PsychologicalReporrs, 1990, 66, 795-801.
O Psychological Reports 1990
USES O F HUMOR I N PSYCHOTHERAPY SHARON A. DIMMER Michigan State Uniuersiiy JAMES L. CARROLL
GWEN K. WYATT
Central Michigan Uniuersify
Michigan State University
Summary,-Given demonstrated usefulness in facilitating learning, aiding healing, and reducing stress, humor has gained recognition as a clinical tool. This article reviews some uses and potential misuses of humor in psychotherapy and suggests directions for practice and research.
Recently there has been growing interest in the clinical uses of humor. Research suggests that humor may be important in facilitating learning (Ziv, 1988), helping to reduce pain (Adams & McGuire, 1986), enhancing immune system functioning (Dillon, Minchoff, & Baker, 1986), lowering stress (Trice & Price, 1986), and promoting general health (Carroll, 1990). Within the last 40 years many therapists representing a variety of schools have recommended the use of humor in both diagnosis and treatment (Goldstein, 1987). In their Handbook of Humor and Psychotherapy, Fry and Salameh (1987) presented a 306-item bibliography of books, articles, and presentations relating to the utility of using humor in psychotherapy. One hundred sixty-four references from 1970 onward attest to interest in the subject; an extensive earlier bibliography was presented by Treadwell (1967). According to Greenwald (1976), laughter is incompatible with depression. Rosenheim and Golan (1986) have stated that a humorous approach to life is characterized by flexibility, potential for broadening one's perspective, and discovering new options. Harder (1976) believes that humor is both the producer and the product of good mental health, while Greenwald (1987) believes humor, usually followed by laughter, is a useful treatment for various types of psychiatric clients. The purpose of this article is to review the recent literature and research on the use of humor in psychotherapy, addressing some of its uses and potential misuses, and suggesting directions for research.
Humor as a Method of Intervention Humor in psychotherapy can be used to deviate anxiety and tension, encourage insight, increase motivation, create an atmosphere of closeness and 'The authos thank the Faculty Committee for Research and Creative Endeavors at Central P h i g a n University for their support. Reprint requests should be sent to Sharon A. Dimmer, A-230 Life Sciences Building, Michigan State University, College of Nursing, East Lansing, MI 48824-1317.
796
S. A. DIMMER, ETAL.
equality between therapist and client, expose absurd beliefs, develop a sense of proportion to one's importance in life situations, and facilitate emotional catharsis (Rosenheim, 1974; Mindess, 1976; Haig, 1986; Rosenheim & Golan, 1986; Reynes & M e n , 1987). Freud (1960) placed emphasis on the content of the humor stimulus and its relation to the individual's current conflicts. Freud thought that humor helped people cope with anxiety by permitting a release of hostile or sexual feelings and allowing a person to say something he could not say openly. Later, Grossman (1976) suggested that it was not as threatening to tell a joke as to describe a dream. Humor is often an ingredient in paradoxical approaches to therapy. Paradox is a technique for mobilizing psychological resistance to eliminate destructive behavior patterns, specifically for people who take life too seriously. Olson (1976) and Ellis (1977) thought that disturbed people tend to take themselves and their problems too seriously. Fay (1978) recommended paradoxical therapy because he found that humorous comments facilitate the disruption of damaging values and enable the person to gain a different perspective. He stated that, even if the patient does not change, paradoxical methods may prevent the patient's support people from becoming frustrated and destructively angry. Erickson and Rossi (1979) also advocated the use of paradox, which they believe helps people break through their too-limited mental sets and initiate unconscious searches for new levels of meaning. Some clinicians (Farrelly & Lynch, 1987; Roller & Lankester, 1987) advocate provocative therapy, a paradoxical approach. They suggest that both clients and therapists overrate the clients' fragility, which can cause the therapist to avoid helpful interventions. If humorously provoked, the client will tend to move toward more effective behavior. Goodman (1983) thought that it was possible for people to invite humor intentionally without overdoing it. Goodman, h e c t o r of the Humor Project (a nonprofit foundation based in Saratoga Springs, NY, dedicated to the therapeutic use of humor), has suggested a variety of experiential techniques including educating people about their "comic vision" so that they can see humor that is around them. He cited an example from a church bulletin announcing a baptismal service: "This afternoon there will be meetings in the north and south ends of the church. Children will be baptized on both ends" (Goodman, 1983, p. 8). O'Connell (1976) thought that humor techniques should occur in an accepting, playful atmosphere where the patient is treated with kindness and respect. Greenwald (1976) took this idea further, positing that therapy should be fun for the therapist to set an example for the patient.
