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HUM9997 - SECTION 5: INTRODUCING USES AND MISUSES OF HUMOR IN GENERAL PSYCHOTHERAPY PRACTICE

“A person without a sense of humor is like a wagon without springs – jolted by every pebble in the road.”

- Henry Ward Beecher, American Clergyman

Starting Points

Hopefully, this course has made a sufficient case to warrant exploration of how humor can be directly utilized in the therapeutic process. First, perhaps, we should explore some general introductory ideas about its appropriate use. In the spirit of providing catchy quotations a la Johnny Cochran, possibly the best way to sum up whether or not to consider using humor is, "When in doubt...leave it out."

This is hardly a groundbreaking concept, that of trusting your instinctual, emotional response before trying something in therapy. An uneasy or anxious feeling may signify the anxiety of experimenting with a new technique. More seriously, however, this may indicate a potentially inappropriate application.

The process of knowing and discovering one's particular comfort level of using humor- and the particular brand of humor, is vital. Though people tend to gravitate towards certain types of humor - based on their personality, environment, and culture - one should not underestimate the ability to view humor as not only a trait, but a learned skill.

Thus, discussing with colleagues their perception of your humor, learning about their humor styles, viewing humorous entertainment, and practicing humorous techniques using role plays, may perhaps be crucial before it feels genuine in the actual therapeutic arena.

Humor throughout the Therapeutic Process

The “nature versus nurture” issue most definitely surfaces when one looks at a framework for using humor in the process of therapy. The extent to which the use of humor in therapy is a learned, orchestrated skill versus an innate, impromptu ability comes into question. Sultanoff refers to maintaining this as “planned spontaneity”. As Shaw (1961) states, “Some of us employ it [humor] deliberately and with a careful awareness of its meaning, others more spontaneously and intuitively." (in Zall, 1994, 34)

According to Mosak (1987), humor can be used longitudinally during the course of therapy in five ways. (in Fry and Salameh, 1993, 11-14) These will be explored throughout the course.

- Establishing relationships
- Diagnosis
- Interpretation
- Therapeutic movement or redirection
- Criterion for termination of therapy


Key Concept to Follow

Sultanoff (1992, 1994) begins to discuss how humor may initially be used in the assessment process. He mentions six prerequisite tasks for using humor in therapy, followed by two invaluable questions.

- Identify examples of practicing humor in the past in one's skill set.
- Establish level of comfort and willingness to take a risk to use humor.
- Assess the client's use, level, and ability to accept humor
- Prepare to respond to the client's reaction to the humor.
- Be willing to take the process seriously but minimize personal emotional investments in the outcome.
- Ensure that the humor is genuine and congruent relative to the counselor using it.

Who will potentially benefit from this humor? If only the therapist benefits from it, this is dangerous because it may serve to provide relief, distraction, or express indirect feelings or needs to the client such as anger or the need for validation. If both the client and therapist may benefit, the therapist's benefit should not overshadow the client's positive response (e.g., therapist is hopefully not laughing harder than the client). Obviously, the client needs to benefit most for the intervention to be considered successful.

Next, asking the question "How will the client likely benefit from this humor?" is crucial. Examples of goals of humor may include:

- Decreasing anxiety
- Building trust
- Role modeling healthy coping skills
- Accessing hidden or suppressed emotions
- Reducing inappropriate guilt or self-blame
- Increasing their sense of responsibility
- Determine degree of insight or functioning of thought processes (e.g., abstract)
- Helping them practice releasing excessive control emotional
- Changing the direction of a session to target intellect, affect, or integration of both
- Confronting a maladaptive pattern

Key Concept to Follow

Three categories of humor assessment include: identifying the target of the humor, environmental conditions, and the individual's receptivity. The target of humor can be the self, other (person or group), or situation.


Key Concept to Follow

Early during the assessment process, discussing a funny encounter that identifies irony in a situation, or poking fun at one's own minor fallacies are examples of targeting the situation and self, respectively. This would generally be safer clinically than directing humor at the client and more appropriate early in the relationship. The more the humor relates to the client, the higher the trust level needs to be.

Key Concept to Follow

There exist several elements of the next concept: environmental conditions. The first is considering the nature and quality of the bond between the therapist and the recipient of the humor. The second is the timing and circumstances when the humor is shared. Finally, the setting where humor is presented is important.

Provided this information, we can draw an important conclusion. The more serious the situation, the weaker the bond, and the newer or more uncomfortable the setting is, the riskier the humorous intervention will be. This means that greater skill and precaution is required.

