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HUM9997 - SECTION 9: SPECIAL CONSIDERATIONS: AFTER THE LAUGHTER

Understanding and Evaluating the Process and Effectiveness of the Humor Therapy

An often overlooked, yet crucial facet when determining the efficacy of an intervention is follow-up and evaluation of results. During this portion of the course, we will explore different methods to determine the success of the particular strategy using informally within the therapeutic relationship and through more objective means.

More importantly, we will provide some methods to respond less than optimal interventions appropriately. The conclusion of this segment will examine explore therapist self-care which helps bolster the ability to remain enthusiastic, inquisitive, and flexible with regards to developing fresh interventions and avoiding “compassion fatigue.”

Let’s discuss the different stages of client reactions’ in utilizing provocation in therapy. Farrelly and Brandsma (1974) describe several distinct stages clients typically experience. Understanding these will help the therapist then determine how to proceed in the therapy – whether to abort or continue the current approach.

Stage One – The beginning stages are marked by a client verbally or non-verbally expressing surprise, shock, anger, confusion, and uncertainty. The following descriptions explain why many clients tend to be attracted to humor in therapy and return for future sessions.

- The client may respond with a sense of injustice, stating that the intervention from the therapist was “unfair” or manipulative.
- Clients tend to feel a greater sense of security in the therapist being more transparent versus opaque. The therapist is seen as multidimensional and the client feels less anxious in wondering about the therapist’s impressions.
- The client feels a sense of safety and accountability in the approach. This sense of being able to give up some control is freeing.
- Clients tend to experience an unparalleled sense of validation because of the therapist’s honesty.

Stage Two – As the first stage transitions, the client tends to react in a humble, irritated, or sulky way. “Darn you, you’re right about me.” Desired behavioral changes in the session may be encountered. Defense mechanisms begin to dissolve or become more adaptive.

Stage Three – The client often begins to clarify, make decisions, and change. The client tends to more strongly protest the therapist by asserting themselves and exhibiting the desired behavior without necessarily being conscious of it.

Stage Four – The final stage involves the client experiencing the benefits both in and outside of the sessions. He or she tends to be more focused on behavioral and character change, and believes they are developing an improved and more stable self-concept. References to old patterns will begin to be viewed as “the old me” or “the old you." (Farrelly & Brandsma, 1974, 131-138)

Given the typical progression of humor therapy, let’s examine how we might be able to conceptualize and evaluate the efficacy of an intervention. Salameh (1983) developed his “Humor Rating Scale” towards these ends. (Buckman, 1994, pg. 22-23) These classifications are described below.

Destructive Humor – This has no therapeutic value and intentionally or unintentionally is designed to emotionally wound the client – and is never appropriate.

Harmful Humor – This is used when the therapist feels disconnected from or unsure of the client’s needs. This is an inappropriate attempt to regain a sense of direction and connection by helping the therapist attempt to derive a sense of comfort and control when feeling lost.

Minimally Helpful Humor – This is a socially appropriate or safe humorous response. It may serve to validate something that is obvious in a humorous way. It is pleasant but only mildly therapeutic or interpretive for the client.

Very Helpful Humor – This demonstrates therapist keen discernment of the client needs, encourages introspection, and phasing out of inappropriate, or rehearsing positive behavior through interpretation.

Outstandingly Helpful Humor – This is similar to the previous category. But intangible qualities such as timing of the intervention and tone of voice make this extremely poignant. It is reassuring at times, but more importantly pushes the client to move beyond their defenses in a seemingly effortless way.

Especially when first experimenting with humor therapy as an approach, it is extremely important to role play interventions with colleagues before using them. Start with clients where you have less counter-transference. Also, after trying an intervention rate it yourself and compare it to a colleague’s rating after reviewing it with them (without telling them you’re rating first, of course!).

Taking this one step further, you might consider asking your colleagues to help you brainstorm other examples of humor that may have ranked higher in the particular situation. Always be willing to generate alternative interventions at one time.

The following discussion provides some different questions to consider individually and in supervision, based on some of the concepts that have been gleamed thus far.

