Acad Psychiatry DOI 10.1007/s40596-013-0018-2
IN DEPTH ARTICLE: COMMENTARY
Can the Use of Humor in Psychotherapy be Taught? Lisa Valentine & Glen O. Gabbard
# Academic Psychiatry 2014
Abstract Objective Despite an abundance of literature detailing the potential benefits of the use of humor in therapy, humor is rarely taught to psychiatric residents as a method of therapeutic intervention. This communication attempts to explain how current understanding of attachment theory and neuroscience may assist psychiatric faculty and supervisors in their teaching of humorous therapeutic interventions. Methods This article reviews and synthesizes the extant literature on the use of humor, as well as recent work in neuroscience, attachment theory, and mentalization. Results Humor can be conceptualized as an instance of implicit relational knowing and may thus contribute significantly to the therapeutic action of psychotherapy as a subcategory of “moments of meeting” between therapist and patient. However, training residents to use humor in psychotherapy requires more individualized attention in supervision and classroom seminars. Factors such as individual proclivities for humorous repartee, mentalizing capacity, and an authentic interest in adding humor to the session may be necessary to incorporate spontaneous humor into one's technique. Conclusions New findings from the areas of attachment theory, neuroscience, and right-hemisphere learning are providing potential opportunities for sophisticated teaching of the use of humor in psychotherapy. Keywords Wit and humor as topic . Psychotherapy . Residency education Humor has long been an area of interest in the literature on psychotherapy, with advocates from virtually all major L. Valentine (*) : G. O. Gabbard Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]
therapeutic orientations. Freud [1] began by exploring the ability of a joke to express forbidden unconscious content in a socially acceptable fashion. Authors since have further defined the concept of humor, extolled its many salutary effects, and cautioned against its indeliberate use. As the focus upon humorous interventions in therapy has grown, and as data has emerged about its use in clinical practice, humor advocates have argued that formal instruction in humor could be of great use to psychotherapy trainees. Despite their urging, humor appears to remain something of a foreign body unassimilated into the whole of formally taught psychotherapeutic interventions. So much depends on spontaneity, intuition, and the individual subjectivities of therapist and patient that systematic teaching is a daunting task. Nevertheless, a recent body of literature deriving from interdisciplinary contributions that meld psychodynamic theory and neuroscience offers a sophisticated understanding of how humorous interchanges may contribute to the therapeutic action of psychotherapy. Educators may find this integrative understanding useful in both supervision and classroom teaching.
Literature Review Up to this point, numerous articles have explained the usefulness of humor in the therapeutic context. Humorous interventions can provide a sense of resilience in the face of life stress [2], can contribute to a potential space in which themes can be explored non-defensively [3], and can facilitate social interactions, such as in group and family therapy [4]. Within the therapeutic relationship, the sharing of humor may enhance the therapeutic alliance by fostering a feeling of belonging [5] and imbue a therapist with a heightened sense of “realness” to the patient [6]. The above are just a few of the benefits the literature describes.
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Enthusiasm for the use of humor is tempered by the potential for its misuse. The Humor Rating Scale, Salameh's [7] observational tool, classifies some humorous interventions as minimally helpful, harmful, or at worst, destructive (as when humor is used in a vindictive or retaliatory way). While Ellis [8] encourages humor as a means to teaching unconditional acceptance of both life and reality, he also provides caution that patients may feel that it is they—rather than their irrational beliefs—that are being targeted. Possibly the most vocal detractor from the use of humor is Kubie [9], whose “The Destructive Potential of Humor in Psychotherapy” describes humor as a “dangerous weapon” that may arrest a patient's stream of thought, restrict the patient's response to interpretation, and mask the therapist's hostility while making it impossible for the patient to express his own aggression. Kubie was particularly concerned about the use of humor by inexperienced therapists, for whom he said the risks of humor use are “doubly loaded.” To these therapists, he argues, humor is “most alluring, and its use most dangerous.” Given these significant concerns, multiple authors have emphasized that therapists should receive training in the use of humor in order to employ it appropriately and for a patient's benefit. While Banmen [10] supported the use of humor in psychotherapy, he explained that training programs should underscore the need for its use to be spontaneous and with discretion. As summarized by Richman [5], “Humor should only be used in therapy by those who know what they are doing, and only when they choose to do so.” One of the most extensive discussions regarding the inclusion of humor in psychotherapy training is by Franzini [11], who proposes that all psychotherapists, regardless of orientation, be offered formal training of this kind. He describes the need for a threecomponent approach involving specific instruction in humorrelated techniques, the use of supervisors to provide modeling and feedback related to humor use, and sensitivity to clients' use of humor. Franzini, like other authors, recognizes how the innate qualities of a therapist may influence not only his or her interest in pursuing formal training in humor but also his or her ability to usefully employ humor with clients or patients. He states unequivocally that the compulsory training of a disinterested therapist is counterproductive. Finally, Franzini provides a practical strategy for creating formal humor training and encourages continued research on the efficacy of both using humor in therapy and training therapists to do so. In this contribution, we hope to build upon the extant literature regarding the use of humor in therapy, highlighting both its possibilities and its perils. Using recent advances in the application of attachment research, implicit procedural knowledge, mirror neurons, and non-interpretive mechanisms to the understanding of therapeutic change, we offer further conceptual thinking regarding why humor is a valuable technique, the use of which educators can nurture in beginning therapists.
Possibilities of the Use of Humor Moments of Meeting Mr. A was a 47-year-old male with depression and both obsessive and narcissistic traits engaged in weekly therapy with a psychiatry resident. He had spent months recounting his strained relationships with his immediate family after a parent's death, his having multiple dating relationships without any of his girlfriends' knowing of the others, and his concern that people in his life felt unimportant to him. The patient, who had been in therapy three times before, had reported his feeling that therapists had little to offer him; he came to therapy, he said, because it helped just to have someone else in the room. It was typical for him to anticipate what the therapist was going to say and then dismiss the point he thought she was about to make. The therapist often had the feeling that she was superfluous to the therapy and functioned as little more than a sounding board. Moreover, the expectations of what the therapist was about to say were often considerably different than what the therapist was actually thinking of saying, much to the therapist's chagrin. Finally, after several weeks of this pattern, the patient started a session by discussing himself in his usual selfdeprecating fashion. After expressing his feelings, he began, “And I know what you're going to say…” The therapist responded, “Oh, well, then do I need to be here?” and pretended to get up from the chair. The patient immediately broke into laughter, which was so infectious, that the therapist found herself laughing with him as well. “Of course you need to be here,” the patient went on, “because you need to tell me what's wrong with what I'm going to say.” (More laughter). As the session drew to a close, the therapist noted the patient's increased attentiveness, providing her space in the room to comment and question, and a greater sense of collaboration between the two of them. At the following session, the patient again began a sentence by telling the therapist he knew that she was about to give him the “glass half full” version of what he was describing. The therapist asked the patient if he had remembered her joking that perhaps she didn't need to be in the room. The patient smiled and nodded. The therapist pointed out the patient's tendency to vacillate between seeing her as critical and seeing her as someone whose job it was to look on the bright side. “I feel as though,” the therapist said, “you're less concerned with what I actually think and more with what you imagine a generic therapist would say.”