The converse is also true. The less serious the situation, the stronger the bond, and the longer and more comfortable the therapeutic relationship, the less risky an intervention using humor becomes.

The final concept highlights individual receptivity to humor. Sultanoff (1994) determines this by calculating one's humor quotient. By the way, it is not necessary to get out your calculators- this will not involve complex computations…

Key Concept to Follow

First, watch how the client uses humor in the present. The more light-hearted and the more the humor is self-directed, the more receptive they may be. Those have a restricted affect or use hostile forms of humor such as sarcasm will likely be less receptive to therapeutic humor.

Next, assess the role of humor in the client's life. This can be done by asking directly or asking the client to provide information about their favorite cartoon, comedian, comedic movie, and so forth. The spontaneity, energy, and detail of the response will provide relevant information about the use of humor in the person's life.

Lastly, watching how individuals are able to laugh at themselves and respond to other people's humor is crucial. A patient who fails to see the humor in his/her silly mistake or respond to someone else's humor may be more challenged in recognizing the therapist’s humor.

Ziv (1984) hypothesizes about the importance of classifying different personality types or presentations that may help differentiate whether humor is appropriate and what type might be most successful with the particular style. (Saper, 1994, 311-312) These are discussed in detail below.

- Emotional Extroverts – agitated, restless, reactive, moody, thrill-seeking, impulsive individuals; more likely to address and view problems as physical versus emotional problems; may demonstrate aggressive humor; may respond better to slapstick or absurd humor

- Stable Extroverts – outgoing, laid-back, responsive, spontaneous, affiliated individuals; may seek therapy due to relationship problems or feeling upset and “out-of-the ordinary,” when having normal reactions to challenging situations; may respond best to humor related to interpersonal interactions and direct humor

- Stable Introverts – introspective, planned, controlled, cautious, and detailed individuals; may seek help for stated problems with identity and internal conflicts; could respond best to intellectual and humor that utilizes obscure references or subtle humor

- Emotional Introverts – moody, internalizing, withdrawn, quietly energetic individuals; most likely to seek therapy; challenging to use humor with this subgroup, early humor should be directed at the therapist; and should validate or reflect their cynicism through exaggeration or curiosity

The therapist may also wish to ask himself or herself what subgroups best describes him or her. This may help determine where a therapist is most intuitively comfortable in their use of humor and where they need to develop more skills.

Humor in Assessment and Diagnosis of New Clients

Laughter could be considered a litmus test for humor. For the case of simplicity, let us clarify what we mean by “laughter” in therapy. An operational definition we will utilize is “any highly stereotyped utterance characterized by multiple forced, acoustically symmetric, similar vowel-like notes separated by a breathy expiration in a decrescendo pattern. (Provine, 1993)

Did everyone get that? The definition of laughter need not induce laughter.

Although the majority of this course discusses therapist initiated uses of humor, it is valuable to explore the reverse. This discussion includes both screening for - and responding to - humor generated by the client.

Our clients may use humor with us early on to vent their anxiety, redirect the focus from their reason for seeking treatment, or to impress the therapist. Depending on the client’s overall mood, level of functioning and defense mechanisms, it may be expressed using hostility or self-deprecation.

It is crucial that the therapist strike a balance between providing a genuine reaction and a natural curiosity to know what lies behind the humor – without this seeming contrived or intrusive. The importance of constantly tracking the meaning of the humor quickly - and before responding - is challenging, but necessary.

Sometimes, identifying several unique responses in dealing with these situations is helpful:

If a client says something intended to be humorous that targets an everyday situation, smiling or mild laughing would be appropriate. This also applies if they say something that lightly pokes fun at themselves. A simple acknowledgement such as “That’s funny” may suffice.

If you sense more affect behind the remark, but it is too early to pose interpretations, saying something like “Hmmm or ha, ha…I hope you’ll continue to share those moments, it will help get me get to know you better.”

In reference to hostile humor directed at the therapist, it may be helpful to communicate that you received the message and are open to expressing it when the client is ready. “I know folks express things in many ways. When you’re ready, I’d be interested in hearing more about what you just said.”

Self-deprecating humor by the client can be dealt with in several ways. It would obviously be important not to reinforce this, but clarify that you recognize what is going on. “Wow, even though you’re laughing, I cannot help but wonder what else is going on for you right now.” Or, if the client’s affect is a little more noticeable, you could say, “Even though you’re laughing, I cannot help but feel some sadness right now.”