When an intervention falls flat or yields an undesirable result, try to get a sense of whether it was the content or the tone of the conversation. Revisit the 4 different tones (i.e., giggling state, friendly banter, wise person, or objective observer) mentioned earlier. Were you able to approach the situation from one of these positions? If not, what kept you from doing so? If you were, how could you have done it differently?

To what extent were you disconnected with the client’s current socio-emotional space or needs? Did your language attempt to connect with the client by genuinely trying to reflect their conversational modes of communication? (e.g., street / locker room, moral) Or, were you expecting them to decipher your clinical or formal style?

It is paramount to reflect to yourself honestly about whether the therapist or client needs are being serviced by the particular intervention and to what degree. An intervention that produces a positive feeling for the therapist needs to be a byproduct of – and not a primary objective of the intervention.

As we have discussed ad nauseam, there exists no substitute for clinical judgment in evaluating the efficacy of your work. Paying attention to the client’s response will help you determine which avenue to venture down in your follow-up.

Responding Therapeutically to the Client’s Reaction

As per the four stages of therapy mentioned earlier in this section, what one may intuitively consider an “unhelpful” response such as being baffled or irritated, is likely a natural response that is to be expected. The therapist must work to be comfortable and desensitize themselves.

However, with extreme or consistently negative reactions such as rage, withdrawal, or missing sessions, the therapist may need to review their approach. This is best dealt with by being direct and asking the client how they have felt about the therapy thus far.

Remember that the client may experience ambivalence about sharing their reaction (e.g., confused but afraid to be seen as incompetent, or angry but really is afraid to upset the therapist), and this will mainly manifest in non-verbal behaviors.

Instead of feeling the need to commit to an interpretation, sometimes taking responsibility for the situation is a huge part of reconnecting. If a client denies an obvious reaction, softly restating the therapist’s subjective experience and objective observation of the client’s response may normalize this for discussion.

As many clients would be reluctant to share this, ask if they would be comfortable being honest with the therapist and under what conditions. Or, inquire as to how the therapist might know they are upset (i.e., based on the client’s own self-awareness of their external signs).

When a client has non-verbally acknowledges being hurt, and the therapist believes the intervention may have been inappropriate, clarifying this is crucial. An apology may serve to rebuild client trust and role model conflict resolution, humility and taking responsibility. Also, this may allow the client to be more comfortable being vulnerable and admit making mistakes in session, or even considering forgiveness with others.

However, be careful of shifting the focus to the therapist or expressing excessive guilt triggered by the need to constantly pacify the client. Be curious of what counter-transference transpired in the dialogue that interfered with the specific intent of the intervention. Then, reflect the situation with a trusted peer.

If a therapist feels guilty about a client feeling betrayed by an intervention (e.g., accusations of manipulation, trivializing, or misrepresentation), refrain from apologizing before you understand what is triggering that response. “Maybe I was…Hmmm…” might be an initial response. Then, asking them to talk about other impressions about what the intervention may have implied for them might be helpful.

If the client appears too distraught to process the intervention, giving them permission to take some time before talking about it may be necessary. The therapist should refrain from trying to gloss over these feelings afterwards, but need not pressure the client to discuss this before they feel prepared to do so. Normalizing communication challenges, the discomfort they create, and the benefits of working through them might be appropriate, especially as this may apply to the client’s presenting problem.

When revisiting the situation with the client, it may also be useful to consider a psychodynamic approach in wondering what was triggered for the client from past or present relationships, and perhaps normalizing this. Only consider this if there appears to be ample evidence that a client has something to gain from the interaction and if it reflects a possible pattern in their life. Again, This is not the forum to explore the therapist’s response in detail.

The therapist could also use this opportunity to empathize with the client’s social system (family, work, or relationships) and expressing how others might be feeling in the client’s life. Be clear on expressing wonderment with the client rather than justifying the therapist behavior or shifting blame to the client.

Then, reframe the experience as at least a partial success in that the client and therapist engaged in successful conflict resolution, which is a form of intimacy. Continue to check-in with the client about how they are experiencing the situation.

