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Title of Course: The Use of Humor in Therapy CE Credit: 2 Hours Learning Level: Intermediate Author: Louis R. Franzini, PhD Abstract: Should therapists and counselors use humor as a therapeutic technique? If so, should they be formally trained in those procedures before their implementation? This course will review the risks and benefits of using humor in therapy and the relevant historical controversies of this proposal. The paucity of rigorous empirical research on the effectiveness of this form of clinical intervention is exceeded only by the absence of any training for those practitioners interested in applying humor techniques. In this course a representative sample of its many advocates' recommendations to incorporate humor in the practice of psychological therapies is reviewed. Therapeutic humor is defined, the role of therapists' personal qualities is discussed, and possible reasons for the profession's past resistance to promoting humor in therapy are described. Research perspectives for the evaluation of humor training are presented with illustrative examples of important empirical questions still needing to be answered. Learning Outcomes: 1. Define therapeutic humor 2. List at least 7 specific benefits of using humor in therapy 3. List at least 5 specific risks of using humor in therapy 4. Identify at least 3 pressing research needs regarding humor in therapy 5. Name at least 4 scientific problematic issues with much of the past and current research on humor in therapy 6. Name at least 3 major training issues regarding humor in therapy Author Bio: Louis R. Franzini, PhD, received his B.S. degree in Psychology from the University of Pittsburgh, his M.A. degree in Clinical Psychology at the University of Toledo, and his Ph.D. in Clinical Psychology from the University of Pittsburgh. He then completed a Postdoctoral Fellowship in Behavior Modification at the State University of New York at Stony Brook (now Stony Brook University). Following the postdoctoral program, Dr. Franzini joined the Psychology Department at San Diego State University where he spent his entire academic career. He retired as Emeritus Professor of Psychology. His international academic experience included a number of appointments as Distinguished Professor of Psychology. Dr. Franzini is licensed as a psychologist in Florida and in California. Course Directions: This online course provides instant access to the course materials (this PDF document) and CE test. Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion. You can print the test (download test from My Courses tab of your account) and mark your answers on it while reading this course document. Then submit online when ready to receive credit. Email any questions to [email protected] – we’re here to help!


The Use of Humor in Therapy

Introduction

We are seeing an increasing interest in interdisciplinary humor research in the form of newsletters, web sites, humor and play conferences, an international interdisciplinary academic society for humor studies, psychology journal articles, and an entire research journal Humor: International Journal of Humor Research whose first issue was published in 1973. Within the field of psychotherapy, four handbooks of "humor and psychotherapy" (Buckman, I994a; Fry & Salameh, 1987, 1993; Salameh & Fry, 2001) have appeared, all advocating the application of humor. An innovative incarnation is a popular online chat hosted by social worker Mark Gorkin (2014), a self-proclaimed "psychohumorist," who in a monthly newsletter offers advice heavily laced with humor on how to deal with life and work-induced stress. Finally, the interdisciplinary Association for Applied and Therapeutic Humor (AATH) promotes the healing power of laughter and humor in its newsletter and annual conferences. There even are guidelines on how to form your own local laughter clubs, which purportedly can help you achieve such idealistic goals as personal health and happiness and ultimately even world peace (Kataria, 1999)! Most advocates of using humor in therapy and counseling have written from a variety of dynamic theoretical orientations (e.g., Cassell, 1974; Dewane, 1978; Mann, 1991; Mosak, 1987; O’Connell, 1975; 1981; Shaughnessy, 1984; Strean, 1994) or rational-emotive perspectives (Ellis, 1977; Ellis & Dryden, 1987). Their essays and clinical anecdotes indicate many potential therapeutic benefits from applications of humor. Vera Robinson (1977) was an early advocate for health care professionals to use humor, both as a healing tool for the benefit of their patients and as a stress reduction tool for themselves as well. She argued colorfully that humor is “the bullet proof vest that protects against the ravages of negative emotions.” The call for the use of humor in therapy has been longstanding and is growing stronger, even though most of those salubrious claims remain essentially untested empirically. Little has changed since Bernard Saper's (1987) review of humor in psychotherapy in which he called for more controlled empirical proof of the effectiveness and value of humor, while acknowledging that such research would be "formidable, if not impossible." Rod Martin (2007) reviewed the published research on humor in therapy and concluded that the overall results on its effectiveness are “mixed”. Some studies found clearly positive effects, while others found negative effects or no effects at all. However, the scientific rigor of nearly all of those studies was quite weak. Later in this course we will summarize the serious criticisms, which plague most of the use of humor in therapy research. Other reviewers examining the literature after Saper (1987) in the subsequent decade and beyond, such as Salameh and Fry (2001), are decidedly more sanguine about the supportive empirical work affirming the value of humor in therapy to both the client and the process itself.

Definitions of Therapeutic Humor

Therapeutic humor includes both the intentional and spontaneous use of humor techniques by therapists and other health care professionals, which can lead to improvements in the self-understanding and behavior of clients or patients. To be most helpful, the humorous point should have a detectable relevance to the client's own conflict situation or personal characteristics.


The form of the humor could include a formal structured joke or riddle (although that would be relatively rare), a pointing out of absurdities, an unintended pun or spoonerism, overtly behavioral or verbal parapraxes, examples of illogical reasoning, exaggerations to the extreme, statements of therapist self-deprecation, repeating an amusing punch line, illustrations of universal human frailties, or comical observations of current social and environmental events. In some cases, the therapist’s comments are illustrated with comic props or cartoons that make a therapeutic point individualized for that client. Typically, the result is a positive emotional experience shared by the therapist and the client, which could range anywhere from quiet empathic amusement to overt loud laughter (Franzini, 2001). The AATH's official definition of therapeutic humor formally adopted in 2000 is "any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life's situation. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, social or spiritual” (AATH, 2014). Salameh's (1987) statement could be added here as well, "Therapeutic humor is well timed, taking into account the patient's sensitivities and specific needs at the moment when a humorous intervention is considered. The judicious therapist is also aware of when not to use humor, depending upon the therapeutic material under discussion and the patient's level of absorption." He stressed that humor is the best gift we can offer our patients because it demonstrates constructively that with a newly acquired positive view, their problems become solvable. Mindess's (1971) definition of therapeutic humor is both comprehensive and persuasive. "Deep, genuine humor—the humor that deserves to be called therapeutic, that can be instrumental in our lives—extends beyond jokes, beyond wit, beyond laughter itself to a peculiar frame of mind. It is an inner condition, a stance, a point of view, or in the largest sense an attitude to life." The distinction between humor as a construct versus laughter as a behavioral event is important and has research implications. The terms are not interchangeable, and each may well have different consequences, which, in turn, can be investigated. Ventis (1987) noted that "the disputed cathartic effects of laughter are not critical for possible therapeutic effects of humor." In his review of humor in psychotherapy, Saper (1987) defined humor as "an affective, cognitive, or aesthetic aspect of a person, stimulus, or event that evokes such indications of amusement, joy, or mirth as the laughing, smiling, or giggling response. The personality trait sense of humor embraces at least two human capacities: appreciation, or the set to perceive things as being funny, and creativity, or the ability to say and do funny things, to be witty. It implies a readiness to find something to laugh about even in one's own adversity." The reputed personal benefits of humor appear across multiple domains: medical (e.g., the alleviation of pain and increased quality of life in terminally ill patients [cf. Kisner, 1994]), physiological (e.g., an increase in released endorphins [Levinthal, 1988] and improvements in natural killer cell activity (Bennett, 1998), social (e.g., becoming a more pleasing social stimulus and expanding one's network of friends [Ruch,1998; Salameh & Fry, 2001]), and psychological (e.g., providing an effective coping device to, modulate stress and enhancing an appealing personality trait [cf. Buckman, 1994a; Fry & Salameh, 1987; Kuiper & Martin, 1998]).