Humor that is meant to dodge questions can be dealt with by saying, “You really put your humor to good use. You managed to avoid that issue!” Remembering these moments may cumulatively help you discover patterns and reflect those to the client. Prefacing an inquiry the client may be uncomfortable with “I wonder how you would feel if we talked more about…” may help the therapist gauge the timeliness of an intervention and depth you may be able to explore it.

During the assessment process, observing the client’s use of humor - or lack thereof - may provide meaningful clues as to their mental status, diagnosis, developmental stage, defense mechanisms, and overall level of functioning.

Sometimes, an important part of the assessment involves asking a client to share his or her “favorite” or first joke that comes to mind. This may be telling not only in terms of the content of the joke, but may point to the depth of their challenges, their ability to connect with others, be spontaneous or creative, and take a risk (i.e., fear of joke failing). Often, the client sharing laughter can begin the process of attachment. If the therapist employs this assessment technique, it is crucial that they find a way to laugh at the joke initiated by the client. (Surkis in Fry and Salameh, 1993, 137-138)

Observing more frequent or intense humor could be indicative of a client’s level of anxiety or avoidance. It is crucial that the clinician notice the client’s level of congruence between their affect and verbal material. Also, if the humor seems to represent an earlier developmental process (e.g., an adult using toilet humor), consider the degree of intellectual functioning, social skills, or regression that might be present. Also, humor that seems nonsensically tied to the current situation may indicate psychosis, as would laughing at internal stimuli that is hidden from the therapist.

Less frequent or non-existent humor may indicate the client’s level of depression, enmeshment or detachment from particular issues, or connectedness to the therapist or session content. Noticing these patterns will be essential both in the diagnostic process and treatment process.

Perhaps Goldstein (1972) provides an extremely succinct yet precise working model of the understanding of humor in therapy. “Humor has both healthy and unhealthy applications and, by itself, cannot be determined as good or bad, adaptive or maladaptive." Instead, humor is regarded by Goldstein as an extension of the individual’s personality and should be considered within the framework of his overall coping mechanisms." (Zall, 1994, 50)

Key Concept to Follow

Robinson (1970, in Volcek, 1994, 118) wisely asserts that “humor is healthy when it pays attention to the immediate needs and assists the individual in handling everyday realities. Humor becomes negative and abusive when it supports pathological denial of reality.”

Contraindications and Cautions When Utilizing Humor

In our next section, we will discuss, in greater detail, more specific humorous techniques with varying clinical populations. In the remainder of this segment of the course, we will direct our attention towards some fundamental contraindications or precautions for applying humor.

Give yourself permission to discover and experiment with various ways of using humor with your colleagues and practice humor in your sessions. Certainly, learning to use humor is a process, relative to your age, experience, personality, culture, and clinical background.

Obviously, are no substitutes for “trusting your instincts.” If you notice your instincts are leading you to constantly avoid or apply humor, irrespective of the clinical context, be willing to explore what personal feelings and dynamics lay behind these drives.

However, there are several instances where the use of humor would be considered inappropriate or contraindicated. These are based on both client and therapist dynamics. These include the following items.

Key Concept to Follow

Avoid or exercise extreme caution using humor:

- When the client is overtly suicidal or homicidal, or presently at-risk for violence or other destructive impulsivity
- When the client is actively paranoid, psychotic, or experiencing acute dementia or delirium
- When the client is experiencing dissociation or flashbacks
- When the client is new to the therapeutic relationship, in crisis, or displays an intense or incongruent affect
- When a new client is directing anger or hostile humor towards the therapist
- When the client’s humor may mask a new feeling they are identifying for the first time with the therapist, such as shame or embarrassment
- When the client is feeling discriminated against due to race, socioeconomic status, education, age, or gender (e.g., avoid jokes that touch these issues in general)
- When the client verbalizes or otherwise communicates the therapist is trivializing their concerns or misunderstanding them
- When the client may be hypersensitive to feeling ridiculed
- When the client is new and the lacks trust in the therapist’s credibility
- When the client voices a sense of not being taken seriously
- When the client asks for something directly from the therapist
- When the client consistently uses humor as a defense mechanism, especially if this may precipitate more self-destructive or defeating patterns
- When the client has not responded well to the therapist’s humor in the past
- When the therapist is unsure of the origin of the client’s affect or symptoms, or when the diagnostics are confusing
- When the therapist is unclear of the client’s reason for seeking therapy
- When the therapist is experiencing obvious counter-transference, especially:
- Antipathy towards the client
- Anger or frustration with the client
- Fighting urges to moralize
- Desire to please the client
- Fear of upsetting the client
- Attraction to the client
- Anxiety around the client
- Feeling defeated by the client
- Feeling disconnected from the client
- When the therapist is unsure of what they want to communicate to the client
- When the therapist is being exposed to a new client with a culture different from their own, especially if the humor relates to culture or experiences differ from therapist’s culture
- When the therapist’s material contains generational or age-related references that may be inconsistent with the clients’ experiences
- When the therapist is unclear of the intended goal of the intervention
- When the therapist is using humor about the client and he or she has an external locus of control (Lefcourt, 1974)