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“But it's not just you,” said the patient, “I am dismissive of everyone. For God's sake, that's why I'm here! I am totally dismissive of other people. You know, because when they become important to me, I become so vulnerable.” The patient then went on to describe a situation in which he had made himself vulnerable, only to feel rejected by others. He explained that he also feared that if he let people know him, they would see that there was nothing inside of him. He then said that he had sought out academic success as a way to conceal his profound sense of inadequacy. The Boston Change Process Study Group [12, 13] has argued that special moments of authentic connection in psychotherapy may have a profound impact on patients and contribute to therapeutic change. These moments, a form of implicit relational knowing, are not symbolically represented or dynamically unconscious in the usual sense. Based on the developmental experiences of mutual regulatory interactions in the infant–caregiver relationship, such moments occur in the realm of procedural knowledge, involving how to feel, behave, and think in specific relational contexts. These moments are spontaneous and lie outside the planned technical interventions of the therapist. They include such phenomena as seeing a tear in the therapist's eye, a shared belly laugh, as in the above vignette, or a meaningful glance at the end of a session. Through new experiences, these moments of meeting may contribute to the modification of old object relationships stored in procedural memory. Amini et al. [14] suggest that psychotherapy can be viewed as a new attachment relationship that has the potential to restructure attachment-related implicit procedural memory. Schore [15] notes that a body of studies in neuroscience has shown that the left hemisphere mediates most of the linguistic forms of communication, but the right hemisphere is linked to unconscious implicit communication and relational phenomena like attachment. Hence, what we call intuition in interpersonal interactions is a right brain phenomenon. Schore postulates that the “now” moments of meeting are the basic fabric of lived experience, and they operate under the stewardship of the right hemisphere at an implicit level of consciousness. Mutual emotional knowing between therapist and patient, then, involves a right brain-to-right brain communication from one relational mind to another, without conscious processing or understanding. Within this model, the therapist's empathic, affective attunement is equally important to the therapeutic action as his or her conscious knowledge of theory and formulation. The shared laughter about Mr. A's preference to do therapy on his own facilitated a deepening of the therapeutic alliance because of a moment of shared recognition. Gallese [16] has linked this mechanism of shared intuitive understanding to mirror neurons. This capacity to grasp in an instant what others are thinking and feeling is hard wired in the brain as
internal representations of the actions, feelings, and intentions of the other person in the dyad. For example, when the patient furrows his brow, the motor neurons controlling those forehead muscles in the therapist are activated and may thus contribute to an understanding of the emotional state of the patient. He refers to this mutual resonance as embodied simulation. It is our view that the use of humor fits into this model. However, we would propose that such mutual resonance does not begin at the moment the humorous comment is made, but in the preceding split second in which the therapist intuitively senses the patient's receptiveness. As Baker [17] suggests, this awareness that the patient is ready to hear a humorous comment may be similar to the spontaneous judgment that an interpretive statement will be heard and processed. In this context, we are suggesting that effective use of humor resulting in shared laughter by the therapist and patient may be a significant contributory factor to change in the patient. Such moments take both members of the dyad by surprise. While an intellectual understanding of a joke may be necessary to “get it,” a major part of the therapeutic value probably lies in the relational connection that is beyond cognitive understanding. Such humor may subsequently be processed and discussed in the therapeutic dialog, as in the above example with Mr. A, but such discussion is not necessary for the moment's therapeutic value. In fact, as illustrated in the subsequent session with Mr. A, the moment of meeting accompanying the humor may be something of a breakthrough in the therapy. It is no surprise that when patients are asked what was helpful in their therapy, they often recall jokes the therapist told or a humorous interchange that departed from the usual format of the therapy [18]. The Running Gag Some moments of meeting are treasured sufficiently that the two members of the dyad refer back to them periodically in the course of treatment. The Process of Change Study Group [12] has called such instances a “flagged now moment.” A variant of this phenomenon sometimes happens with jokes or memorable uses of humor. The connection between therapist and patient may have been such an occasion of bonding that both parties wish to make reference to it now and again. Indeed, sometimes it is recalled in such a way that it has the character of a “running gag” from the days of Vaudeville. Ms. R, a 23 year-old graduate student came to treatment with long-standing problems related to her eating disorder. In the first session, she appeared irritated at her therapist's questions about her eating symptoms and rather sarcastically said, “While I'm sitting here talking to you, I can't help thinking thoughts like how it would feel to eat your kneecaps.” She acknowledged that she was being provocative but was also willing to agree that she was probably trying to communicate the desperate feeling that her voraciousness engendered in her.
