Therapy Is Sometimes a Laughing Matter

It was one of the last sessions of APA's 2008 annual meeting, yet there was a remarkably good turnout. The psychiatrists in attendance had obviously come to get if not the best laugh at the meeting, then certainly the last one.

It was a workshop on humor and psychiatry. “I've been waiting for a session like this for some time,” one of them exclaimed.

The session was conducted by Waguih IsHak, M.D., a psychiatrist affiliated with Cedars-Sinai Medical Center in Los Angeles; Anna Bokarius, B.A., a psychiatric researcher at Cedars-Sinai Medical Center; and Ed Dunkelblau, Ph.D., a Northbrook, Ill., psychologist and past president of the Association for Applied and Therapeutic Humor, whose Web site can be accessed at<www.aath.org>.

Dunkelblau told the audience a little joke, and the audience chuckled. Dunkelblau also asked the audience of about 100 psychiatrists how many were good at telling jokes. Only two raised their hands. “No problem,” he said. “Humor is a lot more than just telling jokes; it's also about laughter and play.”

This laughter and play, he said, then generate “mirth or internal good feelings,” which in turn have been found to provide (anecdotally or in psychological studies) a plethora of mental and physical benefits: a reduction in stress, anxiety, and depression; an increase in pain tolerance; heightened self-esteem; enhanced creativity and problem solving; improved interpersonal interactions and relationships; a building of group identity; and even an enhancement of memory. “Madison Avenue knows the latter and capitalizes on it,” he noted.

Humor, Dunkelblau added, can also “give us ballast and balance during difficult times.” And sometimes people use humor to equalize things when they feel threatened by a person in power, he noted. A psychoanalyst in the audience provided an anecdote from his clinical experience that illustrated this point: A well-dressed lawyer arrived for his first session with the analyst. The lawyer saw a nickel on the analyst's couch. The lawyer said to the analyst, “Say, someone left you a tip.”

Psychiatrist Gets Crowned

A psychiatrist in the audience who had been conducting group therapy also provided an anecdote that illustrated the same point: Usually the patients in group therapy sat in a circle. But one day, they changed the configuration of the chairs from a circle to two rows, ran a red carpet between the two rows, and placed a chair at the head of the carpet. When the psychiatrist came in to lead the group therapy, they indicated that he should walk up the red carpet and sit in the chair. Which he did. They then whipped out a crown and placed it on his head.

Yet even with all the apparent psychological benefits that people appear to derive from humor, virtually no scientific studies have explored humor's potential value as a psychiatric therapeutic tool, Bokarius reported. So she and her colleagues decided to undertake a study in this domain. They assessed 200 depressed subjects to determine the extent of their depression. Subjects also were evaluated to determine whether they liked humor.

The researchers then looked to see whether there was any significant correlation between the level of depression that subjects were experiencing and their tendency to like or dislike humor. There was not, suggesting that depression does not seem to dampen people's ability to appreciate humor. Moreover, subjects indicated that they would not mind humor being incorporated into their therapy. So humor might not only be an acceptable therapeutic tool for depressed patients, it might even help them, Bokarius and her colleagues believe.

But how might humor be deployed as a psychiatric therapeutic tool? It might be most valuable in improving patients' quality of life, IsHak suggested, as opposed to reducing symptoms or in restoring function, which is where medications and psychotherapy excel.

In fact, a quandary reported by a psychiatrist in the audience suggested one possible application of humor in the quality-of-life domain. The psychiatrist had a patient who was convinced that she would never find a husband. Could humor perhaps be deployed to alter this negative conviction? the psychiatrist asked. Dunkelblau replied that he thought that it might.“ Surveys have found that 40 percent of men looking for a spouse want one with a sense of humor,” he said. “You might want to tell your patient that and to encourage her to develop her sense of humor.”

Of course, psychiatrists might decide to use humor themselves during therapeutic sessions, Dunkelblau indicated. But if they do, he advised, they should avoid sarcasm, sardonic humor, or humor directed at their patients and instead use humor directed at themselves. Also, they should be careful about when they use humor, he cautioned, since ill-timed humor could make patients feel that their psychiatrist is not taking them seriously.

Using Humor With the Right Patients

Aside from using the right kind of humor at the right time, it is also crucial for psychiatrists to use it only with certain patients, Dunkelblau continued. For example, humor is often a good way to handle patients' delusions, but with paranoid patients, first “you put a couple of toes in and see how the patient responds.”

On the whole, though, humor is an excellent tool to build a therapeutic relationship with patients, Dunkelblau pointed out. For example, psychiatrists should consider placing humor magazines in the waiting room or playful art on the waiting-room walls. One psychiatrist stationed little airplane-shaped fans around his office, which both amused and fascinated patients.

Meanwhile, many questions about humor's role in psychiatry beg to be answered. For example, does humor have any value in psychiatric diagnosis? One audience member—Robert Nadol, M.D., of Tucson, Ariz.—thinks that it does. If a patient demonstrates absolutely no sense of humor, he said, he worries that the patient might be depressed, psychotic, or even suicidal. And why are there so many comedians who experience depression when they are not making people laugh? Nadol asked at the workshop. To which Dunkelblau replied:“ Some people who do comedy are seeking attention and love from others. It makes sense that they would be depressed when they don't get that attention and love.” ▪