in their responses. The
data and themes were then reviewed and confirmed by
an outside researcher. Based on content analysis of their
responses to the structured interview questions, the three
therapists reported feeling well-prepared and trained for the
workshop, that the workshop was not too time consuming,
and that their facilitation experience was positive. They
also reported that this workshop would be feasible for other
therapists to train for and facilitate.
Finally, in terms of treatment acceptability, participants completed the Credibility and Expectancy Questionnaire at the post-test time point. The highest and
13
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Contemporary Family Therapy (2019) 41:368–383
lowest possible scores were two and 28 for the credibility
scale, zero and 30 for the expectancy scale, and two and
58 for the entire measure. Means and standard deviations
were as follows: Credibility scale (M = 21.98, SD = 4.45),
Expectancy scale (M = 17.18, SD = 6.99), Total Credibility and Expectancy Questionnaire (M = 39.16,
SD = 10.78). These results are similar to other seminal
studies that found total mean scores for adequate acceptability of 35.83 and 42.96 (Devilly and Borkovec 2000).
Participants were also asked to provide any suggestions they may have had. Nine participants did not provide
answers, seven expressed that there should be no changes
made to the workshop, and the remaining 12 participants
provided suggestions for the workshop. A few examples
of suggestions included: more dyadic exercises, less
abrupt transition into discussion of sexual intimacy, more
group discussion to provide interaction between couples
and the group, and have couples create a specific goal at
the end of the workshop that they and their partners will
continue to work towards.
Table 2 Pairwise comparisons:
learning measure 1
(I) timepoint
1
2
3
(J) timepoint
2
3
1
3
1
2
Hypothesis 2: Perceived Knowledgeability
and Knowledge Acquisition
Results from a one-way repeated measures ANOVA on
Learning Measure One (Table 2) showed a statistically significant difference in participants’ perceived knowledgeability (how knowledgeable they felt they were about concepts
directly related to the Hold Me Tight workshop) between
pre-, post-, and follow-up time points (Wilks’ Lambda = 0.4,
F (2,26) = 19.49, p < 0.01) with a large effect size (Partial Eta
Squared = 0.6). Post-hoc tests showed a specific difference
between pre- and post- test scores (p < 0.01) and between
pre- and follow-up scores (p < 0.01). There was not a significant difference between post- and follow-up scores (p = 1.0).
Similarly, a one-way repeated measures ANOVA was run
on Learning Measure Two (Table 3) scores between pretest, post-test, and follow-up time points. Results showed
a statistically significant difference in participants’ knowledge acquisition scores (how well they correctly answered
questions related to Hold Me Tight concepts) (Wilks’
Lambda = 0.49, F (2,26) = 13.35, p < 0.01). There was also
a moderate effect size (Partial Eta Squared = 0.51). Posthoc results showed specifically that there was a significant
Mean difference (I-J)
− 4.107*
− 3.750*
4.107*
.357
3.750*
− .357
Std. error
Sig.a
95% confidence interval for
differenceb
Lower bound
Upper bound
− 2.455
− 1.881
5.759
1.376
5.619
.662
.647
.732
.647
.399
.732
.399
.000
.000
.000
1.000
.000
1.000
− 5.759
− 5.619
2.455
− .662
1.881
− 1.376
Std. Error
Sig.a
95% confidence interval for
differenceb
Based on estimated marginal means
*The mean difference is significant at the .05 level
a
Table 3 Pairwise comparisons:
learning measure 2
Adjustment for multiple comparisons: Bonferroni
(I) timepoint
1
2
3
(J) timepoint
2
3
1
3
1
2
Mean difference (I-J)
− 1.536*
− 1.393*
1.536*
.143
1.393*
− .143
Based on estimated marginal means
*The mean difference is significant at the .05 level
a
13
Adjustment for multiple comparisons: Bonferroni
.298
.365
.298
.312
.365
.312
.000
.002
.000
1.000
.002
1.000
Lower bound
Upper bound
− 2.295
− 2.324
.776
− .653
.461
− .938
− .776
− .461
2.295
.938
2.324
.653
Contemporary Family Therapy (2019) 41:368–383
377
difference between pre- and post- scores (p < 0.01) and
between pre- and follow-up scores (p < 0.01), but not
between post- and follow-up scores (p = 1.0).
