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HUM9997 - SECTION 6: THE APPLICATION OF HUMOR IN PSYCHOTHERAPY WITH ADULTS IN THE INDIVIDUAL AND DIVERSE DIAGNOSTIC POPULATIONS

“Humor therapy involves being humorous to be more rational, and being crazy to be more sane.”

- Unknown


Though many practitioners have referenced the use of humor therapy, in 1974, Farrelly and Brandsma started “Provocative Therapy,” which encompassed a complete therapeutic model onto itself. This model challenged many assumptions of traditional psychotherapy but maintained many of the same objectives.

While responsible for treating the inpatient hospitalized and chronically mentally-ill, Farrelly originated this work in the 91st interview with a schizophrenic. He noticed that trying to repeatedly and directly encourage him and acknowledge his inherent self-worth only created a frustrated therapist and a predictably unyielding patient.

By siding with the client’s hopelessness in a curiously light but genuine way, rather than constantly being the nurturing voice of optimism, he noticed that the patient was positioned to consider the side of mental well-being. Thus, viewing this process as a system seeking homeostasis or balance was useful.

Perhaps most excitingly, Farrelly began to successfully use this approach with a diverse cross-section of clients with various cultures, diagnoses, and ages. He especially encouraged therapists to allow him to intervene with “treatment-resistant” patients who had not responded to more traditional techniques.

Though critics were concerned about the possibility of client’s being offended or wounded by a sense of being ridiculed, it was evident in the interactions that they often felt a sense of connected relief and uncomfortable curiosity.

“If I were a young man entering the field of psychotherapy today, I would be progressing along the lines that Frank Farrelly is doing therapy.”

- Carl Rogers

Witnesses of this therapy were encouraged, including the founder of Humanistic, Client-Centered Psychotherapy, Carl Rogers. The prerequisites of this therapy include an underlying empathy for the client and ability to access, value, and express the therapist’s own spontaneous sense of humor. Also, the therapist must be willing to venture outside the traditional norms and language of psychotherapy.

The word “provocare” is Latin for “eliciting.” This form of therapy has similar objectives as more traditional therapies, but the means are analogous to “taking a back road” or “shortcut”. While many of these interventions may appear insulting or potentially damaging, they more quickly prompt the responses we hope for in our clients. They actually validate many of the client’s most overwhelming and unspoken feelings and thoughts and about themselves, the world, or the therapist.

There are ten assumptions that sometimes challenge the traditional psychotherapeutic or even medical model. They include:

- People can respond to a competitive challenge to grow.
- Clients can change if they choose, and if it benefits them physically or psychologically.
- Therapists often underestimate a client’s ability to develop and achieve. Therapists often overestimate a client’s fragility.
- Immediate and lasting changes can be produced in therapy in spite of the chronic or severe nature of the struggle.
- Regardless of the client’s upbringing, the role of the present is equal to or greater than the past experiences.
- The client’s behavior towards the therapist parallels their outside interactions and relationship patterns.
- People are “exquisitely logical and understandable,” especially when the aim is to view them as such.
- Sometimes expressing “therapeutic hate” and “joyful sadism” with the client is validating and useful.
- Non-verbal communication often determines the tone of an interaction, either in support or opposition to the verbal message being presented. (Farrelly & Brandsma, 1974, 35-52)

Though the underlying framework may vary from traditional psychotherapy, the objectives are remarkably similar. The objectives of Provocative Therapy are for the client to:

- Affirm their self-worth both verbally and behaviorally.
- Assert themselves in their interactions and play a more proactive role in their decision-making.
- Respond to outside negativity in an authentic – and less passive or aggressive way.
- They will perceive and respond to themselves and others more realistically and holistically. Generalizations will often be revised and replaced by more a more discerning view of the world.
- Take potentially fulfilling risks in relationships such as expressing affection and vulnerability. (Farrelly & Brandsma, 1974, 35-52)

The use of humor in psychotherapy, for our purposes, is more likely to be interwoven into our already existing theoretical approaches, or eclectic mix. We will give several examples of how different schools of thought have approached the application of humor.

