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The Tissue Issue

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Traditionally psychotherapy has been known as the talking cure.  But often we pick up on cues that are seen, not heard.  And, sometimes what we observe with one client one can then help us with what we observe with others.  Though the names and identities have been altered, what I came to witness is very true. 

  Carole, a 75-year old, retired librarian came to my office to work on creating more satisfying friendships in her life.  Since her husband passed away, she was left with no confidant, only acquaintances from book clubs and walking tours.  In our time together she talked about her upbringing during the war, her siblings, her mother’s sense of humor, but we hadn’t yet touched on what would help her forge closer relationships. That is until one moving story when she was particularly upset about a friendship that was long-lived, yet unsatisfying.  As the story unfolded, she deftly reached into her purse, brought out a small packet of tissues and retrieved one to neatly dab the few tears that started to form. Nonetheless, my office happens to be well endowed with tissues.  There are two open boxes next to the couch, one on either side.  And, there’s another full box next to me, across from the couch, within arm’s reach.

Carole had been in psychotherapy for about a year at that point.  She has a sharp sense of humor, and a conservative, yet stylish appearance.  At the start of each session, she’d take out a neatly folded piece of paper with her agenda.  After placing her slender reading glasses on the bridge of her nose, she’d recite the issues of the week one by one. We would then find strategies to address the said concerns, and, if appropriate, make a plan for the upcoming week.

As I had come to discover, Carole is someone who is independent, does things for herself, and has a hard time asking for help. All this was embodied in the simple gesture of procuring from her meager supply of tissues rather than taking from someone else’s abundant offering.  When I first mentioned this observation, Carole was startled. She questioned why I was seemingly departing from the subject at hand, her trouble with her friend, to talk about her tissue choice.  I proposed that, in fact, there very well could be a connection between her choice of tissue and her choice of friends.  In many ways she could tolerate a good deal from friends who might not be supportive of her because Carole did so much for herself. It would always take a long time to see who among her friends was selfish since there was never an opportunity for them to offer her anything she didn’t have or need.  

Following that appointment, we embarked on a series of sessions to explore when and how Carole could ask for something from others.  She came to find that rather than face disappointment she would prefer to do for herself.  However, in the long run she faced more disappointment with those who had little to offer her.  With trepidation, she ventured to ask for help or favors.  She faced initial emotional scars, but was able to overcome the self-imposed limitation in the service of more satisfying friendships.  And, with her closest relationships, she grew to appreciate what they could give her.  

I don’t mean to imply that within a few weeks, Carole was cured.  It took many months to work through the issues that asking for help presented.  But with time and persistence, breakthroughs were made. 

And with her personal breakthroughs, came a new professional measure for me.  As a psychotherapist, tissues are the tools of my trade.  Many come because they are in pain and need impartial intervention.  Some strict analysts believe that having tissues at all is a betrayal of impartiality.  However, I believe my clients are going through tough times, and my office should be a safe and accommodating place, thus, the tissues. 

Before therapists start private practices, we go through graduate and post-graduate training.  That training usually gives us a limited view of what’s going to happen sitting in our chairs. One component of what we learn is how to interpret the patient’s narrative by using a theoretic framework. And, we learn to have a non-judgmental stance, we learn to listen and, hopefully to use our intuition by way of checking in with ourselves.  This is called counter-transference.  And, by using my counter-transference I was able to identify Carole’s pattern when she reached for her own tissue.

If we’re lucky we’ll get to know something about body language.  We’ll be able to recognize the nuances of voice or facial ticks.  But what about other behavior?   Although I noticed how my clients used tissues, until Carole, I didn’t bring it into clients’ sessions.   It was identifying a visual cue, something we don’t traditionally learn in school,  that opened up this new territory in my practice. 

Another patient, Rita, was a 19-year old college graduate who regularly came in wearing workout clothes.  When sobbing, she would take one tissue after another, and throw them out after barely touching her face. Some would get balled up before they even got near a tear.  While I sat there in awe, I wondered if I would be opening a new box before my next client came. Rita had a history of binge eating, not tasting her food, and then moving on to the next item. I could see how hard it was for her to use what she had because she didn’t even experience having it in the first place.

We spoke of the tissues as it was a relatively innocuous topic, rather than the loaded subject of her body and her relationship to food.  She was open to the idea of taking a tissue, feeling it in her hand, and disposing it once it was used up.  It took a little getting used to, as she had to stay in the moment and see what it meant for her to feel what was going on.  This was a challenge because her impulsivity was a way to silent her feelings and focus on something outside of herself. 

By using her tissues rather than disposing of them after merely handling them for a moment, we were able to segway into the subject of her binging, and use the same principles we used with managing the tissues.  Again, the tissues became a therapeutic device used to address Rita’s eating disorder.

Then there was Maria, who had a different issue altogether.  She is a bright, immigrant from Argentina who put herself through college, and was working in a non-profit organization. She dressed in designer outfits.  She explained she would rather have a few good outfits than a lot of cheap clothing.  Maria would take her used tissues with her when she left. She didn’t want to leave her trash behind. She worried about what others thought of her; and it was too scary for her to leave her dirty tissues with me, as if by doing so, she would leave me with a bad impression.  She was afraid that when she left I would think poorly of her.  As we explored her background, we came to discover she was often made fun of and others would talk behind her back.  Breaking it down, taking her trash with her was an unconscious desire to prevent this from happening to her now.  It took over a year before she was able to leave a dirty tissue, and return the next week to talk about her lingering anxiety.  Again, it was her tissue usage that put her unconscious fears on our radar.  It’s probable that she wouldn’t have spoken of these fears sooner since she was self editing.  But she rose to the occasion once it was brought into the room, as it were. 

Some clients will sob without touching a tissue, letting the tears stream freely.  Is this telling me that they are not able to take care of even their basic needs?  Or, does it tell me they are completely in the moment and are in touch with their core emotions?  It is my job to make a judgment call when tissue use parallels other issues, and when it’s not emblematic of the bigger picture.  

By observing how a client handles her or his tissues, I, as the therapist, can learn a great deal about the way that particular person operates in the world.  For example, Carole’s private stash of tissues revealed more than her preparedness for any event.  And, Rita gave me a taste of her relationship with food.  While Maria spelled out her fears by taking her tissues with her. 

Because my clients were able to talk about their tissue handling, they were able to take a safe circumstance and start making changes in their lives. What did it mean to leave tissues in the trash can, specifically placed there for that purpose? How frightening that was at first, and how freeing to dispose of them in the end. Could, Rita, a binge eater feel the tissue in her hand and use it until it was damp enough to throw out? Could she translate that into a meal? Eventually she could. And, as demonstrated earlier, Carole learned to use the office tissues, and she was eventually able to enjoy more satisfying relationships outside of her therapy. 

It might not seem earth shattering to change how we use tissues. In fact, we can read an article and alter old tissue habits. However, learning that something we do as a matter of course is key to other aspects of our lives can be transformative. In my experience, the premise of psychotherapy is finding greater insight, and then expanding our conscious understanding of ourselves towards a greater quality of life. Often we can go to our past. Or, we can look at what’s happening in the here and now. Perhaps in the therapy office, as in life, sometimes a tissue isn’t just a tissue.



By Janet Zinn, LCSW MSW, LCSW
All rights reserved. Any reproducing of this article must have the author name and all the links intact.

Author: MSW, LCSW

Biography: Janet Zinn is a psychotherapist in private practice. She is a freelance writer & coach.

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