NDJ:7 Judith Pitlick, LPCC

The Tissue Box

Images of white and purple flowers adorned the cardboard box on the table beside the therapy chair. The box was filled with soft white tissues, neatly folded, overlapped and ready. They were advertised as “ultra soft/deux,” and promised comfort and consolation from painful feelings and suffering. At any moment they might be pulled from their safe dwelling, with an angry yank, a gentle tug, or an emotional flare.

The young blonde woman, my patient, was crying. Much to my surprise, twenty minutes into our therapy session she had already used ten tissues. By thirty minutes into the session she used five more. That was a tissue every two minutes. At that rate she would use at least twenty five tissues by the end of a fifty minute session. With eighty five in a box, she would use almost one third of a box in only one session.

This scenario repeated for months. I felt irritated as I estimated the cost of supplying her with tissues, and her unusually low fee added to my irritation. I tried to reason with myself that the cost of a box of tissues was minimal, and that I should feel pleased to provide this comfort to my patients. I knew that I had a responsibility to analyze my exaggerated reaction.

During each session I continued to count tissues and calculate costs. I felt distracted and was mesmerized by her devouring my tissues with wild abandon. During one session, this distressed woman extracted the last remaining tissue in the box. I froze, wondering what she, and I, would do. She looked at me, longingly eyed the plump box of tissues beside me, and inquired if I had more for her. Somewhat reluctantly, I reached for the box, greedily removed one for myself, and handed it over. Relieved, she accepted the box and dove in for a tissue. I silently lamented that I would need to find time the next day to go the store and purchase more.

At times during sessions I found myself reluctant to bring up or respond to upsetting issues, anxious that more tears might be stimulated, which would require more tissues. When we agreed to increase our sessions from once to twice a week to enrich and deepen our work together, I knew I would have to be witness to the disappearance of more tissues, which would incur greater costs. I struggled to find a helpful way to bring this complex, but interesting, enactment to my patient for analysis.

With the increase of sessions there was a stunning shift in our work, which shed light upon the tissue issue. This young woman, one of several daughters close in age, born to a depressed, dissatisfied mother and a relatively absent father, began to tell her story in more detail. At the time of therapy she was training to be a mental health professional, and was aware of her inability to feel the empathy which was so essential in her work. Her warm, somewhat passive, but loving boyfriend broke up with her after she was repeatedly mean and uncaring toward him. She was bereft at the loss of their future together. We understood that she repeated with her boyfriend the empty, unloving relationship between her parents, leaving her emotionally isolated, like her mother.

With me, she externalized her needy, greedy feelings for her overwhelmed, depressed mother, as she consumed my tissues and stimulated in me unrealistic monetary concerns. From infancy into adulthood she felt she did not get enough from her mother, and she made me feel as though I did not have enough for myself or for her. In part, my “ultra soft/deux” tissues were an attempt at finding a substitute for the comfort and nurturing she longed for from her mother and hoped for from me in the transference. As her memories increased, her need for tissues decreased. With the untangling of the enactment, I felt more empathy for her, and she felt more empathy for herself and in her work.

Her perverse attachment to suffering helped us understand her sado-masochistic conflict. I had held in fantasy my sadistic impulse to stop her from using so many tissues. Over time, we were able to think together about the numerous instinctual meanings that were stimulated by her depletion of my tissues.