Mosak and Maniacci (1993), outline several categories of therapeutic humor listed here, as well as a brief example of each. (in Fry and Salameh, 1993, 6-11)

- Jokes: Therapist-initiated jokes (e.g., How many therapists does it take to change a light bulb?) or having a child tell their favorite jokes
- Handles: Names given to help increase self-acceptance (e.g., a chronic worrier may be asked to say “nervous, nail-biting, Nancy”)
- Images: Help clients’ visualize something to decrease anxiety (e.g., imagining people who intimidate them in underwear) or more concrete images (e.g., give a pebble for those who tend to have self-righteous, anger to remind them not to “throw stones”)
- Reign of laughter: Have the client create or find a funny story and have them keep telling it until you receive laughter, or have others tell you stories until you laugh (Wolfe, 1932)
- Altered Adages: Change a cliché to make a point (e.g., for a client who is a competitive perfectionist, “If you cannot beat them, why not beat yourself?”)
- Parables and Fables: – Tell them to make a point or having the client create their own and develop a more constructive conclusion (e.g., a situation where a client is self-critical “Well…what is the moral of this story?)
- Role-Reversal: the therapist acts more outlandish in anticipation of the client’s behavior (e.g., throw up arms, let out a sigh of annoyance if client gets defensive easily)
- Inside Joking: capitalize on humorous examples from past sessions and use them when these patterns resurface

Farrelly and Brandsma’s book entitled “Provocative Therapy” also highlights four languages that provocative therapists may use to communicate with clients. Without a comfort level with these modes of communication and creating the necessary therapeutic tone, one’s interventions will likely “fall flat” or otherwise be perceived negatively. Again, these probably everything the Psych 101 textbook probably warns us to avoid.

- Religious-moral (good/evil) – (Playfully) “Are you being bad?”
- Locker room-street (vulgarity or popular idioms) – “Like, gag me with a spoon!”
- Professional jargon (pseudo-intellectual) – “So, what you are telling me is, your denial is only surpassed by your apathy!”
- Body language (exaggerated or downplayed) – The therapist could put their head in their hands, have a blank stare, wide-eyed or mouth gaping open. (Dawes, 2005)


Key Concept to Follow

Getting prepared to utilize provocative therapy is important. Visualizing and creating the tone and context of an interaction before you begin is extremely helpful. If one has difficulty with this, it is crucial to practice getting more comfortable in these realms before using humorous interventions with clients. Also, pay attention to how genuine these will feel with the particular client you are considering.

- Visualize and practice getting into a “giggling state.” For example, imagine you are in church and think of something funny even though it is taboo to laugh. Once you start laughing about one thing, everything strikes you as funny.
- Remember a time when you exchanged friendly banter with a close friend and the warmth that surrounded it. During this time, you realize that saying and hearing difficult things is permissible because of the level of trusting the caring intentions.
- Listen to your “inner guide.” Set aside your diagnostic or analytical tools and pay attention to your wise and instinctual self. Allow wisdom to guide you and offer up your reactions. This could be analogous to the concept of free association or stream of consciousness.
- Temporarily release your ties to clinical jargon. See the client as an actor and empathize with them and other people in their lives as an audience member. Imagine a ring of color televisions that portray the client’s work, relationships, and family life, or an aspect of their personality or role. Gradually shift your focus to the one that captures your attention with its humor; irony, absurdity, or embarrassment. Then point these out to the client. Then, walk into one of the sets and describe your observations.

The remainder of this section will be devoted to providing specific types and examples of interventions for the therapist – including specific interventions with different populations and settings combined with internal and external dialogue necessary to make them successful.

The first example involves using an absurd statement to disarm a normally guarded or hostile client. Using this approach to engage with an angry or treatment savvy client may be more successful than trying to ask a directly therapeutic question, which may result in escalation or competition.

Goshen-Gottstein (1994) described this approach in dealing with a client diagnosed with borderline personality, one who consistently challenges the therapist’s credibility when given serious responses and makes abrasive comments. The unexpectedness helps the client detach from their “hostile patient” role and relate to the therapist more openly.

Client: Why do you have so many books since you obviously don’t read them?
Therapist: Of course, to make me look smarter than I appear when facing highly successful clients like you.

