Kleenex in Psychotherapy

Kleenex was the topic in supervision this week. My student asked if I hand clients a tissue when they're crying or let them get it on their own. A lively discussion followed. Believe it or not, conversations like this could keep us talking for hours.

BTW: I know it's called facial tissue. I'm using the product name Kleenex® because 1.) everyone calls it Kleenex, and 2.) I'm trying to attract an endorsement deal. Athletes get shoe contracts and race car drivers plug everything in the hardware store, let's score me the first therapist advertising contract. I'd even consider the college bowl treatment and rename my practice Ryan Howes, Ph.D., presented by Kleenex if I'm hooked up with a fat signing bonus and 40 years of premium aloe vera tissues.

Supervisor is one of the many hats therapists wear and one of the critical elements of therapist training. During supervision the licensed clinician and trainee pool all their resources to help understand the client's experience to improve the treatment. We talk about background information, diagnoses, diversity issues, treatment plans, community resources, case conceptualization, the therapeutic relationship and behavioral observations. That last item, behavioral observation, means we pay attention to the physical actions clients show us during the session. Does she talk fast? Is hygiene an issue? How does he sit in the chair? And once in a while an issue like this comes up: what does she do with the Kleenex?

Through the years it's become apparent that some clients (including us, as most of us have been in our own therapy) handle the Kleenex in specific ways. Here's a small sample:

• The Gap: Grab, fold, dab, unfold, refold, repeat.
• Marsupial: One tissue per tear, each rolled in a little ball, delivered en masse to the trash in a two-handed pouch.
• Peek-a-Boo: Tissue held by the corners at eyebrow level, concealing a tearful face.
• Lone Ranger: A single tissue truly tested to the limits of absorption and resiliency.
• B.Y.O.K.: A full Kleenex box sits next to the client, but when tears come she pulls a travel pack from her purse.
• Commando: Kleenex be damned. I'm letting these tears stream down unencumbered by absorbent paper.
• W.W.K.D.? One well-folded Kleenex, held in a fist with just the top popping out for a quick eye dab. Held with the reverence some reserve for rosary beads.

I crack wise here, but tears are serious business in therapy. When someone reaches for the tissue I know we're out of small talk and into emotion, the realm where we tend to find relief, insight and change. Tears are a sign we're on to something. I don't take that lightly.

So what do these Kleenex styles mean? Feel free to interpret for yourself. I can't paint with broad strokes here, the behavior can mean something different for each person in a given session. But when we're talking about a specific case, information like this can tell us something, giving a clue about who the client is and why they do what they do. We watch, make a mental note, and if we're in supervision or consultation, it might become a topic for discussion.

Behavioral observations like these matter because they give us data. The psyche is so complex and mysterious that we need all the data we can gather to help us understand what is happening and what needs to be done. That's why we pay attention when you're 12 minutes late. Or why we're curious about your new wardrobe. It's why we ask about a scowl on your face or a twinkle in your eye. Many times, our inquiry hits a dead end as we can't find meaning behind the out-of-the-ordinary conduct. But once in a while we find out you're always late because you're afraid to see someone in the waiting room, or you bring your own Kleenex because you don't want to be a burden, or you dress up for sessions because you hope it will help us like you more. We look at the little things because sometimes they point to bigger things, and all that information can help us understand and ideally help you.

Clients might feel uncomfortable with this at first. In other contexts, someone watching this closely means scrutiny and judgment. Not in therapy. We pay close attention to behavior because all this non-verbal communication can help us better understand the symptoms and issues clients want help resolving. Again, it's not for criticism, but for data.

Back to the supervision session. Do I hand clients a Kleenex? No, it's always within arms reach for them. If it seems like they haven't seen it I'll let them know it's nearby. But I don't get up and walk over to the end table to grab a Kleenex and hand it to them. That gesture would go against my beliefs regarding client empowerment. I'll provide the Kleenex, you can grab it and use it however you please, or not. I'll observe and take note, and if something clinically relevant catches my eye I'll make a comment. And that's how we'll do things.

As for the facial tissue itself, it's always top-shelf stuff. The softest, most absorbent, most durable tissue money can buy. There aren't many physical products I provide for my clients, so I'm not about to scrimp on tissue. Only the best. Kleenex® brand facial tissue: It Feels Good to Feel™.