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HUM9997 - SECTION 10: USE OF HUMOR WITHIN MODELS OF THERAPY

Use of Humor within Different Models of Therapy

To understand humor and know how to apply it as a technique, it is necessary to understand how and why to apply any specific technique, and comprehend the various approaches within which the use of humor will be applied. Accordingly, we will address here some important considerations about the use of techniques and an overview of the major approaches to therapy within which humor may be applied as a technique, including Cognitive, Psychodynamic, and Systems approaches. 

 

Applying Techniques


Reasons for Using a Technique

1. A new technique can help a client get unstuck or move past an obstacle to change.
2. A new technique can re-invigorate the therapeutic process and renew the client’s interest in therapy.
3. A technique can incorporate and integrate more than one model of treatment.
4. A technique can be used flexibly on an as needed basis to whatever modality or process is being applied.
5. A new technique may be more effective in addressing a specific symptom or problem than what is found in the overall treatment modality being used.


Principles for Using a Technique

1. The technique must founded in evidenced based theory and practice.
2. The technique must fit the specific client’s needs.
3. The technique must fit your style and strengths.
4. The technique must be user ready at the automatic stage of skill acquisition.
5. If a technique is not working, stop using it.
6. Techniques may need to be adapted to each individual client.
7. There are instances where the use of a new technique is contraindicated.


Cautions in Using a Technique

1. Don’t use a technique unless you have investigated its clinical effectiveness and understand its limitations and contraindications.
2. Don’t use a technique unless you understand its theoretical underpinnings well enough to apply it with knowledge and modify it - as necessary - for use with each unique individual.
3. Don’t use a technique unless you can apply it fluidly and with confidence.
4. Don’t continue to use a technique if it is not working.
5. Keep clear that there will be times when specific techniques will not be effective.

Core Foundational Knowledge: Cognitive Behavioral Approaches

Major Theoretical Models for Cognitive Behavioral Therapy

• Cognitive Therapy (CT)
• Rational Emotive Therapy (RET)
• Cognitive Behavioral Therapy (CBT)
• Dialectical Behavioral Therapy (DBT)
• Acceptance and Commitment Therapy (ACT)
• Brief Cognitive Behavioral Therapy (BCBT)
• Problem Solving Therapy 

Other Models within the Cognitive Behavioral Schema

• Systematic Rational Restructuring (SRR)
• Self-instructional Training (SIT)
• Anxiety Management Training (AMT)
• Stress Inoculation Training (SIT)

Key Principles Underlying Cognitive Behavioral Therapy

• Cognitive activity affects behavior
• Cognitive activity may be monitored and altered
• Desired behavior change may be effected through cognitive change

(Source: Dobson, K and Dozois, D, Handbook of Cognitive Behavioral Therapies)

Key Focal Points for Cognitive Behavioral Therapy

• Focus on current behaviors and thoughts and the conscious processing of information
• Attempts to uncover the underlying assumptions and personal schemas of the client
• Identification and correction of automatic thoughts and cognitive distortions
• Coping skills improvements, including improvements in problem solving abilities
• Desensitization through graduated exposure to feared stimulus
• Best applications are for “neurotic” conditions: anxiety, depression, anger control problems, self-control problems, and problem solving difficulties

Construction of Cognitive Schemas

• Cognitive schemas are structures that organize and process incoming information.
• Schemas represent the organized thought patterns that are acquired early in a person’s life and develop over the lifetime with accumulated experiences. 
• The schemas of maladjusted individuals result in distorted perceptions, faulty problem-solving and psychological disorders
• The principal goal of cognitive therapy is to replace the client’s distorted appraisals of life events with more realistic and adaptive appraisals

Essential Cognitive Techniques

• Teach the client to identify and monitor negative thoughts.
• Inform the client about the relations among cognition, affect and behavior.
• Direct the client to rate the degree of belief in the thought and the degree and intensity of emotion associated with the thought.
• Educate the client in categorizing the negative thought according to the kind of cognitive distortion exemplified by the thought.
• Assist the client in identifying and altering the underlying beliefs, assumptions, or schemas that predispose him/her to engage in faulty thinking patterns.
• Engage the client in vertical descent, exploring the actual consequences that would ensue from the negative thought being true.
• Explore the underlying assumptions and rules connected to the negative thought.
• Identify the costs and benefits, or advantages and disadvantages, of the thought.
• Examine the evidence for the negative thought in order to test the validity of the negative thought.
• Place the event in perspective, grading the event on a continuum from 0 to 100 in terms of what the client would still be able to do even if the event occurs. 
• Address whether the client would apply the same rules and standards to other people.
• Have the client take the role of the person arguing against the negative thought. 
• Ask the client to engage in a logical analysis of the negative thought and the conclusions that have been drawn from it. 
• Explore the degree of completeness of information that the client is using to reach his/her conclusions.
• Seek out one or more alternative explanations for the event in question.
• Help the client to view the event as a problem to be solved and assume the position of a problem solver.

