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HUM9997 - SECTION 8: HUMOR AS A SHORT-TERM, MANAGED-CARE FRIENDLY STRATEGY WITH GROUPS, COUPLES, AND FAMILIES

 

“Humor makes us human. All animals suffer and cry, a few ‘laugh,’ but only the human animal laughs in response to humor, which they alone generate and communicate.”

- Elcha Shain Buckman

There are several hidden benefits to integrating clinically-indicated interventions into one’s practice. Many people are choosing to engage in multimodal therapies that address the needs of the whole system (i.e., couples and family sessions) or provide more cost-efficiency (i.e., group therapy).

While the benefits of these types of therapy on many occasions are obvious, another variable to consider how short-term modes of therapy are sometimes necessary due to the client’s time commitment, need for faster results due to high acuity, and, least of all, pressures from managed care to keep therapy to a limited number of sessions.

Moreover, the use of short-term, solution-focused, cognitive-behavioral, and strategic interventions have received much empirical support in the previous decade – and humorous therapeutic strategies are easily interwoven into these. Thus, the present section will try to address the application of humor to groups, couples, and families seeking treatment under the aforementioned conditions.


Laughter and Group Therapy

The emergence of groups that solely utilize humor experientially and psycho-educationally are becoming more popular (i.e., Go to for information about local groups or becoming a Certified Laughter Leader http://www.worldlaughtertour.com/). The focus of this session, however, will be more geared towards an integrated, eclectic group therapy approach.

Before delving more specifically into the forays of specific interventions, it is important for us to review some of the objectives of “Provocative Therapy,” as this will continue to serve as a template for our developing interventions. These include:

- 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, direct – 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 reason for reiterating these points is two-fold. First, without a therapist visualizing the intent of the intervention, humor should be avoided. Also, utilizing humor in the group setting may be especially tricky given the many layers of transference and heterogeneity that may be present and complicate how the humor is interpreted by the members.

Thus, the therapist must be even more keenly aware of both their internal challenges to manage any counter-transference, as well as what diagnostic or therapeutic dynamics may be present in the group. There is much temptation - especially for the newer therapist - to collude with the group’s use of humor to avoid or lessen the emotional impact of pertinent issues out of fear of conflict.

Also, the need for approval or fear of being an authority figure may prompt inappropriate use of humor by the therapist to relieve his or her discomfort. He/she may also miss out on opportunities to directly explore important issues because of his/her own anxiety. The value of ongoing supervision, again, cannot be understated.

Let us continue by looking at how humor can be applied to groups in a variety of situations. Perhaps, the following excerpt may identify how humor can be used to de-escalate anger and power struggles that often present themselves.

Group Member #1: You, our therapist, is way too young and naïve to help us…How old are you…25? How long have you been doing this?
Other Members: Absolutely…no way in hell. You need to arrange for a therapist who actually has “life experience.”
Therapist: Hmmm…I see. Perhaps you are right. But, maybe, I think this is a clear case of “reverse ageism”. I guess I could drop the charges if you promise NOT to learn one thing from me. That way I’ll know your predictions were justified.

This vignette describes how humor may be used to humanize the group therapist that may be at-risk for idealization and devaluation, early on in the process.

Group Member #1 (to the therapist): Have you ever been in group therapy before?
Therapist: I’d like to understand what makes that important to you.
Group Member #1: If you haven’t been in therapy, it means you probably haven’t dealt with our level of problems.
Therapist: What constitutes “our level of problems”?
Group Member#1: Divorce, Child Abuse Survivor Issues…
Therapist: Well, maybe you’re right. Come to think of it, I have never been sad one day of my life, lost my temper, or even made a mistake for that matter. I’m just much better at helping people work through their history than finding things to work on myself.

Other interventions may help to help the client become aware of their tendency to seek refuge in the “Poor Me” role (Farrelly and Brandsma, 1974, 152) and be protected by rationalizing their behavior, and accept responsibility for it instead.

Group Member #1: (crying): I don’t know why I did it (relapse on Percocet).
Other Members: Don’t beat yourself up…You really cannot help it, addiction is a disease. Would you blame someone for having diabetes? Can you (therapist) explain to her how this is not her fault?
Therapist: It sounds like the group is concerned about J’s guilt over the relapse and wants to make her feel better. Does that seem accurate?
Group Member #1: I don’t deserve their sympathy…I am a poor excuse for a mother, wife and woman!
Therapist: In spite of all the shame and guilt you must feel, you are demonstrating one of your hidden talents. You are so good, in fact, that no one even is aware of or talking about what is going on.
Everyone: What do you mean?
Therapist: Your ability is unsurpassed, but the group definitely cooperated helping you form LIES! Lies I tell, you! You convinced each other that having a disease such addiction means you don’t have choices that could prevent the recurrence of it. Imagine, smart people like you, being convinced of that?! You (Client #1) must be brilliant to orchestrate that scheme!