Exploratory Aim and Hypothesis: Couple
Attachment, Sexual Satisfaction, Sexual
Communication, and Relationship Satisfaction
To explore whether there were differences in participants’
reports of romantic attachment, sexual satisfaction, sexual
communication, and relationship satisfaction at pre-, post-,
and follow-up time-points, the investigators used a convergent mixed-methods design in which both quantitative
and qualitative data were analyzed. This analytic method
allowed the research team to compare and combine statistical results and qualitative findings to develop a more wellrounded perception of the data (Creswell and Clark 2018).
The investigators first collected both sets of data separately
but concurrently. Next, the team conducted content analysis
to identify themes in the qualitative data regarding changes
in participant romantic attachment and sexual intimacy. The
qualitative data and themes were then reviewed by an outside researcher. Simultaneously, the investigators conducted
quantitative analytic analysis to examine the quantitative
data. The researchers were then able to compare the qualitative themes and quantitative statistical results to inform their
understanding of the findings (Creswell and Clark 2018).
The following themes appeared after conducting content
analysis. Nineteen out of 28 participants (68%) reported positive aspects of relationship change. Of these 19 participants,
twelve (64%) reported improved communication. Specific
responses included statements such as: “Realizing how to
improve the way we speak to each other”; “Being able to
communicate and identify the ‘dance’ and talk about it”; and
“Every night we go over any arguments, if there were any,
and we talk about how it could have gone better and then we
give each other a heartfelt compliment. This has helped us to
stay connected”. Participants that reported more connection
and awareness in their relationship provided responses such
as: “We are more aware of how we interact throughout the
Table 4 PROMIS 2.0:
multivariate tests
day”; “We are in sync with each other because we can be
vulnerable in our talking about minor problems”; and “I feel
more connected to him and calmer. I feel more secure in our
relationship”. Along with communication, five participants
(26%) reported better connection with their partners and
awareness in their relationship, one person (5%) reported
improvements in sex, and one (5%) reported increased
forgiveness.
To examine reported quantitative changes in romantic
attachment, a one-way repeated measures ANOVA was
conducted on BARE scores between pre-test, post-test, and
follow-up. Results showed a small effect size. Though results
did not show statistical significance, descriptive statistics
showed movement in the right direction regarding increases
in romantic attachment from pre- to post- to follow-up.
According to qualitative results from the participants,
eight people (27%) reported no change in attachment bond,
and one person (5%) did not provide an answer. Half of the
participants, however, reported an improvement in their
romantic attachment bond in their narrative responses. Common responses included reported value in a new ability to
recognize and address their Demon Dialogues, improved
willingness to show affection and feeling more secure in the
relationship. Examples of statements included: “I feel like
our attachment is stronger. I have been pleasantly surprised
by how much more my husband thinks through his words
and actions and has really softened his pursuing and fighting tendencies”; “This workshop was a good reminder to
continually discuss important relationship matters”; “The
workshop helped to put into terms some of the things we
were already practicing. I learned to recognize when we may
begin to participate in ‘demon dialogues’ so that we are able
to maintain our deep romantic attachment bond”; and “I feel
that we are more attached and feel more secure”.
A one-way repeated measures ANOVA was run to examine differences in PROMIS 2.0 scores between pre-test, posttest, and follow-up (Table 4). Results demonstrated a large
effect size for changes in couple’s sexual satisfaction (Partial Eta Squared = .18) with a trend towards statistical significance (Wilks’ Lambda = 0.82, F (2,26) = 2.87, p = 0.08).
Effect
Value
F
Hypothesis df
Error df
Sig.
Partial
Eta
squared
Timepoint
Pillai’s trace
Wilks’ lambda
Hotelling’s trace
Roy’s largest root
.181
.819
.221
.221
2.868a
2.868a
2.868a
2.868a
2.000
2.000
2.000
2.000
26.000
26.000
26.000
26.000
.075
.075
.075
.075
.181
.181
.181
.181
Design: intercept within subjects design: timepoint
a
Exact statistic
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378
Descriptive statistics support this trend, showing improvement in sexual satisfaction from pre- to post-test time points,
but this improvement slightly declined at follow-up.