Humor and Diversity

When considering the use of humor with more diverse populations, there is no substitute for good clinical judgment. If you are unfamiliar or uncomfortable for any reason, it is best to consider an intervention without humor. The “rule of thumb” is that the more concrete and general the humor is, the more recognizable it will be.

If you are therapist working with a client with a different culture, be cautious in making references about those groups. Even if you believe you have extensive experience and knowledge of the culture or a strong rapport with the particular client, this is risky. Even with experience, the wrong timing or tone could be perceived negatively. In working with similar clients, be careful of assuming that they would find something humorous just because you share certain characteristics.

Being aware of counter-transference towards particular groups is of utmost importance. Even if you believe you are objective, everyone tends to have biases that exist as “blind spots.” Remember to consistently use supervision to help identify these.

Safer opportunities to use humor exist when the therapist is quoting a member of the group with whom they are working. Humor that is directed at the therapist (e.g., therapist laughing at him or herself) or situation, of course, is much safer than humor directed at the client.
Reading about and experiencing the work with diverse populations is crucial. Since much of humor involves subtlety such as modulating the tone of voice, eye contact, facial expressions, and overall timing, know how this may be perceived by another culture.

Certain types of humor may be viewed as humanizing to some people, but unprofessional or mocking to others. A therapist may ask for examples of what the client finds funny, and how they perceive this in the context of their own sense of humor and in comparison to the dominant culture.

Axtell (1998), in his book Do’s and Taboos of Humor Around the World, describes how “humor’s cousin,” the smile, can be interpreted differently in different situations and cultures. For example, in Japanese culture, a smile commonly indicates a person is upset, which may be a false invitation to consider the use of humor. Additionally, Axtell (1998) reminds us of types of humor to avoid. These include stereotypical, linguistic (i.e., wordplay) sexist, religious, and off-color humor (from http://culturalsavvy.com/humor.htm).The mantra “When in doubt, leave it out” is operative here. (Kinde, 2006)

As when working with clients of a different ethnicity, be mindful of how humor that may be more “population specific” is taken. This may need to be considered when dealing with gay or lesbian clients, especially when the therapist is either not gay or not “out.” Even when the therapist believes the have a grasp of the context, this is risky and likely should be avoided – and dealt with more directly.

It is always informative to ask clients about their sense of humor, especially as it exists within their culture, family, and social group. Also, speaking with other therapists who specialize in cultural diversity or have experience living within a particular culture may be useful. Remember not to confuse ethnicity with culture when addressing issues differences and similarities in unique groups.

Again, the next session will be spent discussing examples of humor with adults, children, adolescents, couples, groups, and families with various presenting problems. Hopefully, this segment of the course built a foundation and a “standard operating procedure” to express fundamental prerequisites and skills for using considering the use of humorous intervention at the outset of therapy.

Let’s conceptualize this process in a different way. Consider the preceding sections of the course reflective of the scientific process of understanding the use of humor in psychotherapy – while the remainder will build on the aforementioned by delving into the creative, artistic process of applying the use of humorous interventions to the therapeutic relationship.

After completing Section V, participants will be able to answer the following questions:

How would you discuss the role of intuition and professional development in considering the use of humor in the therapeutic process?

What are 6 basic forms of clinical assessment and steps in preparation for utilizing humor?

Can you describe at least 7 possible goals for utilizing humor during sessions?

What are 3 opportunities for the therapist to assess the client’s use of humor during intake and follow-up sessions?

Could you generate at least 3 ways the client might utilize humor in the beginning of therapy and 3 unique therapist responses?

How is the client’s use of humor diagnostic?

What variables might you consider before using or avoiding humor in a session?


Therapeutic Riddle:

Q: How many therapists does it take to change a light bulb?

A: It doesn’t take any therapists to change a light bulb. Therapists empower the light bulb to change itself! (Shay, 2007)

 

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