Some interventions serve to confront a group’s avoidance or denial of a crucial issue. The following example illustrates an intervention with a group member that manages to avoid being confronted, with the support of the group who wants to be liked by this member and fears retaliation, in spite of obvious mounting feelings of resentment.

Group Member #1: I have this whole anger thing licked. I have gone a month without getting pissed? I should be outta here (group)!
Other: (exasperated): Yea, great. It sounds like he is ready for discharge, right (turning to therapist)?
Therapist: That sounds like progress…Also; I am wondering what constitutes “pissed”? What do you see you have done to keep from “getting pissed”?
Group Member #1: You know, punching holes in walls, breaking dishes, calling my wife a #$%$#. And believe me, I have had opportunities. Everyone is lucky I am restraining myself.
Other: (sighing frustratingly and looking at the therapist)
Therapist: You’re probably right on! Everyone is lucky, except for you (#1) that is...You have a very thoughtful group who doesn’t want to blemish your track record. While this sounds great and all, maybe you should be hurt! Hurt that they don’t talk more directly to you to give you more of an opportunity to muddle through your anger, to practice dealing with these situations as they will inevitably surface in real life. Do you (group) want to rob #1 of this? Do you (#1) want to LET them rob you of this?

Some clinical populations in group settings may organically produce humor in their treatment process. As Maher points out, the therapist working with addictive disorders needs to feel comfortable responding to and initiating humor. (in Fry and Salameh, 1993, 85-96) Below are a set of ideas to consider in these instances.

- Be careful that the tone of the intervention is light and curious, and avoid humor when the therapist is frustrated.
- Humor in storytelling that aids in acceptance of a client’s powerlessness over their addiction rather than minimizing their problem is crucial.
- Identify and explore emotions beyond the humor, such as shame, guilt, sadness, anger, and fear, without dwelling on them.
- Process times when the client may be using humor to escape, numb, or avoid their emotions or the reality of their situation.
- When clients tend to struggle with control issues and they ask if they “have to” do something, respond with “No… (Pause) only if you want to get better!”
- Sometimes appealing to a client’s sense of self-importance is useful when trying to urge them to stay in treatment rather than leaving prematurely. “Other people need you to stay in treatment!”
- For clients who appear in extreme denial, helping access their humor or stories may unlock feelings and increase honesty.
- Focus on using humor with highly intellectualized, articulate clients versus those who appear extremely fragile or medically compromised.
- Family members may be able to confront the addicted client with humorous and revealing stories of their addiction to break their defenses, and then discuss the issues seriously.
- Allow other group members to point out a client’s powerlessness with humor.
- Clients that have an obvious level of guilt or shame can be asked whether they would do “anything” to get better. Then, ask them to do something unexpectedly absurd (e.g., sing part of their favorite song).
- Shared stories that involve rationalization may help relate clients with each other, and they may humorously connect with how they have felt the same way – and are now able to see the problem more clearly.


In my experience working in acute care, hospital settings, the application of humor and creativity in general, has proven useful. This has been especially true in working with groups who have many “institutionalized patients” who are skilled at convincingly providing the “textbook” therapeutic response.

Kuhlman (1993) specifically describes the use of humor with these populations in “Humor in Stressful Milieus”. (in Fry and Salameh, 1993, 19-45) Confronting a client directly with humor in therapeutic milieus can serve three purposes. First, this humor will break down the defenses of the client so they may be more receptive to the feedback. Secondly, it allows the group to feel engaged with the therapist and target client, rather than alienating them. Finally, this scenario can role model and normalize humor-based conflict resolution and interpersonal skills.

A wonderful example of the use of humor in a stressful, group milieu comes from Michael Crichton’s television show “ER”. One of the nurses, Abbey, is trying to gain control of a psychiatric group that is loud and ignoring her pleas for silence. Rather than continue to raise her voice, which has only escalated the group, she lights a cigarette and begins smoking it in the middle of the group! Slowly, the group confronts turns their attention to her, unanimously voicing that she is breaking the group rules. She then responds, “Now we can agree on something.”

Using catchy nicknames or “handles” in these environments can be helpful. For example, a client who constantly minimizes relapse potential can be called “Overconfident Ozzie.” Fellow group members should help identify these names to make them more meaningful. This technique can deflate a client’s shame while confronting their denial.

