HUM9997 - SECTION 9: LAUGHING AND FINALITY: THE APPLICATION OF HUMOR IN PSYCHOTHERAPY WITH OLDER AND TERMINALLY ILL ADULTS
“If the question of comedy is the question of how to live with incongruity, then, since death is the final incongruity, the ultimate question of comedy is the question of death.”
- A. Roy Eckardt
As we have discussed the role of humor and other nontraditional techniques in psychotherapy with countless diagnoses and populations, we need not neglect these two. Many colorful images can be conjured of the elderly. Whether that includes saying what other people only have the courage to think, getting away with saying things other people would be confronted about, or being physically sick while still maintaining razor-sharp wit. Remembering those images will help in addressing humor with this fascinating population.
Also, there exists an interesting parallel between youth and aging: discovery. Discovery in later life takes the form of relying on wisdom and awareness of one’s emotional resourcefulness. While some abilities are peaking, others are dulling and declining. Cosmetic and physical changes can be depressing, and humor can be a partial remedy. This challenges people to revive and not “unlearn” their quality of playfulness. (Volcek, 1994, 112)
Other realities are important when considering humor and its benefits with these folks. When people age or become ill, their physical needs often surface at the forefront, much like those of young children. Thus, countless studies have attempted to link humor to enhanced physiological health.
Shmeck (1983) explored how the expressions of different emotions through facial expressions have a unique impact on the nervous system – especially laughter and happiness. Fry (1963, 1988) describe how movements, heart rates, muscle and respirations are increased – creating more oxygen exchange as in physical exercise. (Volcek, 1994, 113-14)
Though many studies have addressed these issues, there is some disagreement as to the degree long-term and causal effects of humor. Laughter has been shown to have short-term analgesic effects on pain. (Levinthal et al., 1988) Also, many studies confidently address short-term advantages to cardiopulmonary and immunological functioning.
Miller, (2005) a preventative cardiologist, has produced research that indicates an increase in efficient blood flow after people watched a segment of a funny video. Further, he has developed an instrument to measure one’s potential for humor versus hostility, and noticed that individuals with heart disease may be 40% less likely to laugh in situations where those without cardiac problems would laugh.
There is difficulty validating longer-term benefits of humor. In spite of the aforementioned fact, we need not discount the benefits in the immediate future. As we age, the future becomes more and more uncertain, thus enhancing the relevance of today.
A possible implication of Lefcourt’s (1974) research is that humor can help people to develop a more internalized locus of control and autonomy over situations where they may feel powerless, which becomes more likely as people endure loss of their health, sense of identity, loved ones, and ability to self care. Any brief moment of laughter may provide an opening for change by allowing the introduction of other interventions.
Older, Wiser, and Funnier: Using Humor with Aging Adults
“Those who laugh, last.”
- L. Rosten
Many clinicians discuss the needs of the elderly as they relate to psychosocial functioning and development. These are the basis for many therapeutic interventions, including the use of humor. Erikson refers to this as the final life conflict, describing it as “Integrity versus Despair.” McKlusky (in Peterson, 1983) discusses five necessities for elderly. These include coping, expression, contribution, influence, and transcendence.
As people age, these concepts become more and more vital, as one faces illness or death. Volcek (1994) makes a nice distinction between helping elderly with high versus lower self-esteem. People with higher self-esteem often need support in continuing to integrate the past into the present, while those with lower esteem can be helped to generate hope to live their life. (119)
Meyer (1984, in Volcek 1994, 116) provides an example of a study that utilized humorous interventions in a long-term geriatric nursing home designed to “direct and redirect mental attitudes of fear, hopelessness, apathy, boredom, and loneliness.” The results found increases in smiling, interpersonal exchanges among residents, calling each other by name, and interest in programming. Humor can help allow for “projection of conflicts” and “lubricates the interpersonal process among members." (Volcek, 1994, 116)
As we know, as people age, they begin to derive a sense of pleasure and purpose out of “passing on their legacy.” Doing so may involve discussing the impact of world events, relationship losses, and lamenting on past accomplishments and abilities. Also, using more cerebral humor will engage the elderly intellectually, and activate parts of their prefrontal cortex. It is a way of humanizing what can be a sometimes dehumanizing process of receiving help.
Herth (1984) discusses how assessing a person’s historical orientation to humor or “funny bone history” may be useful. Discovering examples of favorite types of humor and comedians, the role humor plays in one’s personal life, well as examples for what is not considered funny, may be part of the assessment.