Similarly, one-way repeated measures ANOVA were run
to examine changes in sexual communication scores on the
DCS. Results were not statistically significant and demonstrated a small effect size. However, descriptive statistics
showed movement in the intended direction of improved
sexual communication from pre- to post-test time-points
with a decline at follow-up. Furthermore, analysis revealed
that 29% percent of participants reported improvement in
their communication. Example statements included: “We are
able to be more vulnerable”; “We opened a couple of doors
at the workshop and are able to communicate better”; “I
understand his unmet needs and that makes me more secure
with myself. He previously made it seem like I was the only
person with these feelings”; and “I feel more comfortable
opening up about my sexual desires and needs since the
HMT workshop”.
Lastly, a one-way repeated measures ANOVA was run
to examine differences in participants’ relationship satisfaction between pre-test, post-test, and follow-up time-points.
Results did not demonstrate statistically significant improvement in participants’ pre-, post-, and follow-up scores on
the RDAS measure along with a small effect size. However descriptive statistics suggest movement in the intended
direction towards better relationship satisfaction from pre- to
post- to follow-up time points.
Discussion
Relationship health and satisfaction are important to family
stability. When marriages and committed long-term relationships deteriorate, there are often detrimental impacts
on physical health, psychological health, and child socioemotional development and well-being (Hawkins et al.
2008; McLanahan and Sawhill 2015; Vaus et al. 2017). Sex
plays a significant role in the success and satisfaction of
romantic relationships. Yet, when couples experience challenges in their sex lives, they often struggle to openly communicate and address their issues effectively (MacNeil and
Byers 2009). The ability for partners to successfully resolve
sex-related issues is often impacted by the strength of their
romantic attachment bond (Johnson and Zuccarini 2010;
Timm and Keiley 2011). Despite this known link between
attachment and sexual intimacy, there is a gap in programs
that target these two constructs simultaneously and emphasize their bi-directional influence on one another. Existing
therapy models that do target both sex and attachment (e.g.
EFT) can require a considerable time commitment and monetary investment from participating couples. Brief psychoeducational programs may be a helpful alternative for couples.
13
Contemporary Family Therapy (2019) 41:368–383
In the current study, we adapted a 10-week psychoeducational program focused on couple attachment, the Hold
Me Tight Program: Seven Conversations for Connection
(Johnson 2010), and produced a facilitator manual for a
1-day Hold Me Tight workshop. The manual was adapted to
highlight the main aspects about the importance of healthy
attachment in relationships and the interplay between attachment and sexual intimacy (sexual satisfaction and sexual
communication). The findings from this study provide preliminary evidence that the adapted workshop can: (1) be feasibly delivered and demonstrate adequate treatment acceptability with clients; (2) help couples gain significant amounts
of new knowledge regarding romantic attachment and sexual
intimacy; and (3) potentially impact actual improvements
in couples’ romantic attachment, sexual satisfaction, sexual
communication, and overall relationship satisfaction, despite
the brief nature of the intervention.
In terms of treatment feasibility, evidence from our
recruitment patterns, attrition rates, observations of therapist treatment fidelity, and qualitative feedback from the
therapists indicates that the adapted one-day Hold Me Tight
workshop can be feasibly delivered. The therapists facilitated
the workshop as intended without skipping or significantly
veering away from the designated sections and flow of the
manual. They also felt as though they were well-prepared,
that the workshop was not too time consuming, and that they
had an overall positive experience. Lastly, the three therapists unanimously felt that this would be a feasible program
for other therapists to train for and facilitate with relative
ease. These findings highlight the workshop’s potential to
attract therapists who may be interested in training in and
utilizing the model in real world settings. In sum findings
suggest that the adapted one-day Hold Me Tight program is
a practical and feasibly delivered format, from the point of
view of program facilitators.
Qualitative responses from couples also suggest that the
adapted one-day program is an acceptable treatment option
for participants. Nearly one-third of participants felt that it
was not necessary to make any changes to the workshop,
which would suggest that the program met their needs and
expectations. Twelve other participants did make suggestions for future workshops (e.g. including more dyadic exercises, smoother transition to discussion of sexual intimacy,
and specific goal-formation). These suggested changes serve
as constructive feedback for future adaptations and empirical studies. Despite these suggestions, participants generally
reported a positive experience participating in the workshop,
as evidenced by their qualitative responses related to their
impression of the program (e.g. “I think the workshop was
great”; “I think it was a well-planned workshop”; “It’s a
good beginning toward opening up and becoming vulnerable”; and “I think it was great! The therapists that ran the
group were amazing as well!”). Past theoretical writing
Contemporary Family Therapy (2019) 41:368–383
regarding psychoeducation programs suggests that shorter
group formats may be favored due to increased accessibility
and convenience, including requirements for less money and
time (Fisher et al. 2014).