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About a year into the treatment, her therapist returned from a vacation, and Ms. R informed him that she had seen a book authored by her therapist called Love and Hate in the Analytic Setting [19]. She said she hoped her therapist would write about her some day in one of his books. She suggested that he could report a case example of a woman with an eating disorder who wanted to eat his kneecaps in the first session. She then quipped, “You could call the book Cannibalism in the Analytic Setting. Both had a good chuckle over her witty play on words. This exchange then became a “flagged now moment” in the sense that when something unusual entered into the therapy process, one or the other would refer back to the comment that had come before. For example, Ms. R was studying physiology in her graduate school curriculum and was puzzled by the term “biliary atresia” and how a condition like that could be compatible with life. After speculating about it for 30 min, she realized that more than half the session had been devoted to the topic, and she noted, “Oh dear, this is ‘biliary atresia in the analytic setting today.” The therapist burst into laughter, and the patient followed suit. Still another time, the therapist's nose started bleeding for unclear reasons, and he grabbed for a Kleenex. As he used pressure to stop the bleeding, he offered an observation on what was going on: “Hmmm. Nosebleed in the analytic setting.” Ms. R was tickled that her running gag had become their running gag. In this vignette, we see how both parties found a way to connect through recurrent use of humor that satirized the therapist's book title. Ms. R could be slightly irreverent while also bonding with her therapist, who she could see was a good sport about it and did not mind her poking fun at his title. In fact, he could even poke fun at himself. These variations on the title continued through a long-term therapy process. The Exit Line To some patients, who are anxious about any hint of hostility, aggression, or contempt in the treatment relationship, humor may be seen as a high-risk phenomenon. After all, it is common knowledge that most jokes have an undercurrent of aggression in them (e.g., man slips on banana peel and falls on his face). Hence, they may only feel a sense of safety to joke as a “parting shot” when they are walking to the door at the end of the session [20]. Mr. S, a shy young man, who feared that his therapist was horrified at all the problems in his family, walked to the door after the session ended. When he got to the door, he turned to his therapist, who had been walking behind him. With a smile on his face, Mr. S summoned his courage and said, “After hearing all my family horror stories, it must be great to go home to your perfect family.” With a look of mock seriousness, the therapist retorted, “Don't get me started.” Both of them laughed heartily. In this snippet of a session, we see a frequent clinical phenomenon with exit lines, namely, that a moment of heightened transference often emerges right at the end of the session [20]. Mr. S had been harboring the concern that his therapist was perfectly adjusted and that Mr. S's family struggles might
be completely outside of his own personal experience. Mr. S took a chance with a humorous comment that conveyed this transference fear. His therapist spontaneously joined in the gag as a way of expressing his appreciation for the humor and sending another message—namely, that no one lives in a perfect family situation. In this moment of meeting, the therapist's response served to reassure Mr. S that he was fully capable of understanding dysfunctional families while also making an indirect interpretation of Mr. S's idealization of him.
Perils in the Use of Humor Laughing with Versus Laughing at Despite its tremendous ability to enhance the alliance and contribute to therapeutic change, humor, like any other therapeutic tool, is subject to the constraints of timing, content, and style of delivery. Beyond its similarity to other forms of therapeutic intervention, however, humor presents unique potential perils. As described earlier, aggression is inherent in humor. The humorous comment made by Mr. A's therapist expressed her frustration at feeling impotent and unimportant in the room. Clearly, had the humor not been well-timed and appropriate to the nature of their particular dynamic, Mr. A might have felt criticized, hurt, or humiliated. His laughing, sharing the moment with the therapist, and expanding upon the topic at hand provided the therapist with positive reinforcement for the humorous exchange. Mr. A's participation in the use of the moment as a foundation in the next session further exemplified his perception that the humorous intervention was acceptable to him. Thus, it may be said that Mr. A provided his therapist a kind of validation, or even “supervision,” suggesting that humor was an appropriate and desirable technique to use in his case. Patients may instead respond to the use of humor by falling silent, verbally expressing their displeasure, or giving a stonefaced indication that the joke is not funny. It is here that the concept of laughing with the patient versus laughing at him warrants distinction. Should a patient feel that the therapist's humor is making light of the situation, missing the meaning of the information, touching carelessly on a vulnerable topic, or insulting the patient's traits or values, the alliance will likely experience a rupture. The therapist must use a trial-and-error approach with humor, realizing that it must be highly individualized, and take into account the particular subjectivities of the two parties. The humorous interventions employed with Mr. A, Ms. R, and Mr. S might each have led to a weakening of the alliance if employed with a different patient or even at a different point in the same patient's therapy. A patient might even accept a humorous intervention made by one therapist, but object to similar comments made by another. Moreover, a countertransference misreading of the patient may masquerade as a “gut feeling” or “intuition.” One simply cannot predict the outcome. As Saper [4] explained, “Psychiatrists or psychologists have at
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the outset no way of knowing precisely how their humor may be received. They need to find (stumble upon?) that core of amusement that fits the patients ‘funny bone.’” This difficulty in discerning the impact of a humorous comment on the patient calls for a concerted effort on the part of the therapist to mentalize [21]. In other words, the therapist must empathically tune in to the patient's emotional state and assess his/her readiness to join in a humorous moment. Ideally, this effort at mentalizing must be an ongoing part of evaluating the state of the therapeutic alliance from moment to moment. Much of mentalizing occurs at an implicit procedural level such that the therapist my intuitively know when the time is right, but conscious efforts in that direction may pay off as well. However, even the possibility that mentalizing may at times be inaccurate need not dissuade a therapist from using humor. Building upon the concepts outlined above, even an unwelcome humorous comment can ultimately be a powerful contributor to positive change. If a “now” moment is recognized by both members of the therapeutic dyad, but they do not successfully engage in a moment of meeting, the result can be a rupture in the therapeutic alliance. The Process of Change Study Group [12] calls this a “failed now moment.” A humorous comment that cannot be shared by both individuals could easily fall into this category. However, as Stern and colleagues explain, these failed now moments may either call the fate of the therapy into question or may be repaired. This reparation itself may enhance understanding and deepen the experience of mutual resonance. Indeed, there is a growing body of literature suggesting that the rupture/repair process may be one of the most powerful common factors in the therapeutic action of psychotherapy [22]. Humor as Escape Freud [1] explained that “humour is a means of obtaining pleasure in spite of the distressing affects that disturb it.” For a beginning therapist, difficulty handling the painful affects produced by a patient's suffering may inspire him or her to seek escape through humor [9]. In these cases in particular, the patient's sharing the therapist's laughter may not represent effective use of humor but rather that the therapist's comment has relieved them both of having to confront the patient's anguish. However, humor for the sake of alleviating therapist discomfort is by definition not used in the service of the patient. It is unlikely, therefore, that this would contribute to shared intuitive understanding. At worst, the patient may feel that the therapist is not capable of entering into the most painful recesses of the patient's psyche. Humor as Beginner's Anxiety Dealing with tragic content is only one of many difficult new experiences for the therapeutic trainee. He or she must remain present with the patient in the room while trying to employ newly learned diagnostic concepts, treatment modalities, and therapeutic tools in a way that is genuine to his or her personal characteristics. Humor may be used to enhance the therapist's congeniality to compensate
for his or her perceived sense of inadequacy. Trainees may also feel uncomfortable with the power differential in the therapeutic dyad and feel clumsy as they gain expertise. They may thus seize upon the potential for humor to equalize their status with that of the patient, using humor excessively, inopportunely, or to the exclusion of refining other therapeutic skills. Here, again, humor could be misapplied in the service of the therapist and to the possible detriment of the patient.