Research and Clinical Studies Scogin and Merbaum (1983) tested the assumption that an inverse rela-
USES OF HUMOR I N PSYCHOTHERAPY
797
tionship exists between humor and depression. They presented cartoons to clinical psychology students and used the Beck Depression Inventory as the criterion for depression. They found no significant differences between mildly depressed and nondepressed college students on self-reported humor appreciation. They did find, however, that students with higher anxiety, depression, and hostility found cartoons with "other" as the target or focus of the humor significantly more humorous than those with ''self'' as the object of the humor. This suggests a person who is feeling depressed, anxious, or angry may be threatened by humor that comes too close to personal feelings of vulnerability. Rosenheim and Golan (1986) investigated preferences of hysterical, obsessive, and depressive patients for humorous or nonhumorous therapeutic interventions. Their results supported the notion that there is a significant interaction between the type of humor preferred and personality. Depressed patients rejected humor aimed at development of perspective but not humor aimed at emotional confrontation and anxiety reduction. Hysterical patients preferred the opposite kind of humor preferred by depressed patients. Obsessive patients strongly rejected all three types of humor. The results suggest that both depressed and obsessive patients may have difficulty accepting humorous invitations to change their bleak view of life; however, the authors concluded that, even though these patients preferred nonhumorous approaches, they still may benefit from other humorous therapeutic approaches. I n a more recent study, Rosenheim, Tecucianu, and Dimitrovsky (1989) investigated the humor appreciation of 25 nonchronic schzophrenic patients in an Israeli mental hospital. The patients were told that the researchers wanted to determine the therapeutic appropriateness of various interventions, presented in either a humorous or nonhumorous style. The results were similar to the earlier Rosenheim and Golan (1986) study-the patients did not appreciate the humorous intervention strategies. However, the authors cautioned that this might be from patients' lack of experience with humorous interventions. Another finding suggested that there was a relationship between personality deterioration and the ability to appreciate the therapeutic apsects of humor. Paranoid patients who had a better organized, though emotionally vulnerable personality structure, were less rejecting of humor than were nonparanoid patients. Humor has been used to reduce the anxiety that clients often experience early in therapy. I t has been speculated (Reynes, 1987) that its use may demonstrate to the client that the therapist will accept and treat him as a person rather than as a problem. Rosenheim (1974) reported his experience with a young man who had been raised with emphasis on obedience, seriousness, and respect for authority. H e took therapy seriously and never allowed himself any small talk, let alone a smile. The therapist asked him if he ever
798
S. A. DIMMER, ETAL.
wondered how therapists managed their own lives. The patient responded in such a way to indicate that such "heretical" thoughts never entered his mind. The therapist responded, "You really think I was ordained for 'angelhood'?" After this, the patient was apparently freer with the therapist and had more relaxed body posture. Levine (1976) illustrated how humor can facilitate a new perspective and help the client to move from a narrow, over-emphasized view of his problem to considering alternative ways of viewing problems and solutions. H e reported that a female client frequently complained about her unfaithful and inconsiderate husband. When asked why she still chose to stay with him, the patient responded that as bad as he was, she was afraid that she could not find anyone better and she was afraid of being alone. The therapist acknowledged her loneliness but pointed out another aspect of her choice to remain married by relating a story. The story was of the man who worked in the circus cleaning up after the animals and giving enemas to constipated elephants. An old friend of his, observing the menial type of work that he was doing, offered to help him get another job. To which he replied, "What,'and give up show biz?" The patient was angry at first and then amused. She was able to recognize some of her covert motives for her complaints about her husband. This laughter and her willingness to share it was the first sign of a positive change in the severity of the woman's depression and marked the beginning of significant therapeutic progress. Savell (1983) studied the effects of humor on depression in adult psychatric patients attending a day-treatment program. H e used the Beck Depression Inventory to rate the patient's level of depression. A treatment group listened to tapes of jokes and anecdotes recorded by six nationally recognized comedians once a day for eight days. The types of humor used were: self-degrading humor in which the comedian is self-debasing, hostile humor in which the comedian attacks his audience or directs his jokes toward belittling others, and situational humor in which the humor of the joke is based upon the absurdity of the situation in a nonhostile way. Savell found that self-debasing, hostile humor and situational humor stimuli used in the study were not effective in reducing depression but they did not inhibit the effectiveness of other treatment approaches. H e found that the enjoyment of situational humor increased as the patient's depression decreased. Another finding pointed out that hostile humor was less associated with the depression than with other types of humor (i.e., even when the patients became less depressed they still disliked hostile or mistreatment humor). This suggests that it is the least desirable type of humor to use with depressed patients. While humor has been described as a positive therapeutic tool, Haig (1986) points out the double-edged aspect of humor in psychotherapy by
USES OF HUMOR I N PSYCHOTHERAPY
799
reporting examples of both constructive and destructive humor in a clinical case. Kubie (1971) expressed the strongest concern about using humor as a therapeutic tool. Both authors listed some of the following concerns: (1) Humor might be used to avoid uncomfortable feelings by the patient or therapist; (2) Humor could be used by patients to defend against accepting the importance of their illness; (3) Sarcastic humor could be used to mask the therapist's hosthties toward the patient; (4) The therapist could use humor to show off how amusing and clever he can be; and (5) Were humor excessive, the patient might doubt that h e is being taken seriously. Both Kubie (1971) and Haig (1986) were concerned that the therapist would use humor to serve their own interests to the disadvantage of the client, a concern that must be respected as valid. However, if therapists keep in mind the possible pitfalls of humor in treatment, they can apply humorous interventions constructively (Mindess, 1976; Ruvelson, 1988).