The next example uses absurd humor to contain intense fears, such as fear of death or abandonment. In this series of exchanges, the client’s boyfriend terminated their one year relationship. Though humor can sometimes be captured in one line, other times it may take longer. Keep in mind, the end of the session was nearing and the client appeared to need some containment give her fears some perspective.

Client: Now that Jake has left me, how do I know you won’t also?
Therapist: It makes sense that you would wonder this after what you have been through. It feels scary to have someone you care about end the relationship without you having a say.
Client: I'm not worried about you deciding to stop being my therapist, but that you might die! Worse than that, what the other people in the office die so they won’t be able to tell me about you?!
Therapist: Wow, that would be awful for you.
Client: Tell me about it. I wouldn’t have imagined it before. But, after what happened with Jake, I need to be prepared for anything.
Therapist: I’ll tell you what. I promise to give you a sign if this happens. What would you like me to do?
Client: (Laughing) Well, if I’m inside turning on the radio and playing “Don’t Worry, Be Happy” would be great. If I’m outside, to have a bird come land on my shoulder would be cool.
Therapist: (Vigorously writing on his pad) Okay, I am making sure to get all this. Clients always want different kinds of signs – I don’t want to get them confused.

Application of the paradoxical statement or notion can be useful when trying to communicate recommendations to someone who is likely to be resistant. For instance, working with an addict who frequently rationalizes their ability to control their using can be especially difficult, especially if they are intelligent and have authority issues! Such an intervention will engage the client’s sense of competition and guide them to taking the more uncomfortable position of self-reflection.

Client: For the last 2 weeks, I have been able to just have a few beers here and there. Last night was a fluke.
Therapist: What do you mean?
Client: I mean, how often will your in-laws come in town after you have this hard of a day at work? Clearly, if anyone had that kind of pressure and company, they would do the same. Don’t you think?
Therapist: What does it mean to you, whether or not anyone else would do it?
Client: I’m not even sure why you responded to that. It was meant to be rhetorical.
Therapist: I hear you. However, my question was meant to be answered. Don’t leave me hanging!
Client: I know what you’re doing. Suggesting that I have a problem and that I can’t control myself- we’ve been over this. AA is not the answer! People there really do have a problem!
Therapist: You’re right. You probably wouldn’t have anything in common. None of them probably ever denied having a problem. And, those guys could probably run circles around your drinking stories!

Another use of exaggeration can be used when a client feels immobilized by excessive amounts of self-blame and guilt. Sometimes, it can be surprising the degree to which a client may defend their need to be punished. The traditional empathetic response may only lead to continued insistence on how inherently bad they are. However, giving them permission to have and even promote these feelings may lead to an emotional awareness of the process and may help the person actually help them to be more compassionate with themselves.

Client: I can’t believe that Jack didn’t get his promotion. I know it must not have anything to do his performance. I have been asking him to spend more time with me and the kids…it’s my fault that this happened. If only I had left things alone (crying)….We weren’t meant to have it all. I always find a way to mess things up.
Therapist: Wow, I’ve got to hand it to you. Your ability to take responsibility far surpasses most other people. Since you are so adept at this, what else can we have you tackle? Rising gas prices, global warming…I would love to hear how you single-handedly caused those!

Surkis (1993) describes the use of humor with obsessive-compulsive populations. As their world is often predictable and behavior measured, using techniques such as “baby talk” and playful mockery is useful to help them access frustration at the therapist. This can break the cycle of self-centered rumination and help the client connect with the therapist on an affective versus purely intellectual wavelength. (In Fry and Salameh, 1993, 122-141)