Implications for Teaching There have been some efforts at developing humor training programs for mental health professionals [11]. These often rely upon formal teaching of humor techniques, utilizing workshops, manuals, or role-playing. As Franzini [11] points out, the programs may show some promise, but few have been systematically studied for therapeutic efficacy. Indeed, in this communication we are arguing that in light of our growing understanding of the neurobiological mechanisms by which humor exerts therapeutic effects, we may need to rethink how humor is taught. One controversial implication is that because humor is spontaneous and reactive to unexpected situations, it may be difficult to incorporate into a treatment manual. Manualized treatments rely primarily on left-hemispheric thinking, whereas shared humor and “now” moments, as we have noted above, are the product of right-brained procedural knowing [15]. Our understanding of Schore's work in righthemisphere perceptions and Gallese's [16] description of mirror neurons and their role in mutual resonance suggest a shift in the focus of humor training. Instead of emphasizing the learning of humor subtypes or how to make a comment more humorous, these neurobiological explanations suggest placing a premium on mentalizing in the therapeutic relationship. Through an enhanced appreciation of mentalization, trainees would be better able to recognize “now” moments and to select the optimal moments for the use of humor. Further, they would be better able to examine why their use of humor yielded either expected or unexpected results. Mentalizing can be encouraged in supervision by open-ended questions to the trainee such as, “What is your understanding of what was going on the patient's mind at that moment?” or “How do you imagine the patient was feeling just before you made that comment?” Teaching trainees how humor operates at multiple levels serves to demystify the therapeutic process, providing an explanation for these “now” moments complete with thoughts about how to potentially harness them in the service of the patient. The neurobiologic underpinnings including mirror neurons, implicit relational knowing, and the intuitive knowledge of the readiness of the patient to receive the humor should be part of this teaching. Learners need to conceptualize humor as a high-risk, high-gain intervention in the same way that Gabbard et al. [23] have characterized transference interpretation as such.
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For a trainee who is interested in understanding humorous exchanges and employing them effectively, supervision provides perhaps the best setting in which to consider therapeutic moments of meeting, missed and utilized opportunities for humorous connection, and mentalization in the treatment relationship. While some of the conceptual matters related to humor can be alluded to in a classroom setting, the idiosyncratic nature of how humor is used within a specific therapist–patient dyad requires hands-on supervision discussions. The supervisory interaction itself can provide a live example of these humor mechanisms at work; as Gabbard [24] has pointed out, the teaching in supervision involves unconscious internalization of the supervisor's humorous style, which demonstrates an implicit relational learning that happens between supervisor and trainee. However, in order to facilitate this experiential learning, the supervisor must foster an atmosphere where a supervisee can talk candidly about failed attempts at using humor without fear of shaming or disapproval. Trainees, who may not receive much formal instruction in humor, may see humor as being outside therapeutic technique, and thus not within the scope of supervisory discussions. Further, if the supervisor is uncomfortable with humor as a therapeutic technique, he or she may implicitly model or explicitly state that humorous interventions are unacceptable. We suggest that supervisors should consider a periodic inquiry regarding the presence or absence of humorous exchanges in the therapy if this topic does not naturally arise in the course of the supervision. This approach provides the trainee the option of either employing humor or discussing having done so. Of course, not all therapists have a knack for using humor and/or may not be interested in developing their abilities further in this area. As acting teachers have long known, comic timing is notoriously difficult to teach to someone without a natural aptitude. Thus, supervisors must be sensitive to the possibility that some trainees may choose not to initiate humorous exchanges. Nevertheless, these trainees may still utilize supervision as an opportunity to explore how to notice and comfortably respond to patient-initiated humor.
Conclusion Humor occupies a borderland between a therapist's technique and his or her personal characteristics. Technique, in general, should be invisible. The therapist should be viewed by the patient as engaging in a natural conversational dialog growing out of the patient's concerns; the therapist should not be perceived as applying a stilted, formal technique. Humor fits into this type of natural relatedness. An overarching theme of this communication is that humor by its very nature is hit-or-miss. The carefully planned jokes of the best comedians will inevitably fall flat with some audiences. Moreover, not everyone should attempt to tell jokes. In the course of one's youth, some people find that their jokes are
less well received than those of others. These difficult developmental lessons often determine how much each individual will risk humor in interpersonal situations in general. Hence, educators and supervisors must be sensitive to the natural aptitudes and weaknesses of trainees in this area. By way of analogy, self-disclosure in psychotherapy may come more naturally to some therapists than to others. The field of therapy draws a wide range of people to its fold. Some tend to be private and perhaps inhibited; others may be outgoing and expressive. Effective therapists emerge from both ends of that continuum. Similarly, some patients may warm up to the therapist who self discloses, while others may be distanced by such revelations. Both humor and self-disclosure can be broadly subsumed under the heading of authenticity. Where humor is a tool that a trainee naturally possesses and has already refined, using humor may be an opportunity for the therapist's authentic self to enter in. A therapist who can authentically relate to a patient with humor may be able to maintain an alliance with the patient while joking. The therapist who is forcing humor, however, may create a rupture in the therapeutic alliance by appearing inauthentic to the patient. In closing, we return to the question in our title: is it really possible to teach the use of humor in psychotherapy? Our answer is in the affirmative, but with the qualifiers we have noted in the course of this communication. We would stress the following points. (1) Research from diverse sources is expanding our understanding of the use of humor in psychotherapy. (2) “Now” moments involving humor have the potential to be regarded as a component of the therapeutic action in psychotherapeutic treatments. (3) While there is a risk inherent in the use of humor, thoughtful teaching and supervising can minimize the risk and draw attention to humor's potential. (4) The teaching of humor must be carefully placed within the context of the individual learner's natural proclivities. Implications for Educators & Research is expanding our understanding of the use of humor in psychotherapy & “Now” moments are part of therapeutic action & Risks exist, but can be managed, especially through supervision & Teaching should take the strengths of the therapist into account
Implications for Academic Leaders & New research in neurobiology suggests that the effective use of humor may depend on certain capacities of the therapist that may not be present in all trainees. & Supervisors should directly inquire as to trainees' use of humor in psychotherapy. & Some trainees may not be as educable as others in how to use humor, suggesting that a careful evaluation of that capacity by a supervisor may be a useful part of psychotherapeutic teaching.