Problems and Directions While some data (anecdotal and otherwise) exists, more and better research on the use of humor in psychotherapy is needed (Saper, 1987). In an effort to objectify the use of humor, many researchers have used canned or prepared jokes which cannot be generalized to spontaneous therapeutic humor. Practitioners engaged in the clinical aspect of their work may use creative approaches, such as "tell your favorite joke"; however, their findings are mostly anecdotal and their approaches have not been systematized (Killinger, 1976). The study of therapeutic humor needs a common ground which takes into account the complexity of psychotherapy as an art, the diversity of humor stimuli, and the need for standardzed research. Salameh (1983) devised a five-point Humor Rating Scale to rate therapists' use of humor in psychotherapy. Level 1 refers to destructive humor, level 2 to harmful humor, level 3 to minimally helpful humor, level 4 to very helpful humor response, and level 5 to outstanlngly helpful humor responses. The author gives an illustrative clinical example for each level. This tool may be useful for both clinical and research classification of humor used in therapeutic interactions, and a taxonomy by Berger (1976) could assist therapists in classifying themes of humorous material. Clearly it is important to consider the client's needs as well as h s personality structure if appropriate humor is to be effective in the therapeutic process. Currently there have been few studies that assess the long-term effects of humorous interventions in a controlled manner; such research is needed before use of humor can be validated. Research is also needed in the
800
S. A. DIMMER, ETAL.
following areas: humor as a coping mechanism, the role of humor in increasing client's inner confidence, and the use of humor to increase personal humility (in both client and therapist). Therapists probably need specific training either during formal psychotherapy courses or through continuing education in the "art" of humor intervention. Other therapists come by their skills "naturally," and only need permission to use their skills therapeutically. A recent book by Mosak (1987) provides approaches to the incorporation of humor to establish rapport, offer interpretations, implement changes, and determine readiness for termination. And finally, another important consideration must be the understanding of cross-cultural issues in humor. Currently many psychologists are struggling with trying to understand the multicultural issues clients bring to the therapy. Few articles have been written that address cross-cultural aspects of humor; Fry and Salameh (1987) listed only two items of a cross-cultural nature while Mosak (1987) listed seven. Further research into cross-cultural aspects of humor in therapy is clearly needed. In conclusion, the authors advocate humor as one useful tool for anxiety reduction and facilitation of insight. Others have taken even a stronger stand. Mindess wrote, "The best way I can envisage for us as therapists to encourage a humorous outlook in patients is to maintain such an outlook in ourselves (1976, p. 338). Narboe (1981) points to the need for risk-taking interventions in his quote, "Our usefulness as therapists lies in the range between what is expected and what is intolerable. Too safe and there's no reason to move; too risky and there's no support for movement." REFERENCES
ADAMS, E. R.,
&
MCGUIRE,F. A. (1986) Is laughter the best medicine? A study of the effects
of humor on perceived pain and affect. Adaptation and Aging, 8(3-4), 157-175.
BERGER,A. A. (1976) Anatomy of a joke. lotirnal of Communications, 26, 113-115. CARROLL, J. L. (1990) The relationship between humor appreciation and perceived physical health. Psychology-a Journal of Behavior (in press)
DILLON,K. N., M~NCHOFF, B., & BAKER,K. H. (1986) Positive emotional states and enhancement of the immune system. International Journal of Psychiatry in Medicine, 15, 13-18. ELUS, A. (1977) Fun as psychotherapy. Rational Living, 12(1), 1-6. ERICKSON, M. H., & ROSSI, E. L. (1979) Hypnotherapy: an exploratory casebook. New York: Irvington. FARRELLY, F., & LYNCH,M. (1987) Humor in provocative t h e y y . In W. F. Fry & W.A. Salameh (Eds.), Handbook of humor and psychotherapy: a vances zn the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 81-106. FAY,A. (1978) Making things better by making them worse. New York: Hawthorn. FEUD, S. (1960) Joker and their relation to the unconscious. London: Routledge & Kegan. FRY,W. F., & SWH, W. A. (Eds.) (1987) Handbook of humor and psychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. GOLDSTEIN, J. H. (1987) Thera eutic effects of laughter. In W. F. Fry 8: W.A. Salameh (Eds.), Handbook of humor anfpsychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 1-20. GOODMAN, J. (1983) HOWto get more smileage out of your life: making sense of humor, then serving it. In P. E. McGhee & J. H. Goldstein (Eds.), Handbook of humor research: Vol. 11. Applied studies. New York: Springer-Verlag. Pp. 1-21.
