The Tissue Issue: Klein and Kleenex

I first thought of the issue of the tissue when I was at the Betty Ford Center, where the famous (and infamous) seek sobriety. I was there in the capacity of a Professional-in-Residence, which allows mental health professionals to participate in the acclaimed in-patient program in order to better understand the center. It was my first day in residence that I learned the tissue rules. The rule is that if you are in-group and someone begins to cry, you don't hand them a tissue---the person crying is responsible for procuring their own tissue. I had, as a therapist, felt a bit ashamed to learn the hard way that it's not okay to tissue enable. The thinking at Betty Ford and other recovery groups is that to intervene with a tissue when someone is crying is akin to codependency, and that it simply isn't done.

This is in stark contrast to my Bionian psychoanalyst, Igor (my nickname for him). Igor keeps a box of tissues on a table that sits between the two of us. When I start to cry, Igor notices even before the tear has formed. Igor is a three-tissue guy. I can always count on him to pull out one, two, and three tissues, and then to hand them all to me in a collective bunch. There is something about this ritual of noticing and anticipating my tears that I find touching, nurturing and even healing.

How I interpret Igor's tissue intervention is at least two-ply. With his action, I see him saying: "I see your emotion. I am responsive to it. I am impacted by your feelings and I am in this process with you. I am not standing back, aloof and unaffected by it. I can and will absorb what you feel and you can count on me." Many psychoanalysts and therapists would find Igor's disposable handkerchief handing as objectionable. They would say that it is enough that the therapist keeps the Kleenex in the room.
But a tissue is not just a tissue; nothing in psychoanalysis is neutral or devoid of meaning. A tissue may seem to be just an accessory of psychotherapy, but it can be so much more. As therapists, in order to do therapy we need a safe, secure and quiet room, some chairs and some Kleenex----everything else (the art, the tables, and the magazines we have in the waiting room) is optional. Tissues are essential, at least to most practitioners.

I have had patients who have come to therapy carrying their own box of Kleenex. When I told Igor about this, he asked me if they had been to a Kleinian before they came to me. "Why?" I asked. Igor told me that Kleinian psychoanalysts take an even harder stance on tissue than those at Betty Ford--they don't even supply Kleenex. No matter how hard their clients cry, sneeze, sniff or snort there is no tissue supplied. Can you imagine that? I can't. I am, as a therapist, a big believer in over-preparing in terms of tissue. I worry that a client might go through a box of tissue and I will run out. I would never want my client to feel that I am ill-prepared for him or her. I get that Kleinians are big on creating space for negative transference. I also believe negative transference can be profoundly important psychoanalytic work; however, there is negative transference that emerges just by sticking to the 50-minute limit, charging a fee and starting and ending the sessions on time. To my mind, withholding Kleenex from a crying client is cruel and unusual treatment. If I had a crying client and had somehow run out of tissue, I would likely offer to cut off a sleeve. Truly, I think it is profoundly important for our clients to know that we are prepared to deal with their pain and if an occasion comes when we aren't (when we run out of tissue or the hour is up and they are in the middle of painful work), I think in the name of authenticity and honesty we should let our clients know how bad we would feel that we can't give them more---if that is honestly how we feel.

At the other end of the tissue spectrum is a highly unusual tower of tissues that exists in one swanky Beverly Hills psychoanalyst's office. This analyst dresses in suits from Saks Fifth Avenue with ties from Barneys--everything about his physical presentation says successful and polished. However, this well-dressed analyst has a shadow side. He takes tissue preparations to near O.C.D.-like levels. This man literally has a wall of Kleenex. His nearly postmodern aesthetic of Warholian boxes is a symbol too large and phallic to go uninterpreted. If I was a patient in his practice I would read the wall of tissues as an attempt at omnipotence. I might read it as, "I am prepared for everything. You cannot cry/feel/need more than I can give you."

My rules for Kleenex, as both patient and therapist: no generic brands (it reads as cheap and as if the therapist is withholding. For the record, I will admit that I am a bit of a snob when it comes to paper goods and cleaning products). The ply must be at least two and it must be scent and lotion free. One might have a lot of tears to cry and one doesn't want scented, colored or harsh tissues to interfere with the dread and despair often associated with insight into unconscious Oedipal longings. Also, Kleenex should be white. I don't want gender-specific or even designer-approved colors disturbing any inchoate consciousness.

Another issue with the tissue: disposal. Not only must therapists provide high-quality tissue to their patients, they must provide a place for clients to dump them. I know this seems obvious, but I remember many sessions when I went through 10 or 20 Kleenex, and then had to hold them on my lap and take them with me when my hour was up. Even before I had begun to study psychoanalytic theory, I read this as the therapist saying, "I don't want to deal with your mess. You have to deal with the unlovable, messy and slimy parts of yourself." If we are going to work with people's deepest thoughts, feelings and memories the least we can do it provide Kleenex and a way to dispose of them. If you can't stand the mess, get out of the consulting room.

And, if anyone from the Kimberly-Clark Corporation (the manufacturers of Kleenex® Brand tissue) is reading this column, I would like to ask on behalf of therapists everywhere that you give us the courtesy of a professional discount. I feel certain that no other organization or profession is responsible for the use and distribution of your products like we are. We, the therapists of the world, are your #1 consumer, and I am not sure that you fully appreciate us.

Besides offering us a generous discount and maybe a frequent-buyer-reward program, you might want to do a series of collectible tissue boxes honoring the great thinkers in clinical psychology (like a Wheaties box, only instead of athletes you could feature Freud, Jung, Winicott, Rodgers, Perlz, and Frankel, to name a few). The catchphrase for the campaign could be something like "Kleenex--we're there for you like your mother never was. Your father was wrong, go ahead and cry. We'll never let you down, the way they did."

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Copyright Tracey Cleantis, LMFT 2010