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References 1. Freud S. The joke and its relation to the unconscious. New York: Penguin; 1905. 2. Mindess H. Laughter and liberation. Los Angeles: Nash; 1971. 3. Winnicott D. Playing and reality. Middlesex: Penguin; 1971. 4. Saper B. The therapeutic use of humor for psychiatric disturbances of adolescents and adults. Psychiatr Q. 1990;61:261–72. 5. Richman J. Points of correspondence between humor and psychotherapy. Psychother Theor Res Pract Train. 1996;33:560–6. 6. Kidd SA, Miller R, Boyd GM, et al. Relationships between humor, subversion, and genuine connection among persons with severe mental illness. Qual Health Res. 2009;19:1421–30. 7. Salameh WA. Humor in psychotherapy: past outlooks, present status, and future frontiers. In: McGhee PE, Goldstein JH, editors. Handbook of humor research. Volume II Applied studies. New York: Springer; 1983. p. 61–88. 8. Ellis A. Fun as psychotherapy. Rational Living. 1977;12:2–6. 9. Kubie LS. The destructive potential of humor in psychotherapy. Am J Psychiatry. 1971;127:861–6. 10. Banmen J. The use of humour in psychotherapy. Int J Adv Couns. 1982;5:81–6. 11. Franzini LR. Humor in therapy: the case for training therapists in its uses and risks. J Gen Psychol. 2001;128:170–93. 12. The Process of Change Study Group. Non-interpretive mechanisms in psychoanalytic therapy: the ‘something more’ than interpretation. Int J Psychoanal. 1998;79:903–21.
13. The Boston Change Process Study Group. Change in psychotherapy: a unifying paradigm. New York: Norton; 2010. 14. Amini F, Lewis T, Lannon R, et al. Affect, attachment, memory: contributions towards psychobiologic integration. Psychiatry. 1996;59:213–39. 15. Schore AN. The right brain implicit self lies at the core of psychoanalysis. Psychoanal Dialogues. 2011;21:75–100. 16. Gallese V. Mirror neurons, embodied simulation, and the neural basis of social identification. Psychoanal Dialogues. 2009;19:519–36. 17. Baker R. Some reflections on humour in psychoanalysis. Int J Psychoanal. 1993;74:951–60. 18. Gabbard GO. Long-Term psychodynamic psychotherapy: a basic text—second edition. Washington DC: American Psychiatric Publishing; 2010. 19. Gabbard GO. Love and hate in the analytic setting. Northvale: Jason Aronson; 1996. 20. Gabbard GO. The exit line: heightened transferencecountertransference manifestations at the end of the hour. J Am Psychoanal Assoc. 1982;30:579–98. 21. Allen J, Fonagy P. Restoring mentalizing in attachment relationships: treating trauma with plain old therapy. Washington, DC: American Psychiatric Publishing; 2012. 22. Safran JD, Muran JC. The resolution of ruptures in the therapeutic alliance. J Consult Clin Psychol. 1996;64:447–58. 23. Gabbard GO, Horwitz L, Allen JG, et al. Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon. Harv Rev Psychiatry. 1994;2:59–69. 24. Gabbard GO. Why I teach. Acad Psychiatry. 2011;35:277–82.
IN DEPTH ARTICLE: COMMENTARY
Can the Use of Humor in Psychotherapy be Taught? Lisa Valentine & Glen O. Gabbard
# Academic Psychiatry 2014
Abstract Objective Despite an abundance of literature detailing the potential benefits of the use of humor in therapy, humor is rarely taught to psychiatric residents as a method of therapeutic intervention. This communication attempts to explain how current understanding of attachment theory and neuroscience may assist psychiatric faculty and supervisors in their teaching of humorous therapeutic interventions. Methods This article reviews and synthesizes the extant literature on the use of humor, as well as recent work in neuroscience, attachment theory, and mentalization. Results Humor can be conceptualized as an instance of implicit relational knowing and may thus contribute significantly to the therapeutic action of psychotherapy as a subcategory of “moments of meeting” between therapist and patient. However, training residents to use humor in psychotherapy requires more individualized attention in supervision and classroom seminars. Factors such as individual proclivities for humorous repartee, mentalizing capacity, and an authentic interest in adding humor to the session may be necessary to incorporate spontaneous humor into one's technique. Conclusions New findings from the areas of attachment theory, neuroscience, and right-hemisphere learning are providing potential opportunities for sophisticated teaching of the use of humor in psychotherapy. Keywords Wit and humor as topic . Psychotherapy . Residency education Humor has long been an area of interest in the literature on psychotherapy, with advocates from virtually all major L. Valentine (*) : G. O. Gabbard Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]
therapeutic orientations. Freud [1] began by exploring the ability of a joke to express forbidden unconscious content in a socially acceptable fashion. Authors since have further defined the concept of humor, extolled its many salutary effects, and cautioned against its indeliberate use. As the focus upon humorous interventions in therapy has grown, and as data has emerged about its use in clinical practice, humor advocates have argued that formal instruction in humor could be of great use to psychotherapy trainees. Despite their urging, humor appears to remain something of a foreign body unassimilated into the whole of formally taught psychotherapeutic interventions. So much depends on spontaneity, intuition, and the individual subjectivities of therapist and patient that systematic teaching is a daunting task. Nevertheless, a recent body of literature deriving from interdisciplinary contributions that meld psychodynamic theory and neuroscience offers a sophisticated understanding of how humorous interchanges may contribute to the therapeutic action of psychotherapy. Educators may find this integrative understanding useful in both supervision and classroom teaching.
Literature Review Up to this point, numerous articles have explained the usefulness of humor in the therapeutic context. Humorous interventions can provide a sense of resilience in the face of life stress [2], can contribute to a potential space in which themes can be explored non-defensively [3], and can facilitate social interactions, such as in group and family therapy [4]. Within the therapeutic relationship, the sharing of humor may enhance the therapeutic alliance by fostering a feeling of belonging [5] and imbue a therapist with a heightened sense of “realness” to the patient [6]. The above are just a few of the benefits the literature describes.