USES O F HUMOR IN PSYCHOTHERAPY
80 1
GREENWALD, H. (1976) Humor in psychotherapy. In A. J. Chapman & H. C. Foot (Eds.), It's a f u n y thing, humour. New York: Pergamon. Pp. 161-164. GREENWALD, H . (1987) The humor decision. In W. F, Fry & W. A. Salameh (Eds.), Handbook of humor and psychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 41-54. GROSSMAN, S. A. (1976) The use of jokes in psychotherapy. In A. J. Chapman & H.C. Foot (Eds.), It's a funny thing, humour. New York: Pergamon. Pp. 149-151. HAIG,R. A. (1986) Therapeutic uses of humor. American Journal of Psychotherapy, 40, 543553. HARDER,J. (1976) Mental health and a sense of humor: the imperative connection. Marriage and Family Counselors Quarterly, 10, 45-46. KILLINGER, B. (1976) The place of humour in adult psychotherapy. In A. J. Chapman & H.C. Foot (Eds.), It's a h n n y thing, humour. New York: Pergamon. Pp. 153-156. KUBIE, L. (1971) The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 127, 861-866. LEVINE,J. (1976) Humor as a form of therapy: introduction to symposium. In A. J. Chapman & H. C. Foot (Eds.), It's afunny thing, humour. New York: Pergamon. Pp. 127-137. MINDESS,H. (1976) The use and abuse of humour in psychotherapy. In A . J. Chapman & H. C. Foot (Eds.), Humor and laughter: theory, research and application. New York: Wiley. Pp. 331-341. MOSAIC, H . H. (1987) HaHa and aha: the role of humor in psychotherapy. Muncie, I N : Accelerated Development. NARBOE,N. (1981) Why did the therapist cross the road? Voices, 16(4), 55-58. O'CONNELL,W. E. (1976) Freudian humour: the eupsychia of everyday life. In A. J. Chapman & H . C. Foot (Eds.), Humor and laughter: theory, research and application. New York: Wiey. Pp. 313-329. OLSON,H. A. (1976) The use of humor in psychotherapy. Individual Psychologist, 13, 34-37. REYNES,R. L., & ALLEN,A. (1987) Humor in psychotherapy: a view. American Journal of Psychotherapy, 41, 260-270. ROLLER,B., & LANKESTER, D. (1987) Characteristic processes and therapeutic strategies in a homogeneous group for depressed outpatients. Small Group Behavior, 18, 565-576. ROSENHEIM, E. (1974) Humor in psychotherapy: an interactive experience. American Journal of Psychotherapy, 28, 584-591. ROSENHEIM, E., & GOLAN,G . (1986) Patients' reactions to humorous interventions in psychotherapy. American Journal of Psychotherapy, 40, 110-124. ROSENHEIM, E., TECUCLANU, F.,& D ~ R O V S KL.Y ,(1989) Schizophrenics appreciation of humorous therapeutic interventions. International Journal of Humor Research, 2, 141-152. RWELSON,L. (1988) The empathic use of sarcasm: humor in psychotherapy from a self psychological perspective. Clinical Social Work Journal, 16, 297-305. SALAMEH, W. A. (1983) Humor in psychotherapy. In P E . McGhee & J. H . Goldstein (Eds.), Handbook of humor research: Vol. 11. Applied studies. New York: Springer-Verlag. Pp. 109-134. SAPER,B. (1987) Humor in sychotherapy: is it good or bad for the client? Professional Psychology: Rest-arch a n l ~ r a c t i c e ,18, 360-367. SAVEU,H . (1983) The effects of humor on depression in chronic emotiondy disturbed adult.. Unpublished doctoral dissertation, Univer. of Mississippi, SCOG~N, F. R., & MERBAUM,M. (1983) Humorous stimuli and depression: an examination of Beck's premise. lournal of Clinical Psvcholonv, 38, 165-169. TREADWELL, ? (1967)- ~ i b l i o g r a ~of h ~ekpiricz studies of wit and humor. Psychological Reports, 20, 1079-1083. TRICE, A. D., & PRICE, G. J. (1986) Joking under the drill: a validity smdy of the Coping Humor Scale. Journal of Social Behavior and PersonaliQ, 1, 265-266. Zrv, A. (1988) Teaching and learning with humor: experiment and replication. The Journal of Experimental Education, 57, 5-15.
Accepted March 23, 1990.