If a client continues to resist exploration, use your clinical judgment as to whether to probe deeper or give permission of the client to revisit any past issues at any point. Then, refocus on where the client consciously feels the need to venture in the session.

Responding with continuous humor may be appropriate as the therapist becomes more experienced. If the therapist is conflicted, it might be advised to explore ways of responding outside of the session in supervision. The better the relationship, insight into the client, and timing of the intervention, the more favorable the results of sticking with humor will likely prove.

The Therapist’s Ongoing Learning Process and Educational Needs

Whether the therapist intends to adopt the style of “provocative therapy” or integrate this more conservatively, the following description by Farrelly and Brandsma (1974, 139-142) highlight the typical progression of changes they experience in their responses.

- Shock and disbelief – I am supposed to say what?
- Curiosity and fascination – I would love to see or hear more about that.
- Tentative experimentation – Even though I am afraid to scare the client away, I am willing to try with some guidance from my supervisor. I need some concrete direction and help from those more experienced to know how to proceed.
- Renewed Enthusiasm – I feel excited by the fact that therapy need not be solely clinical. I have a sense of confidence in beginning to integrate how myself and therapy with the client. I begin to realize that the pain I feared causing will mainly come from the fear and discomfort of consequences of past actions and needing to change. But, it can be presented in a more efficient and “down-to-earth” way.
- Generalization and Integration – I begin to see boundless opportunities for using a humorous frame both in and outside of therapy. Trial and error feels more natural – and it’s a good thing, I do make mistakes. This seems less like a technique and more like a facet of my being.
- Discernment and Revision – I feel more adept at knowing when I am using humor to meet my own needs or in extreme ways. I can have parallel conversations with myself and the client which reflect the nuances of the dialogue.
- Autonomous internalization and commitment – I am less dependent on my supervisor and have developed an internal gauge that guides me. I am excited and awed by the endlessness opportunities for growth this framework provides.

The use of humor in therapy, not to mention a therapist’s personal life could also be helpful in terms of preventing burnout. There are many ways to enhance one’s use of humor to maintain or renew your personal and professional enthusiasm.

- See the references at the end to read more in-depth about the topic.
- Associate with various colleagues who excel at using humor.
- Join a professional organization such as the ones listed below keep abreast of specific opportunities for professional growth in that area.
- The Association for Applied and Therapeutic Humor (online @ http://aath.org/)
- The World Laughter Tour (http://www.worldlaughtertour.com/) about laughter classes or becoming a Certified Laughter Leader
- Salameh (1993) references a systemic program to increase humor skills; “Humor Immersion Training” or “HIT,” developed in 1987.
- McGhee (1999) has developed a workbook to help the layperson and professional enhance their humor skills; “Health, Healing, and the Amuse
System: Humor as Survival Training.”
- Keep a daily log of humorous one-liners or ironic experiences that are amusing.
- Go to comedy shows, watch sitcoms, and try some of the exercises in this course…plan time for humor…but practice being spontaneous also.

Gallows humor is the raw, unedited, and “inside” humor used by people that share a common experience. Therapists, among other professionals, can use this in moderation to diffuse stressful and horrific situations – especially when one can ill afford to experience their full range of emotions (e.g., in the middle of a stressful day) (Salameh & Fry, 1993). Over time, if one fails to use other forms of expression and coping, this can translate to cynicism and burnout.

Now, feel free to breathe a well-deserved sigh of relief. You have completed the majority of the course. By way of reviewing the case studies presented initially, the final section provides an opportunity to compare your pre and post-course knowledge base in applying humor to therapy.


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

How would you distinguish the phases of client responses to humor in therapy?

How can you informally and formally gauge the success of your interventions?

What are 3 appropriate therapist responses to the client’s reaction to the intervention, and in which contexts would you use them?

How might the therapist’s learning process be described in applying humor to therapy?

It is my sincere hope, that this course has allowed for educational and experiential exposure to help you become informed as to the depth and breadth of humor in psychotherapy. Moreover, I hope this provided some needed respite from the monotony routine all of us encounter of our daily professional lives, and reignited a natural curiosity and creativity in you that may have been lying partially dormant or unfulfilled.

 

 

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