Client: I can’t believe my low self-esteem has negatively impacted my social life again. I can’t stop saying to myself “You cannot do anything right”.
Therapist: What happened to make you say that?
Client: (putting his head in his hands) Well, when I was about to ask out Donna, I start quivering with self-doubt, “What if she says no? What if she tells all her friends? What if her friends tell other people and nobody wants to go out with me?”
Therapist: I have a quest… (interrupted by client)
Client: I just don’t know what to do; I’ve told myself all of that positive self-talk its meaningless psychobabble.
Therapist: (switching to a childlike voice) Ummmmm….I’m telling on you!
Client: Excuse me?
Therapist: (exaggerated frustration) I wasn’t done and you cut me off!
Client: (confused) Okay…sorry, I was just saying…
Therapist: You did it again…that’s two times!
Client: Why are you talking like that, anyway?
Therapist: (becoming more serious) Wow, that is the first time you have talked to me directly in a while. You managed to interrupt me to continue berating yourself.
Client: (frustrated) What’s your point?
Therapist: You made the choice to interrupt me, why not your mission of self-deprecation? That’s what really needs the interruption.
Client: I wasn’t aware that was a choice. I just did it automatically.
Therapist: Exactly. Perhaps you are neglecting to realize you have a choice in the other situation.


Farrelly and Brandsma (1974) propose and empirically support two main hypotheses. First, the therapist provoking the client will produce an opposite response than the previous patterned behavior. Second, when pressed to continue their “self-defeating” behaviors, the client will stop and behave more adaptively.

Hollander, Dawes, and Duba (2000) describe various groups “behaviors, strategic patterns, and mental activities” that exemplify specific interventions and frames of reference for the therapist interested in utilizing humor in therapy. These are composed of both interventions and internal processes to understand clinical rationale.

Key Concepts to Follow

The next section includes ongoing therapist affect and behaviors. These involve 9 distinct choices.

- Make physical contact or use intentional body language. This can involve leaning towards the client or making eye contact. These can be exaggerated to facilitate a client dealing with embarrassment or inability to articulate difficult feelings.
- Use different tones of voice that will deliver your message more easily. These include:
a) A joking manner communicates “Come on, now. We both know better than this” when you want to confront some gently challenge the client to be more honest or forthcoming.
b) A hypnotic manner allows the client to become clearer about something they are confused about. This involves talking in a low, monotone voice and speaking “therapeutic truths of an abstract nature.”
c) Mirror the clients’ rate and rhythm of speaking. For example, “All we can do is the best we can.”
d) A quasi frustrated manner expresses a realization of the client being stuck and the effect this might have on others. This will help the client become aware of this without becoming emotionally wounded. “Ahhhh! Not again, I don’t know how much I can take!”
- To non-verbally mirror the client involves imitating the clients’ posture, tone, tempo and physical gestures to develop rapport and connection to their affective presence.
- Try using an anecdote such as a metaphor, quote, or proverb. Such a technique may help simplify a complex issue or give help the client detach from strong affect enough to see something rationally. If within your comfort zone, try matching the saying to a client’s interest. For example, if they are into shopping say “Why do you keep going to the florist to buy milk?”
- For the client that is expressing a great deal non-verbally, inundate them with direct attention and focus, more than they expect or may be accustomed to.
- Especially for Yalom’s category of the “help-rejecting complainer,” refuse to be helpful. Either mention simplistic or irreverent solutions, or give the client rationalizations why you cannot help them or they cannot be helped.
- If the client over-relies on the therapist to provide excessive direction, rather than obliging, make a point to divert attention to trivial matters or change subjects.
- Only offer intellectual insights in a manner that mocks the therapeutic tone the client may expect. Downplay or ridicule the client’s intellectualization.

The following might be a wonderful example to utilize with the treatment-wise help-rejecter.

Client: I am looking forward to our work together. I can tell you’ll be much more beneficial than my other therapists. I am soooo tired of that reflective “I know how you feel” junk. And repeating back what I already said…A parrot can do that!! What’s your theoretical approach, anyway? I prefer a combination of psychodynamic and existential therapy.
Therapist: I use lots of different approaches, depending on the person’s needs.
Client: Well, for example, how would you help me with…?
Therapist: (Interrupting client sheepishly with a faint grin) You know what, you’re probably too savvy and complex a person. My insight may just fall short of your expectations. Insight is overrated, anyway. Perhaps you are unable to be helped. A guy that can outwit all of those talented therapists? Maybe you should be helping them! I am not sure I have anything to offer you. But, maybe I could get some advice from you.