One challenge with this may be that many elderly people may struggle with accepting more nontraditional forms of medicine and may be even more attached to the “medical model.” Herth (1984) continues by discussing how this reality may be considered in writing prescriptions for “laughter breaks,” where specific assignments are given to engage in humor-inducing activities.
Other exercises that can be used may include bringing in bringing photographs and creating captions, developing a cartoon that depicts the present situation, or making a “joy bag” of items that are symbolic or triggering of funny things for the patient. Especially in a hospital environment, developing and role-modeling light-hearted relationships with other staff would be beneficial in creating a more familial atmosphere. (Herth, 1984)
The elderly, especially those who become institutionalized in nursing homes, can struggle with intense grieving over their ability to perform everyday tasks. Also, loss of bodily and sensory functions such as hearing, sight, mobility, excretory, and overall control over one’s health is expected. Campbell (1979) discusses how “ice breakers” can be used. For example, “I know what you’re thinking – there’s nothing I’d rather be doing than getting help with this schmuck!”
Another instance where humor may be helpful is in adapting a playful attitude towards age-related topics. When an elderly client appears to need a particular service, counteracting the helplessness they experience is likely a prerequisite before they agree to exploring that need. (Volcek, 1994, 120) If a client in their 70s states, “That is for old, handicapped people, not me, no way,” responding with something like “We even offered this to someone in their late 60’s, that’s hardly old, just chronologically advanced, right?!”
Another need of the elderly is to have normalized common issues such as forgetfulness. Using humor and storytelling may be useful in this regard. A common example may involve “gentle self-disparaging humor” which “represents our ability to laugh at the shortcomings of our human condition.” (Volcek, 1994, 121)
Husband: Make sure to write down what I say before going into the kitchen. I would like a hot dog with mustard and relish.
Wife: I got it! I don’t need to write that down, you fool…I am right here next to the kitchen!
Wife: Here you go (wife comes out with a slice of toast and hands it to husband)…
Husband: See, I told you that you couldn’t remember, I asked for some jam with that!
Palmore (1971, in Volcek, 1994, 119) alludes to a valuable issue in using humor with the elderly, one that has implications in assessment, diagnosis, and intervention. According to Palmore, a large content analysis of jokes, not surprisingly, reveals negative views about aging, especially aging women.
It goes without saying that a therapist utilizing humor directed at a client’s age should be used with caution in the relationship - and also used sparingly. Also, being aware of a client disguising their sense of loss and depression as humor is important, so as not to dismiss the opportunity to explore these issues in the session.
Key Concept to Follow
Another precaution involves being aware of the extent of hearing loss, cognitive impairment, or paranoia that may contribute to the elderly client misconstruing the humorous intervention. (Volcek, 1994, 120) Such awareness will decrease the likelihood that the therapist will be perceived as ageist and better ensure their sensitivity to the diverse needs of this group.
The Comic and Tragic: Using Humor with Terminally Ill Adults
“Finding humor in a tragic situation is an extremely healthy step. It is a way of looking toward the future and of saying that this suffering can be put behind us…Humor is something to strive for an to embrace. It is a way of saying, ‘The tragedy has happened to us, but is does not define us. Despite what we’ve been through, we are going ahead with our lives…You didn’t destroy us! We are still here. We are still laughing. And therefore we have life and hope.”
- Peter Weingold, MD
“Life does not cease to be funny when someone dies, anymore than it ceases to be serious when someone laughs.”
- George Bernard Shaw
A patient facing terminal illness will struggle with many predictable issues. These include responding to societal hopelessness, degenerative changes in physical and mental states and body image, as well as facing mortality, uncertainty, aloneness, and meaninglessness. (Kisner, 1994, in Buckman, 1994, 133)
Key Concepts to Follow
While the use of humor with this growing population is valuable given the inherent powerlessness that accompanies a terminal diagnosis, there are perhaps more variables to consider before embarking on this path. Klein (1998, 32-35) discusses various considerations, where the use of humor by the client should be addressed seriously and humor initiated by the therapist should be avoided.