Additionally, I have used props to make various points more clear. Magic wands (i.e., for those who want a magic cure), oven mitt (i.e., for those that are self-deprecating as a reminder to be gentler with themselves), and dark sunglasses (i.e., for those who are very pessimistic and need a reminder) are just a few that I have utilized in the past.

Keep in mind, that many of the interventions from the individual therapy can be applied in groups, exercising greater caution, as the complexity of various dynamics are obviously multiplied.

Chaplain Eberhart (1993) discusses the uses of humor in pastoral counseling. Rather than seeing humor as an optional distraction, he interprets it as a spiritual opportunity. He charges the client with humbly embracing humanity and redirecting the suffering and attempts to control external realities to their Higher Power. (From Fry and Salameh’s, 1993, 97-119)

In working with atheist or agnostic clients, the concept of “Higher Power” can be equivalent to a principle, value, or relationship; any entity outside oneself. The following list includes examples of humorous, creative, and playful interventions.

- Allow group members to “free associate” about how a child would respond to everyday situations in life (e.g., see a mud puddle).
- Ask group members to share their most embarrassing moments (i.e., to make the point that sources of humor are consistently available).
- Help the group members identify a funny person in their lives or comedian, and ask how they would respond.
- Facilitate having members identify their internal picture of a “clown” or another form.
- Direct the members to come up with one of their favorite childhood songs or rhymes, and then make their current stressor the topic of that song. Rewrite it (Eberhart, From Fry and Salameh’s, 1993, 97-119).


Humor in Couples Therapy

Given the rising rate of divorce, remarriage, and cohabitating couples (to name a few trends), discussing different humorous interventions with couples seems like necessary task. Many clients arrive at unrealistic expectations during couple’s therapy due to lack of education, denial, entitlement, frustration, or desperation with the current relationship.

As therapists in practice will empirically confirm, couples therapy is prone to being less successful due to the clients’ delays in seeking help until the situation has escalated from being self-reported as discouraging to hopeless. Due to this inevitable reality, the window of opportunity to instill hope and offer strategies for change is often smaller.

Also, the type of short-term strategy that involves humor may more quickly identify underlying issues that negatively affect (if not cause) the presenting problem. Moreover, topics such as addiction, eating disorders, or mental illness may be avoided out of oblivion, fear, and shame without the help of more directive interventions which more quickly establish and build on the therapeutic relationship and provide education. Also, triangulation and other transference issues can be more quickly addressed with the therapist, so these do not sabotage the couple’s progress with each other.

After considering the well-crafted explanations for using humor with couples, the same precautions we have discussed are not to be ignored. Even the most seasoned therapists experience biases that may influence their systemic view of a couple. In light of this, being vigilant of these dynamics is crucial before using humor is vital.

This awareness could help minimize the possibility the therapist will be accused of taking sides or become a scapegoat for the relationship problems. Buckman (1994, 81) describes three common threads of couples therapy – intimacy, regression, and guilt. Thus, humor as a comprehensive intervention should touch all of these.

Key Concepts to Follow

Beware of responding to client’s humor in a couple’s session that is:
- Self-deprecatory
- Passive-aggressive or hostile
- Not understood by the therapist
- Could be isolating or distancing
- Expressing something serious for the first time
- Overuses humor as a defense for anxiety or other strong feelings
- Inconsiderate of the variables such as age, sexuality, gender, SES, and culture
- Attempts to solely comfort the therapist
- Symbolic of the therapist’s anxiety or difficulty aligning with one or both partners
- Other intense counter-transference

Responding to such humor in other reflective and directive ways is crucial. The scope of different situations and methods of responding has already been discussed in previous sections introducing the use of humor.

For the sake of authenticity, it may also be important to express some ambivalence on the part of the therapist when responding to humor seriously. Also, preserving or building the alliance remains in the forefront. Making statements that reflect appreciation of the humor and its function and help the client identify underlying messages simultaneously is vital. “While part of me wants to laugh with you, the other part wonders about…”

As we have noted, the therapist inappropriately responding to humor with humor may have many undesired outcomes. It may reinforce negative messages, demonstrate insensitivity, or alert the client to the therapist’s discomfort, and subsequently question the therapist’s ability to tolerate strong emotions directly.

Two main aspects of humor with couples are nicely captured by Buckman. (1994, 75-76) She discusses the therapist’s use and modeling of humor to improve dialogue; emotional awareness and control, while learning to relay intense emotions and needs in an inviting but genuine way. Secondly, she notes how assessing the couple’s use of humor as a defense to dodge painful or destructive realities can be meaningful.