Remember, the ultimate goals of these interventions are to increase the client’s:

- Assertive Responses
- Ability to Reassure, Soothe, and hold themselves accountable
- Necessary Self-Defense Mechanisms
- Reality-Testing and Insight that is emotionally congruent and meaningful
- Expressions of Intimacy


Key Concepts to Follow

The next section includes therapist interventions that are more contingent on the client’s specific behaviors.

- Alter your tone of voice based on the client’s presentation. Rather than mirroring it within more traditional therapies, express the opposite. Something said in a detached manner that is actually important should be emphasized enthusiastically.
- Use animated body language such as shaking your head or putting hands over your face.
- On the other hand, something containing a great deal of affect could be minimized by using monotone speech.
- Continue what the client demands you stop until a strong emotional response is generated. Discontinue the behavior the client requests.
- If the client has pronounced non-verbal behaviors, describe them in a direct way.
- If the client gives a vague, incomplete, or inaudible statement, respond ask them to clarify in an exaggeratedly specific way.
- When dealing with a fresh traumatic event (or one that is being presenting in the relationship for the first time), use more traditional empathy and reflection. The time to consider using humor would be in responding to their understandably exaggerated sense of guilt or anger.
- If you notice incongruence between a client’s affect and content, exaggerate that in your communication.

Client: (In a glib, monotone voice) I am really excited; I get my annual review next week.
Therapist: (Acting like they are just waking up) Yes, um, ah…What were we talking about…how enamored you are with getting a raise next week.

Such a scenario helps a client confront their own incongruence and provide an opportunity to become appropriately brighter.

The next grouping of interventions involves reacting to the client’s presenting problem.

- Encourage the pathological behavior by giving absurd benefits of continuing it or drawbacks of stopping it.
- Offer bizarre solutions to a series of client problems, no matter how complex.
- When a client makes a vague statement or rationalization, give ridiculous, nonsensical explanations.
- Overemphasize the client’s strengths to the point that it is trivialized in comparison to the presenting problem.

Client: (severely obese woman who has repeatedly resisted looking at the concept of emotional eating and losing weight) My doctor tells me I need to lose 50 pounds or I will most certainly have a heart attack. I know this time is different, my motivation feels solid. You might be just the person to help!
Therapist: (In a skeptical, but slightly lighter tone) I truly think being overweight is perhaps underrated. We seldom discuss the benefits…Take for instance, did you know that people who have some extra pounds tend to save on their heating bills in the winter? Also, a recent study noted that people tend to have a better chance of surviving high-impact automobile accidents because of the extra protection provided.

This example involves intervening with a man with interpersonal challenges related to being self-centered.

Client: I don’t know what everyone’s problem is…They knew my strong personality and expertise came in the same package before they hired me.
Therapist: (with an exaggerated sigh) What frustrating mixed messages… They must be used to dealing with complete morons.
Client: (emphatically and nodding his head) Absolutely!
Therapist: Maybe we should just cancel our session and arrange a consultation with upper management. Clearly they are losing sight of what you have to offer.
Client: (Smiling and beginning to laugh) Finally, someone understands my plight!
Therapist: In fact, let’s not stop there. The Better Business Bureau needs to be called. And, why not take it public…the news would love to get their hands on this one.
Client: Come on, this is getting a bit dramatic, even for me.
Therapist: Well, perhaps we should orchestrate a “Plan B,” in case this brilliant scheme fails.
Client: What can I do to help people accept my contributions?


Key Concepts to Follow

These are instances where strategic patterns are used.

- Enthusiastically reverse the blame. When a therapist encounters self-blame, shift the focus by blaming external people or events. If a client blames others, explain how it might be their fault.
- Taking sides during a decision or conflict may be helpful. This involves colorfully aligning with the client when they expect resistance or against the client when they expect consensus.
- Demonstrate that client’s behavior is boring or demand they be interesting.
- Act more insane than the client. What ever the problematic behavior the client presents, the therapist could do it more frequently and intensely.
- Especially for the depressed client, ask them to think about their favorite humorist. Then, ask them to describe or act out how that person might react to the situation.

A wonderful example involves someone coming to treatment for anger management.