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Enthusiasm for the use of humor is tempered by the potential for its misuse. The Humor Rating Scale, Salameh's [7] observational tool, classifies some humorous interventions as minimally helpful, harmful, or at worst, destructive (as when humor is used in a vindictive or retaliatory way). While Ellis [8] encourages humor as a means to teaching unconditional acceptance of both life and reality, he also provides caution that patients may feel that it is they—rather than their irrational beliefs—that are being targeted. Possibly the most vocal detractor from the use of humor is Kubie [9], whose “The Destructive Potential of Humor in Psychotherapy” describes humor as a “dangerous weapon” that may arrest a patient's stream of thought, restrict the patient's response to interpretation, and mask the therapist's hostility while making it impossible for the patient to express his own aggression. Kubie was particularly concerned about the use of humor by inexperienced therapists, for whom he said the risks of humor use are “doubly loaded.” To these therapists, he argues, humor is “most alluring, and its use most dangerous.” Given these significant concerns, multiple authors have emphasized that therapists should receive training in the use of humor in order to employ it appropriately and for a patient's benefit. While Banmen [10] supported the use of humor in psychotherapy, he explained that training programs should underscore the need for its use to be spontaneous and with discretion. As summarized by Richman [5], “Humor should only be used in therapy by those who know what they are doing, and only when they choose to do so.” One of the most extensive discussions regarding the inclusion of humor in psychotherapy training is by Franzini [11], who proposes that all psychotherapists, regardless of orientation, be offered formal training of this kind. He describes the need for a threecomponent approach involving specific instruction in humorrelated techniques, the use of supervisors to provide modeling and feedback related to humor use, and sensitivity to clients' use of humor. Franzini, like other authors, recognizes how the innate qualities of a therapist may influence not only his or her interest in pursuing formal training in humor but also his or her ability to usefully employ humor with clients or patients. He states unequivocally that the compulsory training of a disinterested therapist is counterproductive. Finally, Franzini provides a practical strategy for creating formal humor training and encourages continued research on the efficacy of both using humor in therapy and training therapists to do so. In this contribution, we hope to build upon the extant literature regarding the use of humor in therapy, highlighting both its possibilities and its perils. Using recent advances in the application of attachment research, implicit procedural knowledge, mirror neurons, and non-interpretive mechanisms to the understanding of therapeutic change, we offer further conceptual thinking regarding why humor is a valuable technique, the use of which educators can nurture in beginning therapists.
Possibilities of the Use of Humor Moments of Meeting Mr. A was a 47-year-old male with depression and both obsessive and narcissistic traits engaged in weekly therapy with a psychiatry resident. He had spent months recounting his strained relationships with his immediate family after a parent's death, his having multiple dating relationships without any of his girlfriends' knowing of the others, and his concern that people in his life felt unimportant to him. The patient, who had been in therapy three times before, had reported his feeling that therapists had little to offer him; he came to therapy, he said, because it helped just to have someone else in the room. It was typical for him to anticipate what the therapist was going to say and then dismiss the point he thought she was about to make. The therapist often had the feeling that she was superfluous to the therapy and functioned as little more than a sounding board. Moreover, the expectations of what the therapist was about to say were often considerably different than what the therapist was actually thinking of saying, much to the therapist's chagrin. Finally, after several weeks of this pattern, the patient started a session by discussing himself in his usual selfdeprecating fashion. After expressing his feelings, he began, “And I know what you're going to say…” The therapist responded, “Oh, well, then do I need to be here?” and pretended to get up from the chair. The patient immediately broke into laughter, which was so infectious, that the therapist found herself laughing with him as well. “Of course you need to be here,” the patient went on, “because you need to tell me what's wrong with what I'm going to say.” (More laughter). As the session drew to a close, the therapist noted the patient's increased attentiveness, providing her space in the room to comment and question, and a greater sense of collaboration between the two of them. At the following session, the patient again began a sentence by telling the therapist he knew that she was about to give him the “glass half full” version of what he was describing. The therapist asked the patient if he had remembered her joking that perhaps she didn't need to be in the room. The patient smiled and nodded. The therapist pointed out the patient's tendency to vacillate between seeing her as critical and seeing her as someone whose job it was to look on the bright side. “I feel as though,” the therapist said, “you're less concerned with what I actually think and more with what you imagine a generic therapist would say.”
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“But it's not just you,” said the patient, “I am dismissive of everyone. For God's sake, that's why I'm here! I am totally dismissive of other people. You know, because when they become important to me, I become so vulnerable.” The patient then went on to describe a situation in which he had made himself vulnerable, only to feel rejected by others. He explained that he also feared that if he let people know him, they would see that there was nothing inside of him. He then said that he had sought out academic success as a way to conceal his profound sense of inadequacy. The Boston Change Process Study Group [12, 13] has argued that special moments of authentic connection in psychotherapy may have a profound impact on patients and contribute to therapeutic change. These moments, a form of implicit relational knowing, are not symbolically represented or dynamically unconscious in the usual sense. Based on the developmental experiences of mutual regulatory interactions in the infant–caregiver relationship, such moments occur in the realm of procedural knowledge, involving how to feel, behave, and think in specific relational contexts. These moments are spontaneous and lie outside the planned technical interventions of the therapist. They include such phenomena as seeing a tear in the therapist's eye, a shared belly laugh, as in the above vignette, or a meaningful glance at the end of a session. Through new experiences, these moments of meeting may contribute to the modification of old object relationships stored in procedural memory. Amini et al. [14] suggest that psychotherapy can be viewed as a new attachment relationship that has the potential to restructure attachment-related implicit procedural memory. Schore [15] notes that a body of studies in neuroscience has shown that the left hemisphere mediates most of the linguistic forms of communication, but the right hemisphere is linked to unconscious implicit communication and relational phenomena like attachment. Hence, what we call intuition in interpersonal interactions is a right brain phenomenon. Schore postulates that the “now” moments of meeting are the basic fabric of lived experience, and they operate under the stewardship of the right hemisphere at an implicit level of consciousness. Mutual emotional knowing between therapist and patient, then, involves a right brain-to-right brain communication from one relational mind to another, without conscious processing or understanding. Within this model, the therapist's empathic, affective attunement is equally important to the therapeutic action as his or her conscious knowledge of theory and formulation. The shared laughter about Mr. A's preference to do therapy on his own facilitated a deepening of the therapeutic alliance because of a moment of shared recognition. Gallese [16] has linked this mechanism of shared intuitive understanding to mirror neurons. This capacity to grasp in an instant what others are thinking and feeling is hard wired in the brain as
internal representations of the actions, feelings, and intentions of the other person in the dyad. For example, when the patient furrows his brow, the motor neurons controlling those forehead muscles in the therapist are activated and may thus contribute to an understanding of the emotional state of the patient. He refers to this mutual resonance as embodied simulation. It is our view that the use of humor fits into this model. However, we would propose that such mutual resonance does not begin at the moment the humorous comment is made, but in the preceding split second in which the therapist intuitively senses the patient's receptiveness. As Baker [17] suggests, this awareness that the patient is ready to hear a humorous comment may be similar to the spontaneous judgment that an interpretive statement will be heard and processed. In this context, we are suggesting that effective use of humor resulting in shared laughter by the therapist and patient may be a significant contributory factor to change in the patient. Such moments take both members of the dyad by surprise. While an intellectual understanding of a joke may be necessary to “get it,” a major part of the therapeutic value probably lies in the relational connection that is beyond cognitive understanding. Such humor may subsequently be processed and discussed in the therapeutic dialog, as in the above example with Mr. A, but such discussion is not necessary for the moment's therapeutic value. In fact, as illustrated in the subsequent session with Mr. A, the moment of meeting accompanying the humor may be something of a breakthrough in the therapy. It is no surprise that when patients are asked what was helpful in their therapy, they often recall jokes the therapist told or a humorous interchange that departed from the usual format of the therapy [18]. The Running Gag Some moments of meeting are treasured sufficiently that the two members of the dyad refer back to them periodically in the course of treatment. The Process of Change Study Group [12] has called such instances a “flagged now moment.” A variant of this phenomenon sometimes happens with jokes or memorable uses of humor. The connection between therapist and patient may have been such an occasion of bonding that both parties wish to make reference to it now and again. Indeed, sometimes it is recalled in such a way that it has the character of a “running gag” from the days of Vaudeville. Ms. R, a 23 year-old graduate student came to treatment with long-standing problems related to her eating disorder. In the first session, she appeared irritated at her therapist's questions about her eating symptoms and rather sarcastically said, “While I'm sitting here talking to you, I can't help thinking thoughts like how it would feel to eat your kneecaps.” She acknowledged that she was being provocative but was also willing to agree that she was probably trying to communicate the desperate feeling that her voraciousness engendered in her.