In terms of knowledge acquisition, our findings suggest
that participants in this adapted shortened program learned
and retained a significant amount of program-based knowledge, despite the shortened format of the workshop. There
were significant changes in participants’ perceptions that
they were more knowledgeable, as well as improvements
in their test scores on a measure of program related content
from pre-test to post-test. Participants retained this increased
level of knowledge weeks after attending the program at
follow-up. These findings suggest that couples learned the
material investigators intended for them to learn and that
therapists were competent in their efforts to teach the material. Qualitative responses from participants regarding education specific to attachment and sexual intimacy support
the quantitative findings (i.e. “new ability to recognize
triggering patterns of communication/Demon Dialogues”;
“The workshop was a good reminder to continually discuss
important relationship matters”; “The workshop helped put
into terms some of the things we were practicing”; and “We
opened a couple of doors at the workshop and are able to
communicate better”). Though many therapists have delivered shorter Hold Me Tight workshops, this is the first study,
to our knowledge, to intentionally adapt the program based
on theoretical and evidence-based literature and to explore
its potential impact on couples’ knowledge acquisition. By
learning new knowledge, increasing understanding about
the connection between attachment and sexual intimacy,
and starting the discussion of specific issues in their relationships, participants achieved first level of our proposed
theoretical model of program-based change (see Fig. 1),
which was a main goal of the adapted program and principle
investigative aim of the study.
Our findings are consistent with reports from previous
studies that found evidence for the efficacy of psychoeducation programs in increasing couples’ knowledge about
relationship related dynamics and problems (Cohen et al.
2014; Cummings et al. 2008; Fisher et al. 2016; Hawkins
et al. 2008). For example, Hawkins et al. (2017) concluded
that couple relationship education led to positive changes,
improved interactional skills, and increased hope for most
couples. The expectation for participants of the current
study was that the learned knowledge and understanding
about the role of romantic attachment in sexual intimacy
would lead to increased readiness and motivation for
change and that couples would be encouraged to seek further resources to improve their relationships and achieve
increasingly greater levels of relationship satisfaction.
Motivation for change was not an original hypothesis at
the time of data collection and therefore was not included
379
in our measurements. This is a limitation of our study, and
future studies should include measurements to assess for
participant motivation for change.
Finally, although this initial pilot study was primarily
focused on assessing program acceptability, feasibility and
program-related learning outcomes, our exploratory analyses
on related relationship and clinical outcomes suggest that
after participating in the adapted one-day Hold Me Tight
workshop, couples did experience several positive changes
in felt romantic attachment, sexual communication, sexual
satisfaction and overall relationship satisfaction. Qualitative
reports provided evidence for improvements in all four of
these domains. Examples of participant responses included:
“I feel more connected to him and calmer. I feel more secure
in our relationship”; “we are actively trying to improve our
sex life”; “we have kind of changed up our approach to our
sexual life which has been interesting and also being more
aware of how we interact throughout the day”; and “we
opened a couple of doors at the workshop and communicate better [about sexual matters]”. In addition, although not
statistically significant, results from quantitative measures
show changes in the expected direction across all measures
from pre to post test, with scores on the sexual satisfaction
measure improved at a level that showed a trend towards
statistical significance, even with the low statistical power
afforded by our small pilot sample. These results are consistent with past studies that provide evidence for the efficacy of
EFT therapeutic principles in enhancing couples’ emotional
closeness, felt romantic attachment, and sexual satisfaction
(Burgess Moser et al. 2015; Halchuk et al. 2010; Soleimani
et al. 2015). Emotionally Focused Couples Therapy, the
original Hold Me Tight manual, as well as our adapted manual, draw heavily from attachment and emotion theories with
the core underlying premise that healthy couple attachment
patterns help to increase comfort with emotional vulnerability and communication and security between partners. Such
improvements are also thought to potentially help couples
understand and address sexual-related issues (Burgess Moser
et al. 2015; Fisher et al. 2014; Johnson and Zuccarini (2010);
Soleimani et al. 2015). Our program is novel in that it jointly
targets couple attachment and sexual intimacy, highlighting the interplay between them. It emphasizes and supports
the importance of identifying “the attachment styles and
relational patterns in patients receiving counseling and psychological treatments focused on sexual problems” (Ciocca
et al. 2014, p. 81).