(Source: Leahy, R, Practicing Cognitive Therapy: A Guide to Interventions)


How the Use of Humor Fits within the CBT Framework

The core understanding related to CBT is that people have cognitive distortions about themselves, the world, and the interaction between the self and the world. These cognitive distortions generate affective material in ways that lead to dysfunctional states of being and dysfunctional behavioral choices. The goal of CBT is to challenge - and change - the cognitive distortions, thereby altering the affective material that is being generated.

Cognitive distortions are held in place by a number of different factors that can create resistance to change. Cognitive distortions that are addressed within CBT are typically those that have become automatic thoughts - the default way of viewing a certain aspect of the world. This automaticity is created by two key interacting components: 1) repetition of the thought over time and 2) the overall affective impact of the thought. The more frequently a thought occurs, and the more emotional loading is associated with that thought, the more rigidly the thought is held in place and the more difficult is the task of creating flexibility to view things from a different point of view. 

At a deeper level, there may also be other factors that generate resistance and impediments to better cognitive flexibility. One of the most well-known proponents of CBT, David Burns, describes two kinds of resistance: Process Resistance and Outcome Resistance.  Process resistance is concerned with the anticipated amount of work that will be required to effectuate the change. Change is hard, and clients usually have a sense early on just how hard it is going to be to do the work of change.

Outcome resistance is concerned with possible anticipated negative effects of living within the changed state - possible loss of a sense of identity, possible loss of safety moving from a known state (however uncomfortable) to an unknown state, possible loss of important roles within relationships, etc. From this perspective, change represents a threat to be avoided. It is this emotional sense of threat that can lead to clients holding firmly onto cognitive distortions based upon ideas that even the client understands - from a cognitive standpoint - to be absurd. The fear can be strong enough to preclude more flexible and adaptive ways of viewing things. This is where the inherent flexibility of humor can be so helpful to the change process.

One of the most essential features of humor is the simultaneous presentation of multiple viewpoints within a single construct - the very definition of flexible thought. The right kind of humorous intervention is able to acknowledge the presence and importance of the client's cognitive distortions while also positing a direct challenge to the grim rigidity of the cognitive distortions.

Done correctly, this can gently peel back the protective layer of defense that keeps the cognitive distortion rigidly in place while offering a potential opening for the emergence of a new and more adaptive direction for the client to shift his/her world view.  It is impossible to simultaneously laugh at the absurdity of a point of view and be held rigidly to that point of view. Change can be envisioned.

While the primary tools of CBT will remain the same - monitoring and challenging automatic thoughts, exploring the ideas and intentions, etc. - humor can be very helpful as a tool for creating that initial unraveling of a cognitive distortion that is held in place with grim rigidity due to outcome resistance and the threat posed by real change. 

Cautions about Humor within the CBT Model

All of the same principles for the use of humor that have been discussed in previous sections are relevant when using humor within the CBT model. The clinician must be skilled and comfortable in the use of humor so that the intervention creates a sense of safety instead of threat. The client must be open to the playfulness that is inherent in the use of humor, so that the intervention is experienced as one that increases the sense of caring and trust. The humor must be playful and supportive, not critical or mean. 

However, perhaps the most critical factor in the effectiveness of humor in loosening up a rigid cognitive construct is the issue of timing. The timing of the intervention must be considered carefully, based upon the readiness of the client to have their resistance addressed and their cognitive distortion challenged. The clinician must have good instincts concerning when a key point of readiness is reached. Then the client will typically clarify whether the timing is correct by laughing openly and demonstrating the emergence of flexibility - or by adhering to the more rigid perspective and not laughing in any honest way.