Client: What the hell are you going to do for me?! The court system is a bunch of crap- referring me to you. I only agreed so I could avoid prison time.
Therapist: Great question. Your anger does seem pretty tame compared to many people I see.
Client: Tame? Hardly. I can kick some serious ass when I need to.
Therapist: You’re tough, I’ll give you that. But definitely far from the folks I am used to seeing.
Client: Whatever…I’m not buying it.
Therapist: Well, maybe we need to spend some time trading stories about the kind of trouble you get into, and I can compare that to the clients who have REAL problems. We can just burn up our time with that. After a few sessions, I’ll just mail a note to the court telling them about their obvious mistake in sending YOU to anger management.
Client: Yeah, like they’ll believe that. You better do something that at least resembles anger management treatment, talking about triggers, relaxation techniques, and all that jazz.

Key Concepts to Follow

The final section refers to other general tools that can be used in humor therapy.

- Bluntly interrupt the client in the middle of a sentence or thought. Give unexpected and pointed responses. Do this before you have reached an understanding of what is being discussed.
- Imitate the client in a theatrical manner.
- Purposefully misinterpret a client’s symptom or presenting problem positively. Frame it in terms of being a strength or resource.
- Empathize with the receiver of the client’s communication. Demonstrate the impact of the client’s behavior in your own behavior.
- Colorfully reject the client’s belief they are making progress. Be skeptical and question everything that appears optimistic.
- Provide retorts for positive feedback the client received. Give explanations about why and how the information is false.
- Direct the client to repeat strong and healthy conclusions, insights, or decisions by purposely expressing your misunderstanding.
A client with low self-esteem, social anxiety, and self-deprecatory tendencies may benefit from this sort of strategy.

Client: (Frustrated after being challenged to accept their strengths) Fine, maybe I am not a complete failure…but a human who makes mistakes...Are you happy?
Therapist: (Getting up out of the chair, raising voice enthusiastically) I am sorry could you repeat that again, my hearing is starting to fade. Maybe just emphasize the crux of that statement, “I am human!” Let’s say it together!

On some occasions, the therapist may find a client is engulfed in their depression or worries, or hear them directly voice their difficulty finding the joyous side of life. Sometimes, a more behavioral approach to developing a sense of humor to manage their mood may be necessary. McGhee and Sayre discuss the role of “laughter meditation” in their work with clients.

- Find a comfortable environment and sitting or lying position.
- Physically relax by shutting your eyes and starting deep breathing.
- Grant permission to self-soothe (e.g., I deserve to laugh).
- Slowly count backwards to become focused and relaxed.
- Set specific goals (e.g., I plan to laugh for the next 15 minutes).
- Begin to relive past humorous experiences.
- Focus on the funniest part of those experiences.
- If this is difficult, try making silly faces or producing fake laughter.
- Another option is to bring up a therapeutic issue once your laughter has dominated your mind, and wondering how laughing about it may give you a sense of confidence and accomplishment.
- Remind yourself that you can continue to use this technique in the future and that it will help.
- Slowly open your eyes and come back to the present.
(Adapted from Sayre, 2007)

Olson (1976) described that a client’s increase, decrease, or change in humor usage may be indicative of a “criterion for termination” or progress (In Fry and Salameh, 1993, 14). For example, if the client above was able to genuinely laugh at this, this would likely be a sign of progress. In contrast, a client who constantly uses humor a defense beginning to express more congruent feelings would symbolize therapeutic movement.

Hopefully, this section has provided copious illustrations to highlight the many uses of humor with a diagnostic cross section of adult clientele. Even though many of these interventions will clearly be effective with adolescents and older adults, we will spend the next several sections specifying various models of applying humor therapy to other populations.

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

How would you compare and contrast the differences and similarities between provocative / humorous and more traditional therapies?

In beginning to construct a humorous intervention, what different therapeutic languages and tones does the therapist have available?

Could you name at least 10 different humorous interventions to utilize with 10 different presenting problems or diagnostic pictures?

Comedic Therapeutic Moment

Client: Doctor, I’m in therapy to try and “find myself.”
Therapist: (getting out of the chair and roaming around the room, speaking loudly) “You can never find yourself by going around looking for yourself; there’s nothing to find, you’re here!”

- Victor Frankl (From Heuscher in Fry and Salameh, 1993, 224).




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