Therapist Steven Sultanoff (2014) adds to the discussion, “My belief is that we are going to eventually discover that the most dramatic health benefits of humor are not in laughter, but in the cognitive and emotional management that humorous experiences provide. The experience of humor relieves emotional distress and assists in changing negative thinking patterns.”

Therapeutic Benefits Freud (1938) himself reportedly told jokes to his patients upon occasion and wrote of the psychological usefulness of humor in gratifying sexual and aggressive drives, which otherwise would be censored or frustrated. According to Swaminath (2006), “Freud postulated that humour works by means of two principal mechanisms, ‘condensation’ and ‘displacement.’ Condensation entails an economy in thought and expression and conserves psychic energy, and displacement transfers this psychic energy arising from conflict or incongruity to a humorous anecdote, which brings relief. Freud believed that cultivating a sense of humour could help lift repression (i.e. unconscious conflictual material) but could also be harmful, particularly in certain forms of sarcasm and irony, directed at the self.” However, it is the psychoanalyst Martin Grotjahn who is credited with first publicly espousing the use of humor in psychotherapy in 1949 in Samiska, an obscure journal of the Indian Psycho-Analytic Society. Since then, there have been increasingly frequent calls for the use of humor in psychotherapy. For example, Kuhlman (1984), speaking for its many advocates, pointed out, "Humor can serve as a potent force in change processes and has a place within the psychotherapeutic relationship as it does in all other forms of human relationships." Interestingly, in his review Kuhlman quoted Carl Rogers, the founder of the once quite popular relationship-based client-centered therapy as eschewing humor because "therapy is hard work." Presumed Specific Benefits of Using Humor in Therapy and Counseling Theorists of therapy and counseling have mentioned numerous possible benefits of the judicious use of humor in therapy and counseling. Franzini’s (2001) review of the topic included a list of different positive uses of humor as suggested in 52 articles, chapters, and books by “representative theorists,” in a non-exclusive compilation from the literature at that time. Many writers mentioned multiple advantages of humor use. Thus, to avoid repetitive overlapping, the list below reflects only those unique uses presented in each of the referenced publications in Appendix A. Such lists of potential benefits and risks of using humor in therapy and counseling are necessarily incomplete and often represent the educated opinions of experienced therapists. However, it should be noted that very few of those therapists’ assertions have been empirically tested. Some of them are contradictory. For example, some theorists suggest that humor should especially be used with depressed patients, while others say it must be avoided with depressed patients. Controlled research is very much needed on the most effective ways to utilize humor in therapy and counseling.


Among the most common functions and benefits of properly applied humor in therapy and counseling are:

• Building trust and empathy • Augmenting and solidifying rapport • Facilitating communication • Aiding both diagnosis and treatment plans • Gaining an accurate understanding of the client’s thoughts, feelings, and behavior • Helping client focus • Enhancing resilience • Improving mood and adding joy • Changing client’s perspective on the problem • Reducing guilt, shame, and/or anxiety • Viewing painful events as less threatening • Decreasing obstructive awe of the therapist • Conveying the message that the therapist is human • Encouraging communication and succinct messages • Lowering concerns about engaging in treatment • Talking with parents about the problems of their adolescent children • Demonstrating that personal problems are solvable • Stimulating insight into sources of conflict • Reducing emotional distress • Modifying dysfunctional behavior patterns • Counterconditioning anger • Restoring patient’s dignity and sense of self worth • Facilitating the healing process by shared laughter which contains a feeling of mutual affection • Improving the four main domains of functioning: feelings, behaviors, thinking, and biochemistry • Enhancing physical functioning, e.g., immune system, stress reduction, pain tolerance, neuroendocrine hormones

reduction, overall sense of well-being by triggering the release of endorphins, relaxes muscles, prevents heart disease, facilitates the respiratory and circulatory systems and even more alleged biological benefits (American Cancer Society, 2008; Chapman & Chapman-Santana, 1995; Johnson, 2009; Martin, 2007; Salameh, 1987; Smith & Segal, 2014; Sultanoff, 1992; Swaminath, 2006).

In a survey of published research on the use of humor specifically within the practice of behavior therapy, Franzini (2000) found no explicit mention of humor other than two case reports (Smith, 1973; Ventis, 1973). Nevertheless, 98% of the practicing behavior therapists in Franzini's sample endorsed the intentional use of humor in therapy, especially for these purposes: to help establish rapport, to illustrate the client's illogical or irrational thinking, and to share a positive emotional experience with the client. Larry Ventis (1987), one of the two case study authors cited in Franzini's article, also reviewed the purposeful use of humor in behavior therapy and found only the same two contributions plus an unpublished 1985 doctoral dissertation on the topic. Ventis elaborated that humor in behavior therapy can potentially serve several specific functions. He suggested that it can be used to compensate for inadequate levels of relaxation within systematic desensitization, it can promote self-efficacy in aiding the client in coping with previously difficult situations, and it can facilitate assertion training by reducing clients' fears while also teaching appropriate expressions of feelings in angry individuals. The American Psychological Association's Monitor magazine featured the "new" notion of therapeutic humor "to promote healing" (McGuire, 1999). In the Letters to the Editor in subsequent issues, the article received praise from a clinical psychology doctoral student, who wondered why psychologists needed reminding of their humanity (Passarelli, 1999) and also a caveat from Kazdin (1999), who warned, "It will be a very sad day if humor is promoted as treatment without evidence in its behalf." In fairness, Kazdin’s argument was more in favor of only using evidence-based treatment techniques than condemning humor use per se.


Presumed Potential Risks of Using Humor in Therapy and Counseling

• Poorly timed humor could damage the therapeutic relationship • Harmful humor (e.g., ridicule or mockery) could exacerbate a client’s problems • Some forms of humor could undermine the client’s sense of personal worth and esteem • Sarcasm could create resentment in the client of the therapist and the process • Client might feel alienated and rejected by the therapist • Therapist might be perceived as trivializing the client’s problems • Therapists could use humor more for their own gratification than for helping the client • Therapist could be perceived as less caring, competent, or potentially helpful (Franzini, 2001; Sultanoff, 1992; Swaminath, 2006)

Appendix B lists more of the specific risks mentioned by numerous theorists and therapists and the associated references. Caveats to Using Humor in Therapy and Counseling The strongest advocates of using humor in therapy also remind us that certain precautions in its use are definitely appropriate (Johnson, 2009; Sultanoff, 1992). For example, Waleed Salameh, who has been one of the most prolific writers promoting humor therapy, reprinted in his 1987 handbook an excellent chart contrasting the characteristics of helpful and harmful therapeutic humor. The late Stanford psychiatrist William Fry was one of the earliest and strongest proponents of therapeutic humor, but he also acknowledged that there are circumstances in which it could be detrimental. Saper (1987) suggested that improper humor is any humor that "humiliates, deprecates, or undermines the self-esteem, intelligence, or well-being of a client." Surely no one would disagree. Martin (2007) among others warns of the possible deleterious effects of using humor in therapy, “… humor may be nontherapeutic, and even harmful, if it leaves clients feeling misunderstood, if it conveys a sense of dismissing or denigrating their feelings and perceptions, or if it is used by therapists to mask their own feelings of discomfort with the issues raised by their clients.” As is the case in many aspects of therapy and counseling, the matter of incorporating humor in the process is a complicated matter. The professional must assess the client’s readiness to accept humor use and be aware that its use could serve multiple functions. The therapist must be aware of them and insure that those functions are positive and clearly for the benefit of the client. Reynes and Allen (1987) urged "a balanced awareness of its risks and benefits." Thomson (1990) noted that humor in therapy can have a powerful impact, positive and negative, and so should be attempted only after establishing a strong therapeutic relationship. Ventis (1987) cautioned "therapists at any level of experience . . . to remember that the use of humor and laughter in therapy is not a goal in itself but one option for facilitating therapy." Saper (1987) explicitly predicted a disaster if the adoption of humor in psychotherapy was 'premature'.