- When the patient’s humor in their denial is preventing them from getting needed treatment
- When the patient appears to be permanently repressing versus temporarily suppressing other feelings through humor, which may worsen their medical condition psychosomatically
- When the patient has undergone invasive surgery (i.e., risk of injury)
- When the patient is using humor to comfort others while they are suffering
- When the use of humor misleads the patient or family into perceiving an overly optimistic prognosis
- When the therapist feels uncomfortable with the patient’s expressions
- When the therapist feels disconnected with the patient
- When the therapist or client has just previously discovered the diagnosis or may be in shock
- When humor is directed towards the client while they are in denial or angry
- When the relationship is new or the therapist is new to the population
- When a patient has later stages of any disease that has impaired their cognitive abilities or creates psychosis
- Beware of “over-empathizing” by trying to convey an emotional grasp which may be perceived as contrived or self-soothing, rather than being supportive of the client
The application of humor to conditions such as cancer, diabetes, AIDS, and Alzheimer’s have been well-documented. Klein (1998, 83) coined a phrase originally discussed by Hamilton, a health care educator and cancer patient. She noted that expressed humor that was specific to a particular disease would only be perceived as funny by someone with the same disease (i.e., in the same circle). Others, however, may fail to see the humor or view it as appalling.
Topics of humor for cancer patients may revolve around chemotherapy patients losing their hair or mastectomy patients needing a prosthetic breast. (Klein 1998, 83-85) AIDS patients may joke about their weight loss and their intense drug regimen. (Klein 1998, 112-113) People with early stages of Alzheimer’s and their family may unsurprisingly joke about memory loss. (Klein 1998, 138-139) These are considerations for the therapist who may encounter these populations, so as not to be alarmed, and to be able to connect to the inner world of their client.
Oftentimes, depression is a clinical response to a terminal diagnosis. While the realization of impending death is certainly more probable in these cases, the use of cognitive distortions such as jumping to conclusions and filtering are understandable responses. However, left unchecked they may blind the individual to seeing his or her options realistically and expend unnecessary energy – energy that could be better spent on self-care and recovery. While education about the disease and different thought patterns that emerge is useful, consider the use of humor to interrupt the client sentencing themselves to certain doom. (Kisner, 1994, 139)
This involves a patient recently diagnosed with prostate cancer – which was caught early before it metastasized.
Patient: I was diagnosed yesterday. I really need to be focused on reviewing my will.
Therapist: I know the thought of leaving your family is saddening and scary.
Patient: I really don’t have time for my feelings right now…Let’s do something, anything!
Therapist: I guess it would be negligent on our part to not focus on what actions might help you feel like you have some control over the situation.
Patient: Tell me about it.
Therapist: Why don’t we avoid all of the legal “mumbo jumbo”? Let’s auction off your estate right now.
Dealing with the physical decline that diseases such as AIDS will produce can be painfully mortifying and humiliating for those who encounter them. In dealing with this, people may often focus on particular losses; hair, weight, skin tone, just to name a few. For instance, a patient with late stage AIDS feels that the beautician at the funereal parlor will pick cosmetics that are “all wrong for her.”
Giving her the client the opportunity to experiment with different colors of makeup may initially seem ridiculous, but ultimately empowering. Rather than just trying to refocus the client on their fears, this may provide a symbolic sense of meaning. (Kisner, 1994, 143) This could involve allowing the client to “dress-up” with wigs, clothing, or provide ideas for belongings that give them a sense of warmth and connection.
An interesting idea was illustrated on the popular David E. Kelly television series Boston Legal. In one particular episode last season, Michael J. Fox decides to have a large gathering and party of sorts to “celebrate his life.” Helping people define their own rituals around death versus succumbing to social or familial norms that limit their experience of grieving is crucial.
Here is a list of creative activities and ideas that may help the dying person and their families reflect on the memories in their relationships and strengthen their connection to positive meaning.
- Create a list of Top 10 “Funniest Moments.”
- Create a list of Top 10 “Biggest Lessons We Learned the Hard Way.”
- Purchase at the local discount (e.g., dollar) store items that represent an important time or experience they shared with the loved one, and attach a short description as to how it is important.
- Develop a mixed musical compact disc with songs that are reminiscent of the various times experienced.
- Create a video based on old footage or pictures.
- Plan a day of activities based on what the person wants. Allow them to choose the theme, people, and refreshments.
- Write part of the eulogy and epitaph to reflect on poignant themes. (Klein, 1998)
Part of the function of mental health professionals is to help create meaning, warmth, and individuality into what can be a cold, clinical, gloomy, and frightening process. To the extent these interventions serve this purpose, they can help this highly deserving population experience the remainder of their life in a richer way.
After completing Section IX, participants should be able to answer the following questions.
What challenges or precautions might be posed before committing to the use of humor with the elderly or terminally ill?
What are benefits to using humor-based approaches versus other clinical approaches with these populations?
Could you name at least 3 interventions and 3 activities that utilize creativity and humor with these populations?
What might be some specific prerequisites for the client and therapist before using those specific interventions?
Patient: Doctor, doctor, nobody understands me.
Therapist: What do you mean by that?