Many clients come into treatment with cognitive distortions that are held in place by very powerful emotional messages with safety implications for their sense of worth and well-being in the world. The phrase "grim rigidity" has been used to clarify how strong the resistance to change can be and the sense of threat that can be experienced by the client when the cognitive distortions are challenged. 

While humor can be a valuable tool for initiating an emerging flexibility, clinicians should be aware of the need to proceed cautiously when entering into such tender territory. If the relationship is not strong enough, if the clinician is not confident enough about their ability to use humor, and if it is not clear that the timing is right, then it is better to err on the side of caution and wait for a better time to try to create flexibility in the client's persistent cognitive distortions.


Core Foundational Knowledge: Psychodynamic Approaches

Foundations of Psychodynamic Theory

• People experience and act on unknown wishes and fears 
• Early experiences shape personality and interpersonal relationship schemas
• During the first 2 ½ years of life, brain growth is primarily in the right hemisphere, where memories are stored in the form of perceptual-representational experiences 
• These perceptual-representational memories are stored in the right brain as implicit memory that is preconscious and holds procedural knowledge, reflecting learning with motor, perceptual and other embodied systems
• Early attachment experiences begin the process of creating the capacity to regulate emotions, first through interactive emotional engagement, then with support for independence
• After the first 2 ½ years, the predominance of brain growth begins to move to the left hemisphere, where declarative memory begins with the acquisition of verbal and symbolic capabilities 
• Declarative memory allows for the verbal stating of memory and allows memories to be consciously known and recalled through symbolic representation, i.e., language
• Perceptual disturbances are ubiquitous, since experiences occur before the capacity exists to evaluate using conscious assessment capabilities 
• If excessively challenging events occur, over-activation of the amygdala from the trauma response can shut down important areas of the brain responsible for information processing and verbalization, inhibiting the ability of the person to process the challenging experience 
• The need to ward off and contain extremely disruptive feelings = traumatic memory not being accessible
• Defenses and resistances occur to help contain the emergence of disruptive feelings, but also prevent the ability to connect the feelings with other cognitive resources 
• People repeat unhelpful behavior in an attempt to master enduring conflict or trauma (repetition compulsion) 
• These repetitive actions can evolve into increasingly large and pervasive behavioral schemata
• Intrapsychic conflict is created when objectionable wishes, thoughts, drives and instincts meet forces that experience or anticipate the presence of guilt, shame or punishment
• People seek to resolve intrapsychic conflict through the creation of compromise formations
• Compromise formations, without the presence of the person’s highest level, conscious evaluative capabilities, will often lead to the development of secondary problems or symptoms
• Transference and countertransference are key components of treatment by clarifying where the key conflicts lie
• Dynamic therapy restructures intense implicit memories within the context of an attuned relationship
• Repetitive feelings, styles of interaction, and intrapsychic conflicts can be brought into consciousness and undergo a process of clarification, allowing for restructuring of neural circuits in stored implicit memory and re-organization of the structures into more complex and more adaptive ways of experiencing and behaving 
• Clarification comes from making linkages between the arrested emotional schemata and higher level structures of organization (conscious thought, insight) in a process called supervenience 
• The process of re-organizing mental structures, narratives and psychological and behavioral schemata into much more complex states is called emergence
• To achieve emergence, the patient must be helped to reach a place where the defensive structures are brought to a state of disequilibrium where re-organization and restructuring can occur, a place called the bifurcation point
• The bifurcation point is a make or break moment, and to reach it there must be a combination of pressure to move through the defenses and support so the disequilibrium doesn’t overwhelm the patient’s adaptive capacities, a combination called the holding environment

Key Focal Points for Psychodynamic Counseling

• Focus on affect and the expression of emotion
• Expectation of attempts to avoid distressing thoughts and feelings
• Identification of recurring themes and patterns
• Discussion of past experience (developmental focus)
• Focus on interpersonal relationships (and attachment)
• Focus on the therapy relationship 
• Exploration of fantasy life

(Source: Sadler, Jonathan, The Efficacy of Psychodynamic Psychotherapy)

Theoretical Models for Psychodynamic Psychotherapy

• Psychoanalysis 
• Ego psychology 
• Attachment theory 
• Object relations theory
• Process-experiential therapies, e.g., Emotion Focused Therapy, Body Work