Rarely does anyone come out 100% opposed to the use of humor in therapy. The closest to that position is probably Kubie's (1971) classic paper aptly titled "The Destructive Potential of Humor in Psychotherapy." Even Kubie was careful to point out that he was not intending "to persuade anyone never to use humor or that humor is always destructive" [italics in original]). Although he did acknowledge that "sometimes humor expresses true warmth and affection," he remained adamant that its role in psychotherapy, if any, is "very limited.” Patients' Humor In its simplest paradigm, psychotherapy is a dyad. The focus of the present discussion primarily concerns the use of humor by the therapist, although the patients too, may use humor or attempt to do so. It is very important how the therapist reacts to the patient's humor efforts. The therapist could laugh genuinely with the patient, laugh falsely out of pity or sympathy, laugh disparagingly, attempt to top the patient with a better story or remark, or instantly attempt to "use" these humor data to interpret cracks or quirks in the patient's personality structure or to diagnose hidden psychopathological tendencies. All of these reactions, except the first, would probably be therapeutically counterproductive.

Salameh (1987) provided specific guidelines on how to introduce humor with different patients who may reveal their negative past experiences with harmful humor. Some patients may exhibit symptoms such as depression or paranoia, which are likely to be associated with misinterpretations of a therapist's well-intentioned humor interventions. Saper (1987) confirmed the importance of establishing a strong relationship with the client and gauging whether the client can accept the therapist in a humorous role. These assertions should be regarded as empirical questions to be researched in controlled studies. Relatively little has been written about the use of humor in couples' treatment (Buckman, 1994b; Schnarch, 1990) or group therapy (cf. Bloch, 1987; Bloch, Browning, & McGrath, 1983; Grotjahn, 1971; Hankins-McNary, 1979; Vargas, 1961), although the group setting would seem to be a natural opportunity for the use of humor by both patients and therapists because of its built-in audience. Salameh (1983) summarized the findings from three unpublished doctoral dissertations on the use of humor in group therapy: (1) that humor could facilitate or disrupt the group process (Childs, 1975); (2) that matching child-care workers with young male delinquents on the basis of levels of successful humor was associated with fewer instances of delinquency (Taubman, 1980); and (3) that laughter episodes indicated an ongoing or imminent shift in the direction or level of group interactions (Peterson, 1980).

Resistance to Therapeutic Humor

Psychotherapy has a very long tradition of being a grim and sober professional enterprise designed to treat psychopathology and to eradicate the pervasive symptoms of mental illness in our society. Saper (1987) used such language and tone when he pointed out that the context of psychotherapy sessions defines "a major problem of attempting to inject levity into a grave and solemn enterprise such as therapy." Swaminath (2006) also acknowledged how difficult it is for health care professionals to “find a workable balance between the toughness necessary to face up to difficult and even threatening behaviour on a regular basis, while at the same time retaining sensitivity, compassion, and interpersonal skills.” Therapists' traditional goals have been to treat, to cure, to teach, and to eliminate disabling and debilitating symptoms and interpersonal conflicts. Surely these are serious and important objectives for our individual patients and for the social benefits to society at large.


Why have therapists and their educators been slow or even actively resistant to incorporating humor into their armamentarium? Several likely reasons emerge: (1) Consistent with the notion of the gravity of mental disorders, psychotherapists have been formally charged with taking themselves too seriously (Ellis, 1977; Kaneko, 1971; Mindess, 1971; Swaminath, 2006). Not only do they see their professional work as very important and serious, they see themselves as very important and serious (present readers excepted, of course).

Harvey Mindess (1971; 1976; 2001) has long been an outspoken advocate of therapeutic humor. Yet, even he claims that as long as therapists are committed to the belief that their theories and techniques of therapy are "cogent, valid, and beneficial, … a deep and genuine sense of humor cannot be achieved and therefore promoted" (1971). Thus, (2) if therapists strongly believe that their techniques are already sufficiently powerful to help their patients, they may feel it is unnecessary to add any new procedure to the process. Ventis (1987) made a similar point with regard to behavior therapists (3) who, thus far, have felt no particular pressure to add humor techniques to their repertoires because their standard clinical procedures have been shown empirically to be so successful. Nevertheless, he suggested that adding humor and laughter would facilitate the practice of behavior therapy. Note that Franzini’s (2000) survey data showed that almost all behavior therapists favored incorporating humor into their therapies, but few actually did so.

Jolley (1982) conjectured that (4) "those therapists who are resistant to humor have difficulty with the issues of closeness and power, and that is a major reason why humor is not considered a 'legitimate' tool in some therapeutic societies." She also highlighted the relevance of the therapist's standard stance of omnipotence and the usual accompanying professional role expectations. (5) "The real fear stems from how a therapist who uses humor will be seen through the eyes of his colleagues. A person who laughs with someone is sharing, and a therapist who does this is giving away some of his power, putting him more or less on, an equal level." Another contributing factor is (6) that many psychotherapists simply may not have the humor skills to implement humor techniques in therapy. Most people, including therapists, can tolerate nearly any epithet about themselves except that they are humorless. Humor theorists have identified two major components to a person's sense of humor: being a humor initiator and a humor appreciator (cf. Lefcourt & Martin, 1986). Although many psychotherapists may be humor appreciators, it could be that relatively few are themselves effective humor initiators in any context. Thus, therapists, while possibly self-reporting excellent senses of humor, may still not perceive themselves as active humor makers or deem its use to be appropriate in psychotherapy. (7) A small percentage of therapists may even agree with Kubie (1971), Kazdin (1999), and Saper (1987) that humor in therapy could at times be "dangerous." A further complication is that the classroom instructors and senior clinical supervisors of novice therapists historically have discouraged the use of humor as part of the psychotherapeutic process. Despite any personal preferences to the contrary, it seems highly probable that therapists in training would pragmatically adopt this no-humor-in-therapy value. (8) Modeling processes and the reward power of supervisors are very effective in producing similar values and, as is likely in this case, non-humor behavior in their students (cf. Egan, 1998). A notable recent exception is found in a chapter by Ed Dunkelblau and two of his supervisees in which they described the effective use of humor in therapy supervision and noted the many striking parallels between the processes of psychotherapy and stages of clinical supervision (Dunkelblau, McRay, & McFadden, 2001)). Although they appropriately acknowledged potential risks of humorous interventions in supervision, such as using humor to avoid serious topics or to deny angry feelings, they strongly recommended using humor for its valuable gratifying, nurturing, and educational qualities. They suggested that humor enhances the supervisory relationship and fosters both competencies in clinical skills and a clear professional identity.