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About a year into the treatment, her therapist returned from a vacation, and Ms. R informed him that she had seen a book authored by her therapist called Love and Hate in the Analytic Setting [19]. She said she hoped her therapist would write about her some day in one of his books. She suggested that he could report a case example of a woman with an eating disorder who wanted to eat his kneecaps in the first session. She then quipped, “You could call the book Cannibalism in the Analytic Setting. Both had a good chuckle over her witty play on words. This exchange then became a “flagged now moment” in the sense that when something unusual entered into the therapy process, one or the other would refer back to the comment that had come before. For example, Ms. R was studying physiology in her graduate school curriculum and was puzzled by the term “biliary atresia” and how a condition like that could be compatible with life. After speculating about it for 30 min, she realized that more than half the session had been devoted to the topic, and she noted, “Oh dear, this is ‘biliary atresia in the analytic setting today.” The therapist burst into laughter, and the patient followed suit. Still another time, the therapist's nose started bleeding for unclear reasons, and he grabbed for a Kleenex. As he used pressure to stop the bleeding, he offered an observation on what was going on: “Hmmm. Nosebleed in the analytic setting.” Ms. R was tickled that her running gag had become their running gag. In this vignette, we see how both parties found a way to connect through recurrent use of humor that satirized the therapist's book title. Ms. R could be slightly irreverent while also bonding with her therapist, who she could see was a good sport about it and did not mind her poking fun at his title. In fact, he could even poke fun at himself. These variations on the title continued through a long-term therapy process. The Exit Line To some patients, who are anxious about any hint of hostility, aggression, or contempt in the treatment relationship, humor may be seen as a high-risk phenomenon. After all, it is common knowledge that most jokes have an undercurrent of aggression in them (e.g., man slips on banana peel and falls on his face). Hence, they may only feel a sense of safety to joke as a “parting shot” when they are walking to the door at the end of the session [20]. Mr. S, a shy young man, who feared that his therapist was horrified at all the problems in his family, walked to the door after the session ended. When he got to the door, he turned to his therapist, who had been walking behind him. With a smile on his face, Mr. S summoned his courage and said, “After hearing all my family horror stories, it must be great to go home to your perfect family.” With a look of mock seriousness, the therapist retorted, “Don't get me started.” Both of them laughed heartily. In this snippet of a session, we see a frequent clinical phenomenon with exit lines, namely, that a moment of heightened transference often emerges right at the end of the session [20]. Mr. S had been harboring the concern that his therapist was perfectly adjusted and that Mr. S's family struggles might
be completely outside of his own personal experience. Mr. S took a chance with a humorous comment that conveyed this transference fear. His therapist spontaneously joined in the gag as a way of expressing his appreciation for the humor and sending another message—namely, that no one lives in a perfect family situation. In this moment of meeting, the therapist's response served to reassure Mr. S that he was fully capable of understanding dysfunctional families while also making an indirect interpretation of Mr. S's idealization of him.
Perils in the Use of Humor Laughing with Versus Laughing at Despite its tremendous ability to enhance the alliance and contribute to therapeutic change, humor, like any other therapeutic tool, is subject to the constraints of timing, content, and style of delivery. Beyond its similarity to other forms of therapeutic intervention, however, humor presents unique potential perils. As described earlier, aggression is inherent in humor. The humorous comment made by Mr. A's therapist expressed her frustration at feeling impotent and unimportant in the room. Clearly, had the humor not been well-timed and appropriate to the nature of their particular dynamic, Mr. A might have felt criticized, hurt, or humiliated. His laughing, sharing the moment with the therapist, and expanding upon the topic at hand provided the therapist with positive reinforcement for the humorous exchange. Mr. A's participation in the use of the moment as a foundation in the next session further exemplified his perception that the humorous intervention was acceptable to him. Thus, it may be said that Mr. A provided his therapist a kind of validation, or even “supervision,” suggesting that humor was an appropriate and desirable technique to use in his case. Patients may instead respond to the use of humor by falling silent, verbally expressing their displeasure, or giving a stonefaced indication that the joke is not funny. It is here that the concept of laughing with the patient versus laughing at him warrants distinction. Should a patient feel that the therapist's humor is making light of the situation, missing the meaning of the information, touching carelessly on a vulnerable topic, or insulting the patient's traits or values, the alliance will likely experience a rupture. The therapist must use a trial-and-error approach with humor, realizing that it must be highly individualized, and take into account the particular subjectivities of the two parties. The humorous interventions employed with Mr. A, Ms. R, and Mr. S might each have led to a weakening of the alliance if employed with a different patient or even at a different point in the same patient's therapy. A patient might even accept a humorous intervention made by one therapist, but object to similar comments made by another. Moreover, a countertransference misreading of the patient may masquerade as a “gut feeling” or “intuition.” One simply cannot predict the outcome. As Saper [4] explained, “Psychiatrists or psychologists have at
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the outset no way of knowing precisely how their humor may be received. They need to find (stumble upon?) that core of amusement that fits the patients ‘funny bone.’” This difficulty in discerning the impact of a humorous comment on the patient calls for a concerted effort on the part of the therapist to mentalize [21]. In other words, the therapist must empathically tune in to the patient's emotional state and assess his/her readiness to join in a humorous moment. Ideally, this effort at mentalizing must be an ongoing part of evaluating the state of the therapeutic alliance from moment to moment. Much of mentalizing occurs at an implicit procedural level such that the therapist my intuitively know when the time is right, but conscious efforts in that direction may pay off as well. However, even the possibility that mentalizing may at times be inaccurate need not dissuade a therapist from using humor. Building upon the concepts outlined above, even an unwelcome humorous comment can ultimately be a powerful contributor to positive change. If a “now” moment is recognized by both members of the therapeutic dyad, but they do not successfully engage in a moment of meeting, the result can be a rupture in the therapeutic alliance. The Process of Change Study Group [12] calls this a “failed now moment.” A humorous comment that cannot be shared by both individuals could easily fall into this category. However, as