O Psychological Reports 1990
USES O F HUMOR I N PSYCHOTHERAPY SHARON A. DIMMER Michigan State Uniuersiiy JAMES L. CARROLL
GWEN K. WYATT
Central Michigan Uniuersify
Michigan State University
Summary,-Given demonstrated usefulness in facilitating learning, aiding healing, and reducing stress, humor has gained recognition as a clinical tool. This article reviews some uses and potential misuses of humor in psychotherapy and suggests directions for practice and research.
Recently there has been growing interest in the clinical uses of humor. Research suggests that humor may be important in facilitating learning (Ziv, 1988), helping to reduce pain (Adams & McGuire, 1986), enhancing immune system functioning (Dillon, Minchoff, & Baker, 1986), lowering stress (Trice & Price, 1986), and promoting general health (Carroll, 1990). Within the last 40 years many therapists representing a variety of schools have recommended the use of humor in both diagnosis and treatment (Goldstein, 1987). In their Handbook of Humor and Psychotherapy, Fry and Salameh (1987) presented a 306-item bibliography of books, articles, and presentations relating to the utility of using humor in psychotherapy. One hundred sixty-four references from 1970 onward attest to interest in the subject; an extensive earlier bibliography was presented by Treadwell (1967). According to Greenwald (1976), laughter is incompatible with depression. Rosenheim and Golan (1986) have stated that a humorous approach to life is characterized by flexibility, potential for broadening one's perspective, and discovering new options. Harder (1976) believes that humor is both the producer and the product of good mental health, while Greenwald (1987) believes humor, usually followed by laughter, is a useful treatment for various types of psychiatric clients. The purpose of this article is to review the recent literature and research on the use of humor in psychotherapy, addressing some of its uses and potential misuses, and suggesting directions for research.
Humor as a Method of Intervention Humor in psychotherapy can be used to deviate anxiety and tension, encourage insight, increase motivation, create an atmosphere of closeness and 'The authos thank the Faculty Committee for Research and Creative Endeavors at Central P h i g a n University for their support. Reprint requests should be sent to Sharon A. Dimmer, A-230 Life Sciences Building, Michigan State University, College of Nursing, East Lansing, MI 48824-1317.
796
S. A. DIMMER, ETAL.
equality between therapist and client, expose absurd beliefs, develop a sense of proportion to one's importance in life situations, and facilitate emotional catharsis (Rosenheim, 1974; Mindess, 1976; Haig, 1986; Rosenheim & Golan, 1986; Reynes & M e n , 1987). Freud (1960) placed emphasis on the content of the humor stimulus and its relation to the individual's current conflicts. Freud thought that humor helped people cope with anxiety by permitting a release of hostile or sexual feelings and allowing a person to say something he could not say openly. Later, Grossman (1976) suggested that it was not as threatening to tell a joke as to describe a dream. Humor is often an ingredient in paradoxical approaches to therapy. Paradox is a technique for mobilizing psychological resistance to eliminate destructive behavior patterns, specifically for people who take life too seriously. Olson (1976) and Ellis (1977) thought that disturbed people tend to take themselves and their problems too seriously. Fay (1978) recommended paradoxical therapy because he found that humorous comments facilitate the disruption of damaging values and enable the person to gain a different perspective. He stated that, even if the patient does not change, paradoxical methods may prevent the patient's support people from becoming frustrated and destructively angry. Erickson and Rossi (1979) also advocated the use of paradox, which they believe helps people break through their too-limited mental sets and initiate unconscious searches for new levels of meaning. Some clinicians (Farrelly & Lynch, 1987; Roller & Lankester, 1987) advocate provocative therapy, a paradoxical approach. They suggest that both clients and therapists overrate the clients' fragility, which can cause the therapist to avoid helpful interventions. If humorously provoked, the client will tend to move toward more effective behavior. Goodman (1983) thought that it was possible for people to invite humor intentionally without overdoing it. Goodman, h e c t o r of the Humor Project (a nonprofit foundation based in Saratoga Springs, NY, dedicated to the therapeutic use of humor), has suggested a variety of experiential techniques including educating people about their "comic vision" so that they can see humor that is around them. He cited an example from a church bulletin announcing a baptismal service: "This afternoon there will be meetings in the north and south ends of the church. Children will be baptized on both ends" (Goodman, 1983, p. 8). O'Connell (1976) thought that humor techniques should occur in an accepting, playful atmosphere where the patient is treated with kindness and respect. Greenwald (1976) took this idea further, positing that therapy should be fun for the therapist to set an example for the patient.