A Modest Proposal Given humor's potential therapeutic benefit for clients, it seems prudent to recommend that the use of humor in therapy be conducted by qualified practitioners and its effectiveness evaluated empirically. A compelling procedural dilemma emerges. Should this "new" clinical technique, or any innovative treatment procedure, first be demonstrated to be effective in controlled research, or should clinicians first be trained in the technique and the evaluation done subsequently? In view of the apparently increasing interest in using humor in therapy, perhaps serious efforts should now be directed to developing a formal course in humor training to be offered to all psychological therapists, regardless of their specific theoretical orientation: psychodynamic, behavioral, cognitive, or the most frequently endorsed orientation, eclectic therapy. This humor training can be accomplished through classroom seminars, workshops, lectures, assigned readings, demonstrations, exercises in humor writing and performance, and, most important, as a part of the clinical supervision process. The opportunity for formal humor training would represent a revolutionary curricular development in the education of therapists. The success of therapeutic humor relies heavily on spontaneity. Familiarity with humor methods from such formal training opportunities would make their spontaneous use more likely (Banmen, 1982). Sultanoff (1992) emphasizes the seemingly oxymoronic concept of “planned spontaneity.” He argues that effective therapeutic humor must be both planned and spontaneous. He elaborates, “At any moment during treatment the counselor selects a particular response based on his/her knowledge of the client and what interventions might be effective with a particular client…. The counselor, to be effective, must be prepared with ‘humor tools’ such as cartoons, anecdotes, jokes, puns, signs, props, etc. which illustrate a wide range of psychological issues. However, the way in which these tools are utilized to intervene therapeutically with a particular client is based on the counselor’s understanding of the client and the timing of the intervention. The humor is planned in that it is part of the counselor’s repertoire of skills and like all interventions is used spontaneously to be most effective with the client.” Of course, you cannot command spontaneity. Similarly, you cannot simply order a therapist, novice or experienced, to be funny. In fact, to force humor in a therapy session by a therapist uncomfortable or inexperienced in humor techniques would be unwise and counterproductive. For example, the inappropriate use of satire could lead to a patient feeling humiliated or ridiculed; or the inappropriate use of exaggeration or the telling of a formal joke might create the impression that the therapist is insensitive or uncaring or excessively self-absorbed. Some debate remains about whether the application of humor by therapists can even be taught. Olson (1994) claimed that, like responsibility, “humor cannot be taught didactically, but must be observed and personally experienced to be mastered.” Bloomfield (1980) cited the importance of “intuitively knowing” when to make a humorous remark in therapy. In contrast, Tallmer and Richman (1994) declared that humor as a “therapeutic tool can be learned, but its effectiveness also depends on the artistic and stylistic talents” of the therapist. MacHovec (1991), Killinger (1987), and Salameh (1983) all have argued that applying humor effectively in therapy is a learnable skill.


The Role of Therapists' Personal Qualities In a special category of its own is psychiatrist N. N. Marcus's (1990) incredible recommendation to treat the patient's humor itself! He noted that other therapists have failed to focus on the pathological aspects of their patients' characteristic of "being amused." He argued that when such patients present with "smiling, laughter, and a humorous attitude," they are failing to take themselves seriously. He maintained that such clinically relevant behaviors need to be understood as inappropriate defenses against emotion that should be eliminated by the application of his own structured approach to cognitive therapy. Fellow psychiatrist G. Swaminath (2006) has suggested that “many” ineffective psychiatrists may themselves “suffer from a laughter deficiency disorder.” He noted that Anne Dean in her 1996 British Medical Journal article had analyzed what personal characteristics are necessary for a successful career in psychiatry. On her list was a “well developed sense of humor.” We may also note that the list did not include a thorough understanding of and competence in administering psychoactive medications. You may make your own interpretation of the meaning of that omission. Alert to the committee of professionals planning for the new disorders to add in DSM-VI: the laugh deficiency disorder (Borins, (2003; Burdett, 2014) aka the humor deficit disorder (Feeley, 2006) aka the acquired amusement deficiency syndrome (Jenkins-Fernandez, undated) are being described in the literature as problematic characteristics of both therapists and patients and therefore are in need of change. A variety of suggestions are typically made to bring more humor into a person’s life by watching funny movies, attending comedy clubs, keeping a humor journal, humor spotting in the real world, and practicing joke telling among many other similar ideas. Several books and manuals with humor-building exercises are available for both lay persons and professionals that could be recommended as adjunct bibliotherapy to appropriate clients with such deficit disorders (Franzini, 2012; McGhee, 1994a; 1994b; 2003; 2010a; 2010b). Greenson (1967) had previously suggested that the best therapists possess a good sense of humor. Good rational emotive behavior therapists reputedly actively use humor in therapy to help their clients identify their silly and irrational beliefs (Yankura & Dryden, 1994). Of course, the founder of rational emotive behavior therapy (REBT), Albert Ellis (1977, 1984), has been outspoken in his advocacy of using humor in therapy. Consequently his REBT therapy sessions became vivid and memorable, especially when he led his clients in the group singing of familiar tunes whose silly lyrics had been modified to conform to the principles of REBT (Ellis, 1987). Strean (1994) added that success in using humor also depends on personal qualities of the therapist such as maturity and flexibility. Killinger (1987) also found that a therapist's level of maturity was the key variable in using humor effectively, not the length of his or her professional experience. Nagaraja (1985) noted that the therapist must be "genuine and capable of savoring the comical," while remaining alert to the clinical opportunities humor offers. Salameh (1987) pointed out that humor represents constructive self-disclosure by the therapist who then reveals his or her own human side to the patients: "We cannot prescribe humor for our patients unless we can accept it in our own lives." Greenwald (1977), a psychoanalytically trained psychotherapist and former stand-up comedian, wrote that if more psychiatrists had a sense of humor, they would not have to prescribe so many pills to relieve tension in their patients.