Essential Psychodynamic Techniques

1. Listen and observe
2. Assume everything is transference
3. Be aware of your tone and how it changes in response to the patient
4. Watch for qualifying remarks and interruptions in the flow of narrative
5. Resist the patient’s desire to case you in a more social role
6. Be “stupid” – use naïve sounding, simplistic requests for more information about the patient’s thoughts, feelings, and behaviors
7. Meet the patient where he is
8. Closely follow the affect – focus less on the facts of a narrative than on how the patient feels about it
9. Confront the patient about repetitive behaviors
10. Interpret in order to put behaviors in the context of deeper truths about what drive the patient to behave in the way he does

(Source: Sublette, ME, Novick, J, Essential Techniques for the Beginning Psychodynamic Psychotherapist)

Two Modes of Knowing

• Declarative knowledge (left brain): information that can be verbally stated and is available for conscious recollection
• Procedural knowledge (right brain): information represented implicitly, as embodied knowledge, reflecting learning with motor, perceptual and other systems

Construction of Emotion Schemes

• Emotion schemes are complex, integrative structures of experience that create motivations for behavior and/or inhibition 
• Emotion schemes include: situations/memories, bodily sensations/expressions, symbolic representations, wishes/action tendencies, emotions and integrative feelings (“felt sense”) 
• Different forms of experiencing (such as thought and feeling) are interwoven and linked 
• Emotion themes are being continuously reshaped
• Emotions can generate other emotions and be secondary to other emotions
• Emotion schemes are unique to each person

Emotion Schemes and Self-regulation

• Too little or too much emotional arousal is dysfunctional (non-adaptive) 
• The ability to regulate one’s emotions and level of emotional arousal is necessary for adaptive functioning 
• Self-regulation of emotion depends upon a combination of successful attachment experiences and the construction of key executive function skills 
• Effective self-regulation requires the ability to access, heighten, and/or tolerate emotion combined with the ability to contain or distance emotion

Theories of Emotional Dysfunction

• Inability to access and utilize all components of emotion schema system leads to impulsive or maladaptive actions 
• Experiencing vestigial emotion schemes that are incongruent with current realities 
• Substitution of less useful secondary reactive emotional responses for primary emotions 
• Over-arousal from flooding of painful emotion
• Under-arousal or excessive emotional containment leading to emotional dysregulation 
• Different aspects of self place multiple emotion schemes in conflict with one another, leading to emotional restriction or paralysis and inability to apply appropriate emotion to circumstance

Dysfunctional Schemata, Coping Styles and Modes

• Dysfunctional schemata are self-defeating life patterns of perception, emotion, and physical sensation. 
• Coping styles are our behavioral responses to the schemas in hopes of making things better, but in fact they very often wind up reinforcing the schema.
• Modes are mind states that we can shift into quickly or more stably that cluster schemas and coping styles into a temporary "way of being."
• If basic emotional needs are not met in childhood, dysfunctional schemas, coping styles, and modes can result


How the Use of Humor Fits within the Psychodynamic Framework

Psychodynamic theory is concerned with cognitive-affective schemas that operate at levels more outside the realm of conscious thought. Attachment theory, object relations theory, and body based modes of therapy start with the assumption that problems develop in the storing of affective experiences on the right side of the brain prior to the develop of left-brain, verbal functioning. These memory formations, because they are pre-verbal, are not accessible in the same manner as are cognitive distortions held in the left brain that are more usually the arena in which CBT operates.

These right brain, affective-cognitive distortions are more difficult to reach through CBT based talk therapy.  Psychodynamic based modes of therapy attempt to bring the dysfunctional affective-cognitive schemas into consciousness in more experiential ways in the client's present relationships - including with the therapist. When they are re-experienced and come into conscious focus, then they can be connected and integrated with the left brain cognitive abilities.

For this integrative process to happen, the thereapeutic relationship - including the transference-countertransference interaction - must be used to invite the client into a safe space where the traumatic experiences can actively emerge. When they are present, they are able to be modified through a corrective emotional experience in the real time of the therapeutic relationship, and ultimately integrated with the person's left-brain cognitive and verbal capabilities through interpretation, insight and other verbal therapeutic interventions. 

While this is experiential change process is being undertaken, the client will be undergoing similar kinds of resistance to what was discussed in the previous section on CBT: Process Resistance and Outcome Resistance. However, the resistance is also likely to be less accessible if the problems exist at a pre-verbal, right-brain level. The client may have llimited cognitive awareness of why he/she is having such a hard time trying to change his/her choices of how to interact with the world. 