Research and Clinical Studies Scogin and Merbaum (1983) tested the assumption that an inverse rela-
USES OF HUMOR I N PSYCHOTHERAPY
797
tionship exists between humor and depression. They presented cartoons to clinical psychology students and used the Beck Depression Inventory as the criterion for depression. They found no significant differences between mildly depressed and nondepressed college students on self-reported humor appreciation. They did find, however, that students with higher anxiety, depression, and hostility found cartoons with "other" as the target or focus of the humor significantly more humorous than those with ''self'' as the object of the humor. This suggests a person who is feeling depressed, anxious, or angry may be threatened by humor that comes too close to personal feelings of vulnerability. Rosenheim and Golan (1986) investigated preferences of hysterical, obsessive, and depressive patients for humorous or nonhumorous therapeutic interventions. Their results supported the notion that there is a significant interaction between the type of humor preferred and personality. Depressed patients rejected humor aimed at development of perspective but not humor aimed at emotional confrontation and anxiety reduction. Hysterical patients preferred the opposite kind of humor preferred by depressed patients. Obsessive patients strongly rejected all three types of humor. The results suggest that both depressed and obsessive patients may have difficulty accepting humorous invitations to change their bleak view of life; however, the authors concluded that, even though these patients preferred nonhumorous approaches, they still may benefit from other humorous therapeutic approaches. I n a more recent study, Rosenheim, Tecucianu, and Dimitrovsky (1989) investigated the humor appreciation of 25 nonchronic schzophrenic patients in an Israeli mental hospital. The patients were told that the researchers wanted to determine the therapeutic appropriateness of various interventions, presented in either a humorous or nonhumorous style. The results were similar to the earlier Rosenheim and Golan (1986) study-the patients did not appreciate the humorous intervention strategies. However, the authors cautioned that this might be from patients' lack of experience with humorous interventions. Another finding suggested that there was a relationship between personality deterioration and the ability to appreciate the therapeutic apsects of humor. Paranoid patients who had a better organized, though emotionally vulnerable personality structure, were less rejecting of humor than were nonparanoid patients. Humor has been used to reduce the anxiety that clients often experience early in therapy. I t has been speculated (Reynes, 1987) that its use may demonstrate to the client that the therapist will accept and treat him as a person rather than as a problem. Rosenheim (1974) reported his experience with a young man who had been raised with emphasis on obedience, seriousness, and respect for authority. H e took therapy seriously and never allowed himself any small talk, let alone a smile. The therapist asked him if he ever
798
S. A. DIMMER, ETAL.
wondered how therapists managed their own lives. The patient responded in such a way to indicate that such "heretical" thoughts never entered his mind. The therapist responded, "You really think I was ordained for 'angelhood'?" After this, the patient was apparently freer with the therapist and had more relaxed body posture. Levine (1976) illustrated how humor can facilitate a new perspective and help the client to move from a narrow, over-emphasized view of his problem to considering alternative ways of viewing problems and solutions. H e reported that a female client frequently complained about her unfaithful and inconsiderate husband. When asked why she still chose to stay with him, the patient responded that as bad as he was, she was afraid that she could not find anyone better and she was afraid of being alone. The therapist acknowledged her loneliness but pointed out another aspect of her choice to remain married by relating a story. The story was of the man who worked in the circus cleaning up after the animals and giving enemas to constipated elephants. An old friend of his, observing the menial type of work that he was doing, offered to help him get another job. To which he replied, "What,'and give up show biz?" The patient was angry at first and then amused. She was able to recognize some of her covert motives for her complaints about her husband. This laughter and her willingness to share it was the first sign of a positive change in the severity of the woman's depression and marked the beginning of significant therapeutic progress. Savell (1983) studied the effects of humor on depression in adult psychatric patients attending a day-treatment program. H e used the Beck Depression Inventory to rate the patient's level of depression. A treatment group listened to tapes of jokes and anecdotes recorded by six nationally recognized comedians once a day for eight days. The types of humor used were: self-degrading humor in which the comedian is self-debasing, hostile humor in which the comedian attacks his audience or directs his jokes toward belittling others, and situational humor in which the humor of the joke is based upon the absurdity of the situation in a nonhostile way. Savell found that self-debasing, hostile humor and situational humor stimuli used in the study were not effective in reducing depression but they did not inhibit the effectiveness of other treatment approaches. H e found that the enjoyment of situational humor increased as the patient's depression decreased. Another finding pointed out that hostile humor was less associated with the depression than with other types of humor (i.e., even when the patients became less depressed they still disliked hostile or mistreatment humor). This suggests that it is the least desirable type of humor to use with depressed patients. While humor has been described as a positive therapeutic tool, Haig (1986) points out the double-edged aspect of humor in psychotherapy by
USES OF HUMOR I N PSYCHOTHERAPY
799
reporting examples of both constructive and destructive humor in a clinical case. Kubie (1971) expressed the strongest concern about using humor as a therapeutic tool. Both authors listed some of the following concerns: (1) Humor might be used to avoid uncomfortable feelings by the patient or therapist; (2) Humor could be used by patients to defend against accepting the importance of their illness; (3) Sarcastic humor could be used to mask the therapist's hosthties toward the patient; (4) The therapist could use humor to show off how amusing and clever he can be; and (5) Were humor excessive, the patient might doubt that h e is being taken seriously. Both Kubie (1971) and Haig (1986) were concerned that the therapist would use humor to serve their own interests to the disadvantage of the client, a concern that must be respected as valid. However, if therapists keep in mind the possible pitfalls of humor in treatment, they can apply humorous interventions constructively (Mindess, 1976; Ruvelson, 1988).