In sum, the outcomes from this study support the manual adaptation and provide preliminary evidence that a
shortened version of the Hold Me Tight psychoeducational
program, in the form of a 1-day workshop, can serve as
an acceptable, feasible and effective intervention for both
participants and facilitators.
13
380
Limitations and Future Directions
While results of this small pilot study are encouraging,
there were several significant limitations. First, this sample
size for this pilot study was small (N = 30; 15 couples). As
expected, due to the nature of pilot studies, this small sample size may have limited our ability to detect relationships
between our constructs of interest, due to inadequate statistical power. The lack of a control group was another limitation
of the study. The study followed a one-group pre-test posttest design, and therefore we cannot say with assurance that
changes experienced by participants (i.e. knowledge acquisition, improved couple attachment, sexual satisfaction, or
relationship satisfaction) were solely due to effects of the
workshop, although this certainly seems the most plausible
explanation for our findings on knowledge acquisition. Use
of a control group in future studies could help to further
develop evidence for treatment efficacy and differentiate
between the effects of the program and potential outside
influences. Future studies may also benefit from comparing this adapted workshop to the original 10-week Hold Me
Tight program to better understand the differences between
and potential benefits of the two. All administered measures
were self-report surveys. Drawbacks of self-report measures include their susceptibility to influence by participant
mood, bias, or lack of understanding of the questions asked.
Future work using multi-method approaches (e.g. observational studies, performance tasks) could add additional
validity to our findings. Finally, although the study sample
was relatively diverse in terms of race and age, there was
no variation in sexual orientation. All couples were heterosexual, and investigators did not explore whether or not the
program would meet the needs of couples in the LGBTQ
community. Future studies may benefit from first collecting
needs assessment data from this population for suggestions
on how best to adapt workshops to meet their specific needs
(Kornbluh et al. 2015). By using more participatory actionbased research methods, investigators can collaborate with
minority populations, reflect with them on the socio-political
forces that impact their lives, and develop programs that best
meet their specific needs (Kornbluh et al. 2015). Despite the
diversity in race and age in the sample, as well as among the
facilitators, the study did not extensively take into consideration cultural differences.
Implications
Despite these limitations, results from this study add to
evidence base on the benefits of brief psychoeducational
programs for couples and the value of EFT-based programs for targeting couple attachment and sexual intimacy
(Cohen et al. 2014; Cummings et al. 2008; Fisher et al.
13
Contemporary Family Therapy (2019) 41:368–383
2016; Johnson and Zuccarini 2010; Hawkins et al. 2017;
Péloquin et al. 2014). It is important to mention that due to
its brief educational nature, this adapted one-day Hold Me
Tight workshop would not be recommended for highly distressed couples. Conflict may arise during the workshop,
and couples in significant distress may not be equipped to
resolve their issues quickly on their own. Instead, more
intensive therapy would be recommended for such couples.
However, for couples with mild- to moderate relationship
distress who aim to learn and implement new relationship
skills, our study findings provide preliminary support that
this one-day workshop demonstrates adequate treatment
acceptability and can be feasibly delivered. Additionally,
findings indicate that participating couples learn and retain
program-based knowledge and demonstrate changes in
markers of attachment, sexual communication, and overall
relationship satisfaction.
It is important to highlight the fact that various shortened Hold Me Tight workshops are being facilitated by
EFT therapists all over the country, but that no studies
exist on how material for these one- or two-day workshops
are chosen or what the impacts of these programs are on
couples. The procedure for adapting our one-day workshop can give insight to other therapists and researchers
to inform future manual adaptations for various populations. If the results of this study are replicated with larger
and more diverse samples, and the adapted manual is
published, couples therapists will have access to a brief,
highly accessible and empirically informed psychoeducation program for helping distressed couples. The brief
nature of the program could help community-based therapists to improve accessibility and implementation of support programs for couples and families. It provides a clinical contribution to the field of Couple and Family Therapy
through the production of a new and easy-to-use therapy
tool for clinicians.