The following example highlights the use of humor to make “overstatements” and confront in a way that allows for interpretation. Fenichel (1945) notes that “Laughter to an interpretation is better evidence to its correctness than yes or no. (Buckman, 1994, 78)

Wife: (starting to tear up and look down) I don’t know what is wrong with me, I just can’t seem to do things like I used to. I let the laundry piles up, I burn dinner…
Husband: (nodding his head) I know honey, you used to be so efficient – like a machine, now you are floundering…and I have to come home to a mess! How can you help her, doc?
Therapist: (animatedly) I don’t know what to tell you. I guess if you can’t fulfill your duties solo and to perfection, why bother?

The next example utilizes a common power struggle that couples have, when they appear to be reenacting “parent-child” communications.

Husband: You know how much I hate lasagna; I can’t believe you made that for our company last week!
Wife: Oh, give me a break; I made you a side of spaghetti! Nothing I do is ever good enough for you!
Husband: You said it. It isn’t good enough, because, according to you, I always come in as runner-up – to your parents, the children, and our company.
Therapist: Interrupting in an exaggeratedly condescending tone) Beth, you’ve been a bad girl. John, you’ve been a bad boy. Can you look at each other and apologize?

Guilt is another issue that couples struggle with, both to punish themselves or avoid the other person’s anger or abandonment. While some guilt may serve to help a partner apologize or take responsibility, other guilt may also be used in toxic ways. An example of this is a partner either enabling another and being manipulated into submission or rationalizing the other partner’s behavior.

Husband: She has “borderline personality disorder,” I understand why she rages at me. (Turning to wife) I love her unconditionally and wish she could forgive herself, the way I forgive her. I recognize that W is sick and I am one of the only people who truly gets it.
Wife: (crying) You don’t deserve me. I always push people away when I need them the most. I break your best pictures, called you the worst names…
Therapist: I know your pain probably keeps you from realizing…You really know how hold onto your guilt. I can experience it emanating from your pores. I have never seen anyone do that as adeptly as you.
Wife: (sniffling, but with a curious face)
Husband: (interrupting) How can you possibly turn that in some sort of strength?
Therapist: I can see why that seems like nonsense. But, part of this may actually keep the family together! It allows H will be more forgiving without experiencing frustration, while it helps W keep from really taking the risk to change. How long are you both willing to commit to this pattern?

Humor: Official Family Business

A gently humorous redefinition of a situation may jostle (a system) in such a way that the challenge is softened.

- Zuk et al.

As we’ve covered couples and groups, let us not neglect the role of humor in family therapy. As families often bring their unique brand of “inside” humor (or lack of humor) to sessions, to broach therapist-initiated humor seems like a necessary offshoot.

Farrelly and Brandsma (1974) list several points that make family therapy a vehicle for humorous interventions. Family members seem to become comfortable more quickly and “tell” on themselves and each other. They provide much more “contradictory” data that draws from an extensive relationship history. Members can more readily “decipher” each other’s use of language and communication to expose more specific and covert truths. The therapist is also more easily notice alliances and patterns and can form more customized interventions to fit these.

In Farrelly and Brandsma’s provocative therapy, several themes have emerged in terms of opportunities to utilize humorous interventions. The first involves loss of parental control, where children attempt to split the parents and they are often afraid to play “the bad guy” out of guilt or the need to please. One purpose can be to help parents create rules and creatively respond to unreasonable demands or behaviors, even if they are not perfectly consistent.

Mother: No matter what we do, your room is always messy.
Father: Your mother and I have been over it.
Therapist: So what happens if you don’t clean your room?
Father: You would think the embarrassment of the messiness would be enough!
Child: Whatever, it’s my room!
Therapist: I know you live in that room, but what makes it yours?
Child: I live in it!
Father: And who bought the house and stuff in the room? I wish we could take that stuff away since he clearly neglects it!
Child: You can’t do that!
Therapist: Well, maybe they have a point, but I know you like to play. Maybe turn the rule into a game. Mom and Dad, you keep all of C’s stuff you find on the floor or not put away correctly in a hidden place. When he is ready to restore the item he may request one or two items at a time…At the end of the week, you could see who has more stuff!

In some situations, provocative therapy may seek to restore a sense of parental efficacy in rebutting the belief that “My parents exist to meet all my needs”. Therapy can restore more realistic expectations that are contingent on the child’s behavior.

This can take forms such as denying the child has the particular need, delaying gratification of the need until the parents can reasonably meet it, or helping the child meet the need elsewhere. Closely tied to this, there is importance in overhauling the concept that “parents have obligations and children have rights.”