Problems and Directions While some data (anecdotal and otherwise) exists, more and better research on the use of humor in psychotherapy is needed (Saper, 1987). In an effort to objectify the use of humor, many researchers have used canned or prepared jokes which cannot be generalized to spontaneous therapeutic humor. Practitioners engaged in the clinical aspect of their work may use creative approaches, such as "tell your favorite joke"; however, their findings are mostly anecdotal and their approaches have not been systematized (Killinger, 1976). The study of therapeutic humor needs a common ground which takes into account the complexity of psychotherapy as an art, the diversity of humor stimuli, and the need for standardzed research. Salameh (1983) devised a five-point Humor Rating Scale to rate therapists' use of humor in psychotherapy. Level 1 refers to destructive humor, level 2 to harmful humor, level 3 to minimally helpful humor, level 4 to very helpful humor response, and level 5 to outstanlngly helpful humor responses. The author gives an illustrative clinical example for each level. This tool may be useful for both clinical and research classification of humor used in therapeutic interactions, and a taxonomy by Berger (1976) could assist therapists in classifying themes of humorous material. Clearly it is important to consider the client's needs as well as h s personality structure if appropriate humor is to be effective in the therapeutic process. Currently there have been few studies that assess the long-term effects of humorous interventions in a controlled manner; such research is needed before use of humor can be validated. Research is also needed in the
800
S. A. DIMMER, ETAL.
following areas: humor as a coping mechanism, the role of humor in increasing client's inner confidence, and the use of humor to increase personal humility (in both client and therapist). Therapists probably need specific training either during formal psychotherapy courses or through continuing education in the "art" of humor intervention. Other therapists come by their skills "naturally," and only need permission to use their skills therapeutically. A recent book by Mosak (1987) provides approaches to the incorporation of humor to establish rapport, offer interpretations, implement changes, and determine readiness for termination. And finally, another important consideration must be the understanding of cross-cultural issues in humor. Currently many psychologists are struggling with trying to understand the multicultural issues clients bring to the therapy. Few articles have been written that address cross-cultural aspects of humor; Fry and Salameh (1987) listed only two items of a cross-cultural nature while Mosak (1987) listed seven. Further research into cross-cultural aspects of humor in therapy is clearly needed. In conclusion, the authors advocate humor as one useful tool for anxiety reduction and facilitation of insight. Others have taken even a stronger stand. Mindess wrote, "The best way I can envisage for us as therapists to encourage a humorous outlook in patients is to maintain such an outlook in ourselves (1976, p. 338). Narboe (1981) points to the need for risk-taking interventions in his quote, "Our usefulness as therapists lies in the range between what is expected and what is intolerable. Too safe and there's no reason to move; too risky and there's no support for movement." REFERENCES
ADAMS, E. R.,
&
MCGUIRE,F. A. (1986) Is laughter the best medicine? A study of the effects
of humor on perceived pain and affect. Adaptation and Aging, 8(3-4), 157-175.
BERGER,A. A. (1976) Anatomy of a joke. lotirnal of Communications, 26, 113-115. CARROLL, J. L. (1990) The relationship between humor appreciation and perceived physical health. Psychology-a Journal of Behavior (in press)
DILLON,K. N., M~NCHOFF, B., & BAKER,K. H. (1986) Positive emotional states and enhancement of the immune system. International Journal of Psychiatry in Medicine, 15, 13-18. ELUS, A. (1977) Fun as psychotherapy. Rational Living, 12(1), 1-6. ERICKSON, M. H., & ROSSI, E. L. (1979) Hypnotherapy: an exploratory casebook. New York: Irvington. FARRELLY, F., & LYNCH,M. (1987) Humor in provocative t h e y y . In W. F. Fry & W.A. Salameh (Eds.), Handbook of humor and psychotherapy: a vances zn the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 81-106. FAY,A. (1978) Making things better by making them worse. New York: Hawthorn. FEUD, S. (1960) Joker and their relation to the unconscious. London: Routledge & Kegan. FRY,W. F., & SWH, W. A. (Eds.) (1987) Handbook of humor and psychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. GOLDSTEIN, J. H. (1987) Thera eutic effects of laughter. In W. F. Fry 8: W.A. Salameh (Eds.), Handbook of humor anfpsychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 1-20. GOODMAN, J. (1983) HOWto get more smileage out of your life: making sense of humor, then serving it. In P. E. McGhee & J. H. Goldstein (Eds.), Handbook of humor research: Vol. 11. Applied studies. New York: Springer-Verlag. Pp. 1-21.