Furthermore, if results are replicated, findings from
this and future studies should help to inform advocacy
efforts, funding initiatives and policy decisions regarding
couple and family support programs (Bradford, Hawkins,
and Acker 2015; Hawkins et al. 2008). As family focused
researchers, it is important that we help translate findings from our work into real-world practice, and that we
advocate for public policies that support the availability
and accessibility of evidence-based support programs for
couples and families (Hawkins et al. 2008). As noted by
Rhoades (2015), policies that support healthy couple and
family relationships have the possibility to make significant and positive changes in the life trajectories of many
adults and children.
Funding This research was not supported by outside funding.
Contemporary Family Therapy (2019) 41:368–383
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441–452. https://doi.org/10.1111/fare.12268.
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval Informed consent was obtained from all individual
participants included in the study, and all procedures performed in
studies involving human participants were in accordance with the ethical standards of the Drexel University Institutional Review Board
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Sage Reference
The SAGE Encyclopedia of Marriage, Family, and
Couples Counseling
For the most optimal reading experience we recommend using our website. A
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Author: Quintin A. Hunt, Matthew Nelson
Pub. Date: 2016
Product: Sage Reference
DOI: https://doi.org/10.4135/9781483369532
Keywords: touch, sexual dysfunctions, sensation, anxiety, breast, sex, equal time
Disciplines: Counseling & Psychotherapy, Counseling Setting / Client Groups, Theory & Approaches,
Relationship Counseling, Family Therapy
Access Date: July 28, 2023
Publishing Company: SAGE Publications, Inc
City: Thousand Oaks
Online ISBN: 9781483369532
© 2016 SAGE Publications, Inc All Rights Reserved.
Sage
Sage Reference
© 2017 by SAGE Publications, Inc.
Sensate focus refers to a technique therapists and counselors employ to help couples experiencing certain
types of sexual dysfunction build trust and reduce their anxiety. It involves nondemand touch (touch that is not
meant to be sexual or produce orgasm). Many people struggling with sexual issues in their relationship will
have experienced numerous failed sexual experiences over time, and each of these creates anxiety. Such
anxiety can interfere with the sexual relationship and the ability to become aroused or achieve orgasm. Sensate focus exercises are meant to pair touch, and eventually sexual behaviors, with relaxation rather than
anxiety. The exercise involves couples taking turns touching and massaging each other, without having the
pressure of being sexual or having an orgasm. In the beginning stages they are not allowed to touch breasts
or genitals, and the goal is to relax and communicate to the partner what feels good or does not feel good.
Over time the couple builds up to more sexual touch.
The aim of sensate focus is to build trust between couples, allowing them to explore giving and receiving pleasure. The emphasis is on positive emotions, feelings, and sensations while reducing any negative responses.
The technique allows for feedback from each person in the couple and allows for a great deal of flexibility
in how it is presented and when a couple moves through the various stages. The stages themselves can be
modified as needed to adapt to the needs of each couple. In the sections that follow, the history and rationale
for sensate focus, the process of sensate focus, and possible challenges are discussed. The entry concludes
with a discussion of the elements necessary for success in sensate focus and the benefits of the technique.
Origin of Sensate Focus
The sensate focus technique originated from work by William Masters and Virginia Johnson in the 1960s and
1970s. Their technique was further refined by Helen Singer Kaplan, a sex therapist and professor of psychiatry who held doctorates in both medicine and psychology. Over time this process has evolved and has
become a standard practice for those practicing sex therapy. Originally Masters and Johnson would focus
on the individual patient who was presenting with the sexual dysfunction and using the partner as a type of
cotherapist at home to process the dysfunction. Systemically it is helpful to work with both partners equally,
as both are influenced by problems in the sexual relationship and the other partner may have developed behaviors and beliefs that feed into sexual problems.
The Concept of Sensate Focus
The idea behind sensate focus is that underlying anxiety prevents couples from experiencing arousal and
orgasm with one another. Basically, anxiety interferes with sexual functioning and sexual pleasure with a partPage 2 of 7
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ner. It is not uncommon that partners experiencing these sexual difficulties will have little problem performing or enjoying sexual experiences either alone or outside of the marriage—but by no means is this always
the case. The purpose of sensate focus is to help couples enjoy touching one another without the anxiety
response that has been conditioned into their pattern and interferes with their sex life. Sensate focus is commonly used to treat issues of deficient sexual desire, difficulty in achieving sexual arousal or erectile dysfunction, and difficulty in reaching orgasm.