Humor is both an experiential and a cognitive-affective intervention. If the ultimate goal of psychodynamic therapy is to provide 1) a corrective emotional experience and 2) integration between the deep right-brain memory experiences and the more evolved verbal capacities of the left brain, humor can be a great vehicle. From an experiential standpoint, humor can create a sense of safety and playfulness that operates at a very primitive level in deep areas of the brain. Shared humor is shared closeness and connection, and this in itself can create an emotionally corrective experience around difficult topics. 

Humor can also create a certain amount of cognitive distance between a client and a difficult subject. This cognitive distance may be able to support the client allowing the re-experiencing of the painful emotional material, as the emotional distance decreases the immediacy of the impact of the painful area.  

As previously noted, humor is also able to integrate multiple viewpoints around a single subject. It can help integrate deeply felt emotional experiences with a more cognitively distanced perspective. Deeply held fears and worries can be presented in a format that challenges the grim seriousness of what is being experienced - with the inherent lightness that accompanies humor. 

As before, done correctly, this can gently peel back the protective layer of defense that holds the experiential pain or fear rigidly in place. At the same time, it can offer a potential opening for the emergence of a new and more adaptive direction for the client to move his/her traumatic experience.  

While the primary tools of psychodynamic therapy will remain the same,  humor can be used sparingly as a tool for creating that initial connection between the affective material causing so much distress and a path to reshape that experience into a more evolved and more adaptive state.

Cautions about Humor within the Psychodynamic Model

All of the same principles for the use of humor that have been discussed in previous sections are relevant when using humor within the psychodynamic model - but with perhaps a higher degree of importance and more caution. Because the therapeutic relation, including transference and countertransference, are at the center of the clinical work, the use of humor must not be employed in ways that are damaging to the therapeutic relationship. If the client needs for the clinician to be serious about his/her problems in order to maintain a sense of trust, then the insertion of humor - particularly earlier in the relationship - may be problematic.

However, if the treatment proceeds forward successfully, there are likely to arise certain points in the course of the treatment where the relationship has become sufficiently secure and  the client feels safe enough and ready enough for the change process to take a bigger step forward.  This is the point where the right humorous intervention may be used to create an opportunity for a bigger change step - inviting the client to push through his/her resistance and reshape his/her distressing emotional experience. 

When the client has reached that point of readiness, all of the previous cautions also apply. The clinician must be skilled and comfortable in the use of humor so that the intervention creates a sense of safety instead of threat. The client must be open to the playfulness that is inherent in the use of humor, so that the intervention is experienced as one that increases the sense of caring and trust.  The humor must be playful and supportive, not critical or mean. The humor must evolve from the nature of the therapeutic relationship, not be too different and jarring from the rest of the treatment. Otherwise, the client may experience it as too strange and potentially threatening to how he/she understands the relationship, otherwise the transference may be altered in detrimental ways. 

 

Established Systems Models and Techniques

Theoretical Systems Models

• Bowenian or Intergenerational Therapy
• Structural Family Therapy
• Strategic Family Therapy
• Communication/Experiential


Premises of Social Systems Theory

• The whole is equal to more than the sum of its parts
• Systems are highly organized
• Boundaries are important
• Patterned interactions are important
• The behavior of the individual cannot be understood without reference to the system to which s/he belongs

Practical Application of Systemic Therapy

• Practical rather than analytical
• Does not work to determine causes nor diagnose people
• Looks for problematic patterns of behavior in groups of people
• It addresses those interactional patterns directly
• Therapist does not have power to change people or systems
• Therapist serves as a guide to help systems change themselves through the us of creative gentle pokes
• The basic structure of a session usually moves through three stages: initial complaints, transition to resourceful emphasis, and a homework assignment to maintain momentum.