USES O F HUMOR IN PSYCHOTHERAPY
80 1
GREENWALD, H. (1976) Humor in psychotherapy. In A. J. Chapman & H. C. Foot (Eds.), It's a f u n y thing, humour. New York: Pergamon. Pp. 161-164. GREENWALD, H . (1987) The humor decision. In W. F, Fry & W. A. Salameh (Eds.), Handbook of humor and psychotherapy: advances in the clinical use of humor. Sarasota, FL: Professional Resource Exchange. Pp. 41-54. GROSSMAN, S. A. (1976) The use of jokes in psychotherapy. In A. J. Chapman & H.C. Foot (Eds.), It's a funny thing, humour. New York: Pergamon. Pp. 149-151. HAIG,R. A. (1986) Therapeutic uses of humor. American Journal of Psychotherapy, 40, 543553. HARDER,J. (1976) Mental health and a sense of humor: the imperative connection. Marriage and Family Counselors Quarterly, 10, 45-46. KILLINGER, B. (1976) The place of humour in adult psychotherapy. In A. J. Chapman & H.C. Foot (Eds.), It's a h n n y thing, humour. New York: Pergamon. Pp. 153-156. KUBIE, L. (1971) The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 127, 861-866. LEVINE,J. (1976) Humor as a form of therapy: introduction to symposium. In A. J. Chapman & H. C. Foot (Eds.), It's afunny thing, humour. New York: Pergamon. Pp. 127-137. MINDESS,H. (1976) The use and abuse of humour in psychotherapy. In A . J. Chapman & H. C. Foot (Eds.), Humor and laughter: theory, research and application. New York: Wiley. Pp. 331-341. MOSAIC, H . H. (1987) HaHa and aha: the role of humor in psychotherapy. Muncie, I N : Accelerated Development. NARBOE,N. (1981) Why did the therapist cross the road? Voices, 16(4), 55-58. O'CONNELL,W. E. (1976) Freudian humour: the eupsychia of everyday life. In A. J. Chapman & H . C. Foot (Eds.), Humor and laughter: theory, research and application. New York: Wiey. Pp. 313-329. OLSON,H. A. (1976) The use of humor in psychotherapy. Individual Psychologist, 13, 34-37. REYNES,R. L., & ALLEN,A. (1987) Humor in psychotherapy: a view. American Journal of Psychotherapy, 41, 260-270. ROLLER,B., & LANKESTER, D. (1987) Characteristic processes and therapeutic strategies in a homogeneous group for depressed outpatients. Small Group Behavior, 18, 565-576. ROSENHEIM, E. (1974) Humor in psychotherapy: an interactive experience. American Journal of Psychotherapy, 28, 584-591. ROSENHEIM, E., & GOLAN,G . (1986) Patients' reactions to humorous interventions in psychotherapy. American Journal of Psychotherapy, 40, 110-124. ROSENHEIM, E., TECUCLANU, F.,& D ~ R O V S KL.Y ,(1989) Schizophrenics appreciation of humorous therapeutic interventions. International Journal of Humor Research, 2, 141-152. RWELSON,L. (1988) The empathic use of sarcasm: humor in psychotherapy from a self psychological perspective. Clinical Social Work Journal, 16, 297-305. SALAMEH, W. A. (1983) Humor in psychotherapy. In P E . McGhee & J. H . Goldstein (Eds.), Handbook of humor research: Vol. 11. Applied studies. New York: Springer-Verlag. Pp. 109-134. SAPER,B. (1987) Humor in sychotherapy: is it good or bad for the client? Professional Psychology: Rest-arch a n l ~ r a c t i c e ,18, 360-367. SAVEU,H . (1983) The effects of humor on depression in chronic emotiondy disturbed adult.. Unpublished doctoral dissertation, Univer. of Mississippi, SCOG~N, F. R., & MERBAUM,M. (1983) Humorous stimuli and depression: an examination of Beck's premise. lournal of Clinical Psvcholonv, 38, 165-169. TREADWELL, ? (1967)- ~ i b l i o g r a ~of h ~ekpiricz studies of wit and humor. Psychological Reports, 20, 1079-1083. TRICE, A. D., & PRICE, G. J. (1986) Joking under the drill: a validity smdy of the Coping Humor Scale. Journal of Social Behavior and PersonaliQ, 1, 265-266. Zrv, A. (1988) Teaching and learning with humor: experiment and replication. The Journal of Experimental Education, 57, 5-15.
Accepted March 23, 1990.