To encourage a humorous outlook in our patients, therapists must keep that dimension alive in themselves. Therapists must continually engage in self-monitoring regarding why they are employing a particular intervention—humorous or otherwise—to ensure that it indeed is enacted for the patient's benefit and not for self-gratification. Humor appreciation and initiation may be easier to facilitate via formal training than the other personal qualities that are universally desired and recommended for therapists such as empathy, genuine concern, emotional warmth, and a sense of moral and ethical responsibility (cf. Egan, 1998). After reviewing therapy outcome research, Martin (2007) concurs with Egan when he makes the subtle point that the value of humor in therapy is not so much the humor per se, but when that humor is presented by therapists who simultaneously convey the essential attitudes of empathy, caring, and genuineness. Those are the personal qualities of all effective therapists. Most of the theorists and therapists referenced in this course have written about the value of humor in therapy and counseling. The evidence for their recommendation, if any, has been in the form of clinical case reports. Anecdotes of success, although intriguing, cannot be scientifically persuasive. Nearly all of these authors make a case for applying humor and may also issue a few words of caution about its inappropriate usage, but they hardly ever become specific about just how therapists might learn to use humor in their practices. Despite the extent of the literature advocating the use of humor in therapy, it is remarkably rare for anyone to recommend specific humor training for practitioners. The few exceptions include Prerost (1985), Salameh (1993; 1994), Sultanoff (1992), and Thomson (1990). For example, Sultanoff (1992) includes physical props in his armamentarium of humor techniques. He keeps juggling balls in his office to illustrate a specific point: “When a client is discussing the many problems he/she is ’juggling,’ I may pull out the balls and show how it is easy to juggle one ball (e.g., a new relationship). However, when there are two balls (e.g., the relationship plus a new job), it becomes more difficult. If we increase to three balls (new relationship, new job, and buying a home), the task is much more difficult. As we add more balls, we find that the balls exceed our capacity to juggle.” Surely, his simple juggling demonstration becomes a memorable and important point that might have easily glossed over with a clichéd comment in the therapy conversation. Another attention-getting prop is a cartoon. Many “comic” (that is, non-editorial) cartoons illustrate points that are relevant to the therapeutic process on specific issues. Some particularly appropriate cartoons for use in therapy are “Lockhorns” (for marital relationships), “Andy Capp” (male chauvinism), “Dilbert” (workplace-related issues), “Dustin” (parenting), “Marvin” (self-improvement), “Non Sequiturs” (irrational thinking) and many others. Therapists could regularly monitor the newspaper comic pages to discover several such cartoons that might be especially apt for the kinds of problems typically presented by their patients. The cartoons could be laminated for durability or even duplicated to hand out to patients to take with them, as a reminder of its cogent therapeutic point as they live their lives in the other 127 hours of each week. Sultanoff (1992) often uses an old Peanuts cartoon “for clients who seem to take on too many of the world’s woes…. Charlie Brown, Sally, and Snoopy are inside the house looking out at a driving rain storm. As they look out into the night’s darkness, Charlie Brown and Sally are sharing how difficult it must be for all the animals out in the storm including the birds, deer, rabbits, and even the little bugs. Snoopy goes off and returns moments later in his slicker and with a flashlight and Charlie Brown says to him, ‘No, I don’t think we can rescue all of them.’ By sharing this cartoon many co-dependent clients gain perspective on their own rescuing behavior. They learn to laugh at themselves while placing perspective on the situation.” This is an excellent example of the value of this technique. Of course, the therapist or counselor has to have done some preparation by seeking out appropriate cartoon stimuli and having them available in the office. That task can be fun for the professional. Not all rewards for the practicing therapist need be cash and their patients’ dramatic improvements and gratitude.


Comic props, such as juggling balls, fake red noses, and cartoons are easy ways to add humor to the therapy session. It is best for the therapist to acquire verbal humor skills as well to be able to react with humor spontaneously, when something inadvertent is said or happens unexpectedly. Such skills are much easier to endorse than to produce. All skills are learnable, but they vary with the complexity and the amount of practice required (even juggling the three balls.) Verbal humor often involves word play, double meanings, careful timing, and a sensitivity about not crossing the line into potential offensiveness or humor that might be perceived as hostile to the client. Franzini’s (2012) book on how to use humor effectively, not designed just for therapists, may be helpful to facilitating your own sense of humor, which could then be incorporated into your practice. Similarly, the self-help books by developmental psychologist and humorist Paul McGhee (1994a and b; 2010b) can be followed to improve your sense of humor. McGhee (1994a) has presented a systematic eight-step humor development training program along with an exercise workbook (1994b) intended for anyone interested in improving his or her sense of humor. Although he specifically suggested that the program was applicable to lay individuals, businesspeople, and self-help groups, it would also seem to be a most appropriate basis for establishing a humor training curriculum for therapists. Supervisors and trainees must first accept the value of incorporating humor into the practice of therapy and commit to acquiring those skills. Formal humor training should include these components: (a) the modeling and reinforcement of therapist humor behaviors by clinical supervisors, (b) specific training in the variety of humor techniques, and (c) sensitivity to any humor attempts by their clients, which can become critical transition points in the therapeutic process. Therapists must first openly accept the value and desirability of adding humor to their therapy. Obviously, to force such training on uninterested students would be counterproductive. There is evidence that some therapists in training desire their supervisors to demonstrate humor as a major feature of the supervisors' relationship skills. In an interview study of 85 family therapy trainees' perceptions of supervisor competence, the most frequently cited criterion was the use of humor (Liddle, Davidson, & Barrett, 1988). According to Liddle et al., the best clinical supervisor "helps trainees use their natural sense of humor in therapy and also uses own sense of humor in the supervisory relationship." The educators and trainers of therapists must themselves appreciate and model the appropriate use of humor in therapy. As noted previously, this appreciation represents a major change from the historical tradition of discouraging humor use. For example, Strean (1993) commented, "It may not always be a sign of unprofessionalism to laugh with the patient when he or she is experiencing true joy and thereby demonstrate that a serious, disciplined relationship has room for laughs, too. . . . In teaching and supervising, I have often found that when students and supervisees are laughing, they can listen with less resistance." Clearly, mentors can shape the professional use of humor by their trainees and interns through their explicit contingent approval of any efforts toward the appropriate use of therapeutic humor. In their discussion of functional family therapy training, Haas, Alexander, and Mas (1988) noted the reward potency of trainers within the supervision process, "The supervisor may provide the trainee with feedback in order to reinforce the trainee's use of that particular tactic. . . . Trainee change will be affected by observational learning, cognitive restructuring, and evaluative feedback." Similarly, supervisors should be alert to potential misuses of humor by their trainees and be ready to offer constructive alternative verbal behaviors. Close supervision of novice therapists' clinical work is always essential, and that attention certainly should not be relaxed when using humor techniques (cf. Dunkelblau et al., 2001).


Finally, future and current therapists who express interest in applying humor in their therapy can be offered didactic humor training seminars featuring discussions, readings, and practice role-plays. Relevant curricular topics in these seminars might include the major psychological theories of humor, the available research findings on the advantages of the proper implementation of therapeutic humor with illustrative examples, the risks from misuses of humor in therapy, practice in sense of humor-building exercises, learning to heighten sensitivity to humor stimuli in the everyday environment, the role of timing, and other specialized humor development and performance techniques. Prerost (1985, 1994) is one of the few humor-use advocates to describe a specific humor training technique for teaching therapists humor skills—the humorous imagery situation technique (HIST). The HIST is a form of therapist-directed imagery primarily designed to reduce anxiety and to reinstate a sense of humor in mildly depressed patients. The technique is quite similar to the systematic desensitization procedure in behavior therapy. Prerost (1985) indicated that the therapist first induces the patient to relax by quasi-hypnotic mental and breathing exercises. Typical non-personalized images are introduced to aid the achievement of a state of relaxation, followed by images which have specific personal meanings to the patient. At this point in the HIST, the therapist draws the patient's attention to humor in the fantasy scenes and then provides comments that are intended to introduce incongruity and laughter into the scenes. Observing humor in the fantasized scenes and the resolution of the incongruities presumably helps the patient reflect on personal concerns and cope with them more effectively. If the HIST were more widely adopted by practitioners, systematic evaluations of its effectiveness could be conducted. Sultanoff (1994) also has provided detailed descriptions about how to train professionals in delivering therapeutic humor and how to distinguish helpful from harmful humor. He pointed out that therapists must first examine the target of the humor and the setting conditions for its delivery; then they must assess that specific patient's receptivity to humor. Targets of humor can be oneself, the situation, or other people. Healthy humor, according to Sultanoff (1994), is "that which brings people together, reduces stress, provides perspective, and feels good," whereas harmful humor is "that which alienates others, increases hostility, and ultimately feels bad." If the humor is aimed at oneself, it is likely to be healthy; if aimed at others, it is likely to be harmful; if aimed at situations, it likely falls in between. Environmental conditions, such as the nature and bond of the relationship, the timing and circumstances of the humor, and the delivery setting are all important factors in successful therapeutic humor. Finally, Sultanoff (1994) suggested assessing the patients' "humor quotient" by careful observation of their use and appreciation of humor to determine the probable degree of receptivity to therapeutic humor. For example, if the patients use humor in healthful ways rather than in distancing ways, such as sarcasm or put-downs, they will likely be receptive. In addition, the therapist can question patients directly about the role that humor plays in their daily lives. Finally, the assessment can include observing the patients' ability to laugh at themselves and noting their responses to the humor presented by the therapist. Laughter or smiling, demonstrating an increase in energy, and sharing some form of one’s own humor indicate a positive receptivity to therapeutic humor.