(www.mindfortherapy.com)

Established Systems Therapy Techniques

• Use genogram to show intergenerational patterns
• Use joining to engage client system through tracking the content of family facts.  Joining is accomplished through mimesis, whereby the therapist becomes more like the family in style or content of communication; confirmation by using a feeling word to reflect an expressed or unexpressed feeling of a family member; and accommodation through therapist’s personal adjustments in order to achieve a therapeutic alliance.
• Help client system strive for balance, achieving self-definition but not losing spontaneous emotional expression.
• Dismantling triangles as a way to dilute anxiety
• Use family mapping to depict structures and patterns in the family system
• Therapist determines alignments and power within the family unit
• Reframing, which involves explaining a perception from a different context in order to change the meaning without changing the facts
• Enactment, whereby families play out problematic behavioral sequences into the counseling session
• Spontaneous interaction allows the therapist to point out the sequencing and dynamics of observed behaviors while focusing on process rather than content.
• Restructuring the family roles through suggested role reversals or changes
• Use family communication style to determine feelings of self worth in members
• Family sculpting is used to experientially allow family members to understand and feel how they are perceived by others within the family
• Use of ambiguous or indirect worded directives to foster resistance and subsequent change
• Therapist uses paradoxes to lower or eliminate resistance to change by restraining, prescribing, redefining troublesome actions.
• Cultural grams and ecomaps are used as pictorials to show the influences and connections systems have to their nurturing and sustaining cultures.

How the Use of Humor Fits within Systems Frameworks

Systems theory is concerned with the development of dysfunctional behavioral patterns and sequences within complex systems and how to alter the playing out of these patterns by the parties who play various roles in the maintenance of the dysfunctional sequences. Systems theory is not as concerned with the etiology of the problems but is much more focused on intervening in ways that interrupt the dysfunctional sequences and re-direct the system towards more adaptive ways of interacting internally (towards other parts of the system) and externally (towards the world). 

As with other modes of therapy, one of the key challenges in systems-based clinical work has to do with the issue of resistance. System resistance is complex, embodying elements of resistance based upon both cognitive distortions and deeply embedded affective material that plays itself out between multiple parties in complex relationships. Working with one element of the system to lead him/her towards healthier ways of being may seem like a good goal of treatment. But such change can create threats and disruptions in the rest of the system, triggering responses designed to pull the wayward member back towards compliance with the more dysfunctional purposes of the larger system. 

At the heart of this systemic distress lie fears, worries and anxieties about what will happen to the system and its members should change occur. In this regard, the presence of Outcome Resistance may be noted. Like individuals, systems may be marked by various degrees of rigidity in their resistance to change. 

If a clinician is able to be invited to participate in the dysfunctional system, humor may play a similar role to what has already been discussed in the two previous sections. Done correctly - and when the system is ready for it -  humor can create a sense of safety and playfulness when addressing difficult concerns about what might happen to the cohesiveness of the system as it moves towards a changed state.

The modeling of playfulness on the part of the clinician may also invite other members in the system to relax in the presence of whatever anxiety is responsible for the rigidity and resistance to change. And because shared humor also creates a shared sense of closeness and connection, it can reduce the worries that the system has about the loss of cohesiveness, attachment and closeness in the face of change. When more than one member of a system begins to approach serious matters with a more humorous method of interaction, it can mark the emergence of a new degree of flexibility in important areas.   

As previously noted, humor is also able to integrate multiple viewpoints around a single subject. If there are deeply held roles, values, perceptions, and beliefs that interfere with a system moving towards a more evolved state, then this factor can also contribute to increased flexibility. Deeply held fears and worries about the loss of identity, purpose and meaning may be more successfully approached with gentle and respectful humor. 

Envisioning a different way of managing systemic material with a humorous and playful quality may allow the system to "try out change" without fully committing to change. Jokes and humor are not "real", after all.   

Cautions about Humor within a Systems Model

All of the same principles for the use of humor that have been discussed in previous sections are relevant for working within a systems model. The clinician must be very comfortable and able to invite clients into a playful mode of interaction when approaching topics associated with change work. The humor must generate safety in ways that respects the resistance and doesn't push things forward more than the system is ready to be pushed.

However, there is an additional level of complexity when it comes to timing within systems approaches. Within a system model, there are multiple points of impact that must be considered, not just a single client. The clinician must evaluate the readiness of each of the members of the system to ensure that the parties critical to initiating and facilitating change are ready to embrace the use of humor.  

This acknowledges the need for a different kind of assessment when working with systems. Each part of the system may have one or more different roles within that system, different permissions to lead, different obligations towards the system and other members of the system. Additionally, there must be assessment of the way in which the system as a whole operates, including the interactive effects between the various system parts. 

Only when all of these different factors are known will the clinician have clarity about how to apply humor within the total system. Done correctly, humor can contribute to greater flexibility. Done incorrectly, humor can increase systemic resistance.  

 

 

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