Child: You have to take me to soccer practice; I can’t drive until next year. You know I am trying to win “Player of the Year.” I am the one that deserves it! I am the only one in the family that is athletic, anyway. Plus, I get awesome grades. My friends and teammates NEED me.
Parent: We do take you almost everywhere you need to go. And, your brother and sister need us also.
Therapist: You obviously are popular with your peers – and smart! In fact, you probably don’t need your parents at all for the ride…it’s just convenient. Clearly you could walk or bum a ride! If the whole team was to face falling apart with your absence – surely you could get their help with transportation. I think you’re that good!

Another theme that can be addressed is helping children humanize their parents rather than see them in purely idealistic or authoritarian ways. One way this could be done would to have children or adolescents refer their parents by with their full names rather than simply “Mom and Dad". (Farrelly and Brandsma, 1974, 145-160)

Streff (1994) outlines some various themes in family therapy, in which applying humorous interventions may be useful. For instance, the next example involves confronting problematic behaviors without utilizing focusing on pathological causes or language.

Mother: I don’t know what is wrong with the boys. The counselor thinks they may have oppositional defiant disorder combined with ADHD. What do you (therapist) think is going on?
Child: (looking dejected) All we ever do is talk to shrinks! That’s what!
Therapist: Maybe that’s the problem! Tell me some of your symptoms.
Child: Talking back, interrupting and thinking “BORING!”
Therapist: So, Mom, maybe all of this is possible. Would everyone agree that it would be preferable NOT to have to come to see shrinks?
All: Yes!!!
Therapist: But, you have been going to see shrinks A LOT, maybe it would be more realistic to see them LESS. Does that seem reasonable?
All: (Looking at each other) Yeah, we guess so.
Therapist: So, what’s one thing each person wants to work on between sessions? Let’s think of one behavior that causes the “biggest” problem for each of you. Yes, you too mom! We don’t want to leave ANYONE out!

Also, as an application of Minuchin and Fishman’s strategic family therapy, using humor to “join the family” may prove especially beneficial (Streff, 1994, 93). In working with the family, even one that uses humor to avoid or covertly attack, sometimes using similar tactics is crucial in order to permeate the boundaries.

Father: Well, we are starting with another therapist again. In our insurance company’s infinite wisdom, they offered us, yet another provider who was incompetent. Either the counselor is out-of-network, unavailable, or is a complete moron!
Therapist: (Deep in thought)
Father: You appear to be incredibly introspective at the moment, please share.
Therapist: I’m thinking…and not liking the conclusion I have drawn. I am in-network and available, that must make me a moron! Although, I prefer to think of myself as “cerebrally challenged.”

Minuchin and Fishman (1981, 79) also discuss how play in therapy can “gather information that the family members do not consider relevant, and even more difficult, how to gather information that the family members do not have available.”
This can help children become more vocal without threatening the parental authority. Streff (1994) speaks of making each person in the family an actor and writer in a show while the therapist acts as the director and editor. (Streff, 1994)

Identifying and modifying patterns of triangulation and enmeshment can also pose a challenge. Oftentimes, members becoming protective and defensive results, and using play may help circumvent some of these barriers. (98) Taking a light and curious tone and saying and entertainingly making reference to a clinical concept like codependence, for example:
"Hmm…Sometimes when your parents fight you feel you have to hug them because it’s scary. I wonder what would happen if one time you decided to play the role of Curious George instead of Mother Goose?"

As a final example, absurd humor can intensify a family’s sense of their strengths and resources. Giving names as reminders can be helpful. Encouraging people in the family to be cheerleaders, for example, may be a fun versus overly sappy or awkward way of encouraging loving responses that are consistent with the member’s already existing identity.

For example, fathers may have a more difficult time expressing approval and recognition, so helping them incorporate that into something familiar may include “broadcasting” their children’s successes.

"3:15 home from school, she does it, wolfs down her snack in 5 minutes, runs up stairs and record speed, does her homework without hesitation, and what attention to detail!! She washes up, comes down for dinner the moment she is called…Ladies and Gentlemen, how does she do it?!"

As the family system changes over time, so must the therapeutic approach. Thus, the last clinical populations we will study are contained in the next section. This includes utilizing humor in therapy with the elderly and terminally ill.

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

What are some advantages of using humor with dyads, families, and groups versus using more traditional approaches?

What are some extra precautions you might consider before deciding whether or not to apply humor in these modalities?

Could you name at least 3 couples, 3 group, and 3 family therapy interventions?

Funny Factoid

“Cherophobia” is defined as the fear of merriment or that one might “die laughing.” From http://humormatters.com/definition.htm

 

 

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