Salameh (1987, 1994) has created a formal humor training program to train mental health therapists and others in humor creation and development. His Humor Immersion Training teaches humor-making techniques such as overstatement or exaggeration, understatement or simplification, incongruity by synthesizing two non sequiturs, reversals that create new meaning, and wordplay such as puns and layered meanings. Trainees are taught the psychological and physiological benefits of humor, the 11 major attitudes that can block uses of humor, the 11 key distinctions between therapeutic versus harmful humor, and they learn numerous exercises and role-plays through the 12 major facets of the program. Salameh (1994) also urged therapists to use their personal history and their own physical characteristics to identify funniness in their lives that would facilitate their humor making. He also drew upon such diverse sources as the Zen tradition by recommending metaphorical storytelling by the therapist to communicate humor and behavioral environmental management theory by recommending creation of an explicitly humor-oriented consulting room with funny posters, quotes, or cartoons. Research Perspectives for Humor in Therapy Saper (1987), Kazdin (1999), and others have called for empirical studies on the effectiveness of humor in therapy. As with the evaluation of any clinical procedure, new or old, such studies should be ongoing and continual. Salameh (1983) has presented a 5-point Humor Rating Scale, ranging from destructive humor to outstandingly helpful humor, which can assess therapists' use of humor with clients. Each of the five levels of humor is defined in detail and is illustrated by a clinical vignette. This scale could be used to assess changes in therapist humor prior to and following formal training in humor skills. The scale could also be used to measure changes in humor use by the client as therapy progresses and as correlates of symptoms increase or decrease. Salameh (1983) has previously raised a number of critical empirical questions that can be addressed by clinical researchers immediately. For example, is it important for therapeutic effectiveness to match therapists and clients according to their levels of humor use? Does the role of ethnic humor by the client facilitate the therapy process when the ethnicity, age, sex, or religion of the clients and the therapist differ or are the same? Are humor techniques more or less effective with clients of certain personality constellations or with certain symptoms or diagnoses? Which forms of humor stimuli are most effective in therapy? Many important clinical research questions emerge concerning humor as a therapy technique. It would be valuable to know whether a therapist can be equally effective without using humor. Meanwhile, therapists are being encouraged to apply humor in their practices by popular and professional sources. It is being conducted in offices and even on the Internet. Humor as a technique to facilitate clients' new learning and the rethinking of their own problematic situations is now appearing in the latest texts for students who are learning to be professional helpers (i.e., counselors and therapists; cf. Young, 2001). Fry and Salameh (1987) have also identified two likely beneficial side effects of the use of therapeutic humor for the therapists themselves—as a coping device for stress reduction and as a preventive tool for professional burnout. Brooks (1994) has cautioned that therapists should never use humor with a client they do not like. This point represents just another plausible assertion that deserves empirical investigation. One could easily argue the opposite position—that humor could help dissolve rapport difficulties and facilitate the liking of a client. Data are definitely needed on whether humor in therapy can be effective when the therapist does not like the client.


Therapists must be especially sensitive to how clients are likely to react to any humor efforts (Brooks, 1994). To be humorous, therapists must possess certain humor skills, be verbally facile, and display a sense of comic timing. For those therapists who have been drawn to use humor in their practices, it seems vital to train them properly in humor techniques. Since it seems indisputable that such techniques are already being applied, sometimes inappropriately and perhaps harmfully, it is crucial to seek data on their effectiveness. One indirectly related evaluation study has recently been reported. Some of Salameh's (1983, 1987) earlier humor training suggestions were incorporated in a 13-session training program for improving sense of humor conducted by Nevo, Aharonson, and Klingman (1998). The participants were 101 female high school teachers in Israel who frequently encountered frustration and professional burnout. Although the participants in this study were not therapists or counselors, this report illustrated that humor training can be conducted and evaluated empirically. The components in this program included modeling, reinforcement, specific teaching of humor techniques, joke telling practice, lessons on the benefits and forms of humor, cognitive restructuring, countering resistance, promoting acceptance through nonjudgmental attitudes, encouragement to regress, and direct suggestions on how to apply humor in the classroom. Nevo et al. (1998) reported mixed results indicating small and positive improvement in some elements of the sense of humor, but no effects on participants' humor production. The Future of Humor in Therapy Any proposed new therapeutic procedure must be empirically verifiable, and its efficacy must be tested by controlled research. Humor is no exception (Kazdin, 1999; Saper, 1987). Given the many potential positive uses of humor in therapy, innumerable empirical questions are available for controlled research to investigate. Problems with Humor in Therapy Research

1. The interdisciplinary journal Humor attests that research in humor studies is increasing. However, because of its broad scope of interests in humor studies, very little of the research in that journal has addressed explicitly the questions of humor in therapy, such as those posed above by Salameh (1983) and Saper (1987).

2. Scientific research on therapeutic processes is extremely difficult to conduct well. Most reports in the professional literature are clinical case reports and anecdotes of success by the wise and clever therapists responsible. Human subjects research on any topic naturally progresses from some individual case studies, which, in turn, can generate hypotheses to be tested more rigorously. Correlational studies may follow and then more controlled formal experiments are conducted, where an independent variable is manipulated and objective dependent measures are taken. This is the normal sequence for scientific rigor.

3. Therapy research, whether the role of humor is being investigated or not, has suffered from several limitations: a. Analogue studies. The studies are essentially simulations of actual problems. Participants are expected to

“act” depressed or anxious or stressed, etc. They may be asked to imagine or fantasize a negative event that might make them feel depressed or anxious or stressed. They might be shown a tape or film of such an event or listen to “sad” music, which presumably would stimulate such feelings. Then they are tested afterwards in some way, compared to a group that imagined a neutral scenario or watched a travelogue film. These testing procedures assume a great deal that may or may not be true. That is, do these manipulations of imagined or observed images or songs really induce the corresponding feelings in the participants? What are the influences of social desirability in these studies?


b. The dependent measures in these studies tend to be subjective (ratings, opinions, etc.) rather than objective (time and intensity of laughter, facial changes, etc.).

c. The subjects in these studies tend not to be real clients or patients. They often are undergraduate college students who must earn some experimental participation hours for their course requirements.

d. The “therapists” tend not to be professional or experienced therapists or counselors. At best, they are often novice graduate students learning how to be therapists or counselors.

e. Sometimes the data are gathered from students, who we could fairly consider to be “naïve,” who observe and rate videos or audio recordings of simulated or real therapy sessions.

f. If humor is intended to be an independent variable in the experiments, there are many relevant aspects to its manipulation: skill of the humorist, timing, the form of the humor, the type of humor, the delivery style and more, all of which are important aspects of the effective use of humor in therapy or anywhere. An independent variable must be presented equally to all subjects. That would be a formidable task, but not impossible, if that variable was humor.