Therapeutic Use of Sensate Focus
Many therapists enjoy assigning homework, but for homework to be successful it should make sense to the
couple and be clearly explained. If poorly explained and executed, the incorporation of sensate focus into couples’ treatment can appear as a pointless assignment or do harm to the couple’s relationship. Poorly preparing and assigning sensate focus to clients may reinforce the conditioned anxiety. Clients typically respond
well when the purpose and point of sensate focus are explained to them. The purpose is to enjoy touching
one another, not orgasm. Once couples enjoy touching and being touched by one another, the orgasm will
occur in later stages.
There is no one right way to introduce or to implement sensate focus. Some clients will move through the
steps with ease, while others will have anxiety triggered by the mere thought or discussion of sensate focus
exercises. Generally, there are two major sections of this process: sensual and sexual. The assignments,
however, should be gradual and require satisfactory completion of each step before moving to the next step.
This helps to ensure the clients’ comfort level and allows the clinician to assess for sexual anxiety.
Pressure and anxiety are two roadblocks to successful sexual encounters for many couples. The process of
sensate focus should allow those feelings to be lowered, and an atmosphere of comfort and trust should be
created. The point of the exercise is not to have sexual orgasm as the goal; it is to be aware of sensations
that occur when being touched. Not infrequently couples report failing the assignment as they proceeded to
intercourse or orgasm rather than waiting. Each of these responses, as well as any others, can be used to
further understand and focus further treatment.
Typically, couples are encouraged to participate in the activities two to three times a week as time permits.
Each sensate focus session should include uninterrupted time that is disconnected from electronics, pets,
children, or other distractions. Each partner should have equal time as the partner touching and the partner
being touched. The amount of time is dependent on how much time is available but should be somewhere
between 10 minutes and 1 hour, based on availability of each partner. At the start of each turn a timer should
be set so that there is no subjective interpretation of how much time has passed.
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The couple take turns touching and caressing one another; they can alternate who initiates the touch. The
couple should have a space that is pleasantly lighted and at a comfortable temperature, as the clients will
remove as much clothing as they feel comfortable with. Here is another area where flexibility is important, as
some individuals may have body image issues that they are working to overcome. Alcohol and recreational
drugs should be avoided before and during the activity because they are likely to interfere with the process of
feeling sensations. In general, there are five stages to sensate focus practice:
1. Touching and caressing with no breast touching
2. Touching and caressing including breasts but no genitals
3. Touching and caressing including genitals
4. Mutual touching including insertion (fingers or toys) but no intercourse
5. Intercourse but not orgasm
The clinician explains at the onset of the intervention that sexual intercourse and sexual activity should be
avoided. The rationale is that by removing sexual activity performance, pressure is removed, and a nondemand atmosphere is created, and each person can feel more relaxed. The pressure to have sex can deter
from the process and is often the root of much of the anxiety experienced. The initial stage has the couple
find a comfortable place to engage in the touch exercise. They avoid touching the breasts and genitals and
focus on the feeling, pressure, and temperature. This touching should be done by the hands and fingers only,
with no kissing or full body contact. All areas of the body, except those off limits, should be explored. The
focus should be on the sensations of touch, pressure, and temperature. If anxiety arises, the individual should
refocus on the touch sensations and move on to a new part of the body. The touch should be long enough
that the awkwardness is overcome but short enough that the partners do not get bored or tired. Each partner takes turns throughout the session performing both roles of toucher and being touched. If the one being
touched feels physically uncomfortable, he or she can redirect the partner away nonverbally or by placing a
hand over or under the partner’s hand and guiding to a new area.
Steps one through three focus on the sensual nature of touch, while the last two gear more toward sexual
touch. It is important to remember through each step that sexual intercourse and orgasm are not the goal;
rather the goal is to increase understanding and awareness of one’s own body and sensations.
How to Have Success With Sensate Focus
The important keys of having success with sensate focus revolve around the level of comfort the couple are
able to experience. The more that the clinician is able to explain the process and allow the clients to feel comfortable, the more likely success will happen. The clinician also needs to be aware of the level of readiness
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of the clients. A thorough assessment of the couple’s skills and levels of communication will be helpful, as
any perceived failure with sensate focus will impact the couple’s level of marital satisfaction. As part of the
exercise, it can be helpful for the clients to have sofa sessions. These consist of a debriefing of sorts for the
couple to share their experiences and to listen to their partner’s experiences. The clients expand their communication about what they are feeling and respond to their partner.