4. Different types of humor may be appropriate for different kinds of clients and differently diagnosed clients. Therapist characteristics may need to be matched to a reasonable degree with client characteristics: for example, possibly similarities in sex, age, social class, ethnicity, sexual orientation, religion, education, and more.

Conducting rigorous scientific research with objective measurements in true experiments on the use of humor in therapy is incredibly difficult. It would not be impossible, of course. In the meantime the nature of the research that has been published in this area leaves very much to be desired by science criteria. It is important to know and to acknowledge the current limitations. Otherwise, practitioners could be inadvertently deceived about the state of knowledge and make attempts to use humor in therapy inappropriately and ultimately harmfully. It would be best for the applied practitioners if their scientist colleagues conducted experimental research with objective measurements on real patients with real problems being treated with standard procedures by real health care professionals (psychiatrists, psychologists, social workers, counselors, mental health therapists). Putting it another way—valid research would involve no simulations, no fantasized stressors, no imagined feelings, no role plays, no subjective ratings, no analogue presumptions, no paper and pencil testing of “success,” no faking. In a therapy-related empirical study of conjugally bereaved volunteer participants, laughter displayed in a structured grief-symptom interview conducted about 6 months post-loss was associated with adaptive responses to stress. Those adjustments were indicated by increased psychological distance from the distress; reduced negative emotions such as anger; increased experiences of positive emotions; and enhanced bonds in social relations with friends, relatives, and affiliated organizations (Keltner & Bonanno, 1997). This study featured direct measures of smiling and laughter behaviors in the interviews, rather than self-reports, along with a well-validated behavioral measure of distress.


Martin (2007) reviewed a study by Megdell (1984), who looked at videotaped sessions in order to evaluate therapist initiated humor on the clients’ attraction to or liking of the therapist in two alcoholism treatment centers. Martin concluded “that client liking of the therapists tended to increase significantly following segments that were perceived as being humorous by both the therapist and the client, but not following humor that was perceived as funny by only one of them. These findings suggest a potential benefit of humor, but only when it is enjoyed by both the client and the therapist together.” Thus, yet another variable must be considered when investigating the use of humor in therapy. One-way humor appreciation is not a successful humor use in therapy. Any clinical technique or medication that is powerful enough to be helpful is powerful enough to do harm. Humor again is no exception. Its administration should be governed by "dosage" guidelines for certain client problems and delivered by qualified practitioners. Salameh (2001) actually referred to the emergence of humor in psychotherapy and toward human wellness as a "tectonic force." Why not systematically train those practitioners first and then empirically evaluate both the training programs and the effectiveness of those humor techniques with actual clients? Brief Summary The use of humor may turn out to be one of the more powerful specific therapy techniques available. At this point we do not know that for certain. Humor appears to be applicable within nearly all of the therapeutic schools ranging from the analytically oriented to the humanistic and the behaviorally based. Once we know what works and with whom and under what conditions and styles, then only properly trained practitioners who possess honed humor skills, the usual standard clinical techniques, along with all other requisite positive personal qualities of "good" caring health care professionals should use humor in therapy. Humor and laughter do occur in therapy and frequently so. We need to know if that is a good thing and under what circumstances it is or is not a good thing. How much humor in therapy is appropriate? How can humor treatments be administered most effectively? And for whom? These are the kinds of questions and issues that good scientific research can answer in time. Although the concept of humor use in therapy is showing greater acceptance than ever before, researching humor in universities is still not the most highly regarded activity for professors and certainly not for granting agencies. Documenting the positive effects of humor, especially for physical changes and medical applications, will help facilitate professional acceptance of humor techniques as viable and important adjuncts to psychotherapeutic and counseling interventions. That time is nigh. The training in humor techniques will necessarily be carried out by clinical educators and supervisors. As Liddle (1988) suggested, "Like therapy itself, training therapists is a serious business, but when we unwittingly check our perspective and sense of humor at the entrance to the observation room, we are suddenly in jeopardy of losing our humanness and, indeed, compassion itself..."


APPENDIX A

Positive Uses of Humor in Psychotherapy as Suggested by Representative Theorists

Barry, 1994 To signify an “encouraged person” with positive mental health. Bloomfield, 1980 To scale the idealized therapist down to size (i.e., to humanize the therapist). To challenge

preconceived notions and sacred notions. To pinpoint resistances. To recognize absurdities and contradictions between feelings and their expression. To express affection and to provide intimacy.

Cassell, 1974 To resolve intractable resistances. To highlight the fatuous nature of patient's irrational beliefs.

Corey, 1986 To learn that one is not unique or alone in pain or tragic situations. Dewane, 1978 To measure level of patient's ego strength. To serve as cathartic release. To broach

sensitive or potentially embarrassing material. To serve as a test of assertiveness. To understand how culture influences patients' behavior. To promote a "god's-eye view" (an objective, indifferent, semi-detached perspective on one's situation).

Dreikurs, 1967 To encourage easy acceptance of therapist's interpretations of patients' self-worth. To allow the therapists to demonstrate their humanness as "regular" folks.

Ellis, 1977 To make the therapy sessions more vivid and memorable. To accept responsibility for one's own disturbances. To teach unconditional self-acceptance despite errors and other human fallibilities. To cease demanding utter certainty from a world of degrees of probabilities. To accept reality and its imperfections. To reduce role disparity between therapist and patient.

Ellis, 1996 To treat morbid jealousy in those patients who usually have lost their humor. Ellis, 1998 To display genuine emotion. To teach humorous coping strategies. To puncture low

frustration tolerance. To further the development of insight. Ellis & Dryden, 1987 To stop taking themselves and life itself “overseriously.” Epstein, 1998 To reduce "discomfort anxiety" from being in therapy involuntarily. To broaden patients'

schemas (i.e., to shift their perspectives in a dramatic way). To identify biases in patients' thinking processes. To reinforce the therapeutic alliance. To show that life can be fun; to feed into the philosophy of happiness and joy. To get unstuck from relationship deadlocks.

Erickson, 1984 To choose fun in "serious" life areas, after breaking taboo of having fun in therapy. Farrelly & Mathews, 1981 To move toward positive self-concept and other self-affirming behaviors. Freud, 1938 To overcome "inhibitions of shame and decorum." Regression of id elevates the ego. Friedman, 1994 To avoid replicating patient's inability to tolerate ridicule. Furman & Ahola, 1988 To serve as an antidote to "hypnotic" pull of patients' efforts to influence the therapist to

see their problems in the same way that they do. Gelkopf & Kreitler, 1996 To create an immediate emotional gratification and a later new cognitive perspective

(insight). Humor is a neutral but broad tool useful in a variety of therapy systems. Greenwald, 1977 To address the inevitable by reflecting on death and dying. To learn that laughter is

incompatible with depression. Grossman, 1977 To alert the therapist to specific problems and probable prognosis. Kaneko, 1971 To coerce, control, seduce, or charm. To cover feelings of inadequacy or sexual

identification confusion. To obtain restoration or respite from pain or shame and embarrassment. To gain mastery and superiority via projection.

Klein, 1974 To enhance self-observation skills and improve interpretations. Kuhlman, 1984 To achieve short-term tactical benefits in therapy process. Levine, 1977 To provide a safety valve in controlling sexual and aggressive urges. Lusterman, 1992 To disarm and touch patients deeply, using the humorous metaphor for therapeutic goals. MacHovec, 1991 To lighten mood, to test insight and treatment progress, and to assess mental status. Mann, 1991 To develop capacities for richer experiences with self and others and to play. To indicate

stages in the evolution of the transference. Mindess, 1971 To become more resilient to the stresses of living. To endure reality.


Mindess, 1976 To encourage the ability to laugh through one's tears by seeing the funny side of life. Nagaraja, 1985 To identify patient's veiled and yet revealed thoughts. Napier & Whitaker, 1978 To keep the therapists sane! O'Connell, 1975a To permit patients to see the useless things they are doing without becoming offended. To

indicate a therapeutic alliance and the patient’s observing ego. O'Connell, 1975b To allow the patient to see that that everything can also be something else. O'Connell, 1981 To travel the royal road toward self-actualization and a "natural high." O1son, 1994 To reduce patient's anxiety about awesomeness of therapist and process of therapy. To

facilitate trust in the client and respect for patient in building the therapeutic alliance. To inform patient that the therapist is hopeful and not overwhelmed by patient's problems. To grow in feelings of self-control over problems, especially depression. To provide a model of sense of humor.

Poland, 1971/1994 To demonstrate the therapist's concordant identifications with the patient. To teach emotional modulation. To release repressed hostility via laughter.

Perost, 1985 To revive a healthy sense of humor in the patients and increase their positive social exchanges.

Ravella, 1988 To treat couple’s differing levels of sexual interests with humorous homework tasks. Rosenheim, 1974 To provide a corrective interpersonal and intrapsychic experience. To strengthen accurate

perception of both internal and interpersonal realities. To create a closer therapeutic alliance than would be possible by formal means. To make it possible for patient to express ambivalent, contradictory feelings.

Roth, 1987 To make the unbearable bearable (the essence of psychotherapy). Rutherford, 1994 To have the courage to be imperfect. To enhance social interest and move from feelings of

inferiority to superiority. To strive for a healthy attitude toward conforming and a healthy perspective.

Salmeh, 1983 To promote cognitive and emotional equilibrium. To attack negative behaviors while affirming the essential worth of the patient. To act as an "interpersonal lubricant." To "help define problems in a quick, flexible, economical, and easily retrievable format."

Sands, 1984 To transcend emotional dilemmas. To refresh one's self-esteem and offer "peace for the superego." To recognize double binds and avoid getting caught in them. To regulate affect both intrapsychically and socially. To rely less on unrealistic defense mechanisms. To gain more self-control over behaviors.

Satow, 1994 To express spontaneity, mastery, and strength by the patient. To permit expression of id impulses. To serve as an adaptive mechanism (psychic economy). To integrate a different, more intimate reality. To force the patient to confront the wider world. To enhance group cohesion in group therapy.

Shaughnessy, 1984 To transcend one's problems (i.e., so that logotherapy patients can rise above themselves). Shelly, 1994 To muffle anxiety in both patient and therapist. To instigate affective responses. Smith, 1973 To countercondition anger responses in behavior therapy. Tallmer & Richman,1994 To point out anxiety-provoking themes. To illuminate conflict and aid ego in overcoming

stress. To monitor effectiveness of therapy programs. Thomson, 1990 To develop alternatives for change and to reframe problems in positive context. Ventis, 1973 To replace anxiety responses in systematic desensitization therapy. Wolfe, 1998 To develop an attitude of playfulness in sex therapy. To promote anti-perfectionism and

anti-grandiosity in cognitions. Yankura & Dryden, 1994 To serve as a novel teaching device. Young, 1988 To detect nonverbal collusive family alliances and to promote positive reframing of

problems.


APPENDIX B

Cautions Noted in Using Humor in Psychotherapy by Representative Theorists Bloomfield, 1980 Risk that patient will accuse therapist of making fun of him/her. Humor at times will be

inadequate as a monitoring or change tool. Humor does not give a complete picture of patient or therapy needs.

Dewane, 1978 Can "exacerbate the complex entanglements of countertransference." Can be threatening to paranoid or other psychotic patients.

Ellis, 1977 Risk that patients feel attacked rather than an attack on their irrational beliefs. Ellis, 1998 Can put patients down or be inappropriate (e.g., racist humor). Can make therapy appear

too easy, when it requires work and practice by the patient. Epstein, 1998 Least appropriate uses: word play and impersonating patient's style. Specific

contraindications: tragic situations, grief, depression, when patient is concrete and wants only a serious discussion, and there is a poor therapeutic relationship.

Grossman, 1977 Jokes can hide conflicts and prevent patient from facing problems. Kaneko, 1971 Humor can help patient maintain a "neuroticism or characterological rigidity." Kubie, 1971 Therapist may indulge a fantasy of having a license to attack. Can blunt the sharpness of

disagreement. Can mask hostility. Can seduce therapist out of therapeutic role. Can divert patient's flow of feelings and thoughts. Usually perceived as "heartless, cruel, and unfeeling."

Kuhlman, 1984 In short-term, humor can increase psychological distancing, and in the long-term it can "tyrannize" the patient under guise of being helped. Therapist's amusement at patient's humor could be seen as approval of the taboo being voiced. Non-amusement in the therapist may be felt as disapproval of patient.

Lusterman, 1992 If humorous metaphor turns to simile, it can engender resistance. MacHovec, 1991 Humor can be disparaging and a direct or indirect weapon. Mann, 1991 Can disrupt chain of associations. Can be expression of conflict with therapist. Therapist can

collude with patient's defensive use of humor. Mindess, 1971 Can be "risky" and not well received. Olson, 1994 Must exclude sarcasm and cynicism. Parry, 1975 Jokes or responses to them are not appropriate in this serious setting. Poland, 1971 Dangers in use of humor: acting out some erotic interaction on a symbolic level, to gratify

sadistic aggressive impulses, and to get narcissistic gratification. Humor cannot and should not be a "major tool" of therapist.

Rosenheim, 1974 Possible countertransference problems (e.g., therapist's inability to take a humorous attitude when called for or if the therapist is "unduly humorous").

Rosenheim & Golan, 1986 Humor is not likely to be appreciated by obsessive or depressed patients. Salameh, 1983 Humor Rating Scale includes "destructive, harmful, and minimally helpful forms.” Sands, 1984 Even if use of humor personally benefits the patient, social usefulness may not follow.

Effects of humor are not always predictable. Saper, 1987 Need to assess patients' personality and specific humor preferences. Avoid comic relief. Satow, 1994 Must avoid scapegoating when using humor. Schnarch, 1990 Avoid sarcasm, ridicule, and self-aggrandizing buffoonery. Some patients feel

misunderstood or disqualified by authority figures. Patients with hearing difficulties or cognitive deficits may miss the point.

Sultanoff, 1994 When patient is in stressful situation, humor intended to attack that situation may be confused with a personal attack leading to alienation and hostility.

Thomson, 1990 Humor can imbalance the therapeutic relationship, block effective communication, and produce negative feelings in patients.

Vargas, 1961 Permits patients to conceal distressing or undesirable personality features. Wolfe, 1998 Could lead to possible misinterpretations by either patient or therapist


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