It is essential that each partner have equal time in each role. When being touched, the partner being touched
should focus on the experience and being mindful of how things feel. The partner being touched is not in
control of the experience but is encouraged to express what is enjoyed. A prepared list of basic expressions
can be provided to the couple to assist in directing the touching partner: yes, no, harder, softer. These expressions are best delivered after completing the activity in the debriefing time. This allows for questions in
a nonjudgmental way. The strength of sensate focus lies with the openness of the concept. Clients are able
to stretch their comfort zones and learn to explore pleasure in a nonperformance demanding way. In the later
stages as the couple has progressed, the clinician may suggest adding lotion or other objects to change the
touch dynamics. A few of these might include feathers, ice cubes, or soft fabrics. This is dependent upon the
couple’s level of comfort and the ultimate goal of the relationship.
Benefits of Sensate Focus
Sensate focus is a directly applicable intervention that can help couples reduce their anxiety with one another
and help couples learn to communicate about their wants and desires in a nondemanding way. The patterns
of communication in failed sexual experiences are extremely predictive of the patterns of communication that
couples experience when in distress.
Sensate focus can be used as a diagnostic tool to determine a couple’s readiness to commit to therapy and
their levels of communication outside the therapy room. Many people are uncomfortable saying what they
want or like from their partner, both in and out of the bedroom. Sensate focus helps the couple learn reciprocal connection that is focused on pleasing each other. These skills can directly be applied to much more than
just the bedroom, but like sensate focus, they work well only when each partner works to please the other.
Sensate focus is not just an intervention used by couples that are struggling to enjoy sensual and sexual experience with one another, it can also teach couples how to do foreplay. Sex is not simply a matter of getting
to orgasm as quickly as possible; it can also be about pleasure and enjoying being pleasured sensually and
sexually.
Quintin A. Hunt and Matthew Nelson
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See alsoAnxiety; Couples and Marriage Counseling; Homework Assignments in Therapy; Mindfulness; Sex
Therapy; Sexual Enhancement, Sexual Toys; Sexual Intimacy; Sexuality Education
Further Readings
Coren, C. M., Nath, S. R., & Prout, M. (2009). Computer-assisted sensate focus: Integrating technology
with sex therapy practice. Journal of Technology in Human Services, 27(4), 273–286. doi:10.1080/
15228830903329823
De Villers, L. (2014). Getting in touch with touch: A use of caressing exercises to enrich sensual connection
and evoke ecstatic experience in couples. Sexual and Relationship Therapy, 29(1), 87–97. doi:10.1080/
14681994.2013.870336
Gupta, P., Banerjee, G., & Nandi, D. N. (1989). Modified Masters Johnson technique in the treatment of sexual
inadequacy in males. Indian Journal of Psychiatry, 31(1), 63–69.
Joanning, H., & Keoughan, P. (2005). Enhancing marital sexuality. The Family Journal, 13(3), 351–355.
doi:10.1177/1066480705276194
Kaplan, H. S. (1974). The new sex therapy. New York: Brunner/Mazel.
Masters, W. H., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown.
McAnulty, R. D., & Kazdin, A. E. (2000). Sex therapy. In Encyclopedia of psychology (Vol. 7, pp. 328–241).
New York: Oxford University Press.
Regev, L. G., & Schmidt, J. (2008). Sensate focus. In W. T. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (pp. 486–492). Hoboken, NJ: Wiley.
Van Hasselt, V. B., & Hersen, M. (1996). Sourcebook of psychological treatment manuals for adult disorders.
New York: Plenum Press.
Weeks, G. R., & Gambescia, N. (2009). A systemic approach to sensate focus. In K. M. Hertlein, G. R. Weeks,
& N. Gamescia (Eds.), Systemic sex therapy (pp. 341–362). New York: Routledge.
Weiner, L., & Avery-Clark, C. (2014). Sensate focus: Clarifying the Masters and Johnson’s model. Sexual and
Relationship Therapy, 29(3), 307–319. doi:10.1080/14681994.2014.892920
Wiederman, M. W. (2001). “Don’t look now”: The role of self-focus in sexual dysfunction. The Family Journal,
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9(2), 210–214. doi:10.1177/1066480701092020
• touch
• sexual dysfunctions
• sensation
• anxiety
• breast
• sex
• equal time
Quintin A. HuntMatthew Nelson
https://doi.org/10.4135/9781483369532
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