Stern and colleagues explain, these failed now moments may either call the fate of the therapy into question or may be repaired. This reparation itself may enhance understanding and deepen the experience of mutual resonance. Indeed, there is a growing body of literature suggesting that the rupture/repair process may be one of the most powerful common factors in the therapeutic action of psychotherapy [22]. Humor as Escape Freud [1] explained that “humour is a means of obtaining pleasure in spite of the distressing affects that disturb it.” For a beginning therapist, difficulty handling the painful affects produced by a patient's suffering may inspire him or her to seek escape through humor [9]. In these cases in particular, the patient's sharing the therapist's laughter may not represent effective use of humor but rather that the therapist's comment has relieved them both of having to confront the patient's anguish. However, humor for the sake of alleviating therapist discomfort is by definition not used in the service of the patient. It is unlikely, therefore, that this would contribute to shared intuitive understanding. At worst, the patient may feel that the therapist is not capable of entering into the most painful recesses of the patient's psyche. Humor as Beginner's Anxiety Dealing with tragic content is only one of many difficult new experiences for the therapeutic trainee. He or she must remain present with the patient in the room while trying to employ newly learned diagnostic concepts, treatment modalities, and therapeutic tools in a way that is genuine to his or her personal characteristics. Humor may be used to enhance the therapist's congeniality to compensate
for his or her perceived sense of inadequacy. Trainees may also feel uncomfortable with the power differential in the therapeutic dyad and feel clumsy as they gain expertise. They may thus seize upon the potential for humor to equalize their status with that of the patient, using humor excessively, inopportunely, or to the exclusion of refining other therapeutic skills. Here, again, humor could be misapplied in the service of the therapist and to the possible detriment of the patient.
Implications for Teaching There have been some efforts at developing humor training programs for mental health professionals [11]. These often rely upon formal teaching of humor techniques, utilizing workshops, manuals, or role-playing. As Franzini [11] points out, the programs may show some promise, but few have been systematically studied for therapeutic efficacy. Indeed, in this communication we are arguing that in light of our growing understanding of the neurobiological mechanisms by which humor exerts therapeutic effects, we may need to rethink how humor is taught. One controversial implication is that because humor is spontaneous and reactive to unexpected situations, it may be difficult to incorporate into a treatment manual. Manualized treatments rely primarily on left-hemispheric thinking, whereas shared humor and “now” moments, as we have noted above, are the product of right-brained procedural knowing [15]. Our understanding of Schore's work in righthemisphere perceptions and Gallese's [16] description of mirror neurons and their role in mutual resonance suggest a shift in the focus of humor training. Instead of emphasizing the learning of humor subtypes or how to make a comment more humorous, these neurobiological explanations suggest placing a premium on mentalizing in the therapeutic relationship. Through an enhanced appreciation of mentalization, trainees would be better able to recognize “now” moments and to select the optimal moments for the use of humor. Further, they would be better able to examine why their use of humor yielded either expected or unexpected results. Mentalizing can be encouraged in supervision by open-ended questions to the trainee such as, “What is your understanding of what was going on the patient's mind at that moment?” or “How do you imagine the patient was feeling just before you made that comment?” Teaching trainees how humor operates at multiple levels serves to demystify the therapeutic process, providing an explanation for these “now” moments complete with thoughts about how to potentially harness them in the service of the patient. The neurobiologic underpinnings including mirror neurons, implicit relational knowing, and the intuitive knowledge of the readiness of the patient to receive the humor should be part of this teaching. Learners need to conceptualize humor as a high-risk, high-gain intervention in the same way that Gabbard et al. [23] have characterized transference interpretation as such.
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For a trainee who is interested in understanding humorous exchanges and employing them effectively, supervision provides perhaps the best setting in which to consider therapeutic moments of meeting, missed and utilized opportunities for humorous connection, and mentalization in the treatment relationship. While some of the conceptual matters related to humor can be alluded to in a classroom setting, the idiosyncratic nature of how humor is used within a specific therapist–patient dyad requires hands-on supervision discussions. The supervisory interaction itself can provide a live example of these humor mechanisms at work; as Gabbard [24] has pointed out, the teaching in supervision involves unconscious internalization of the supervisor's humorous style, which demonstrates an implicit relational learning that happens between supervisor and trainee. However, in order to facilitate this experiential learning, the supervisor must foster an atmosphere where a supervisee can talk candidly about failed attempts at using humor without fear of shaming or disapproval. Trainees, who may not receive much formal instruction in humor, may see humor as being outside therapeutic technique, and thus not within the scope of supervisory discussions. Further, if the supervisor is uncomfortable with humor as a therapeutic technique, he or she may implicitly model or explicitly state that humorous interventions are unacceptable. We suggest that supervisors should consider a periodic inquiry regarding the presence or absence of humorous exchanges in the therapy if this topic does not naturally arise in the course of the supervision. This approach provides the trainee the option of either employing humor or discussing having done so. Of course, not all therapists have a knack for using humor and/or may not be interested in developing their abilities further in this area. As acting teachers have long known, comic timing is notoriously difficult to teach to someone without a natural aptitude. Thus, supervisors must be sensitive to the possibility that some trainees may choose not to initiate humorous exchanges. Nevertheless, these trainees may still utilize supervision as an opportunity to explore how to notice and comfortably respond to patient-initiated humor.
Conclusion Humor occupies a borderland between a therapist's technique and his or her personal characteristics. Technique, in general, should be invisible. The therapist should be viewed by the patient as engaging in a natural conversational dialog growing out of the patient's concerns; the therapist should not be perceived as applying a stilted, formal technique. Humor fits into this type of natural relatedness. An overarching theme of this communication is that humor by its very nature is hit-or-miss. The carefully planned jokes of the best comedians will inevitably fall flat with some audiences. Moreover, not everyone should attempt to tell jokes. In the course of one's youth, some people find that their jokes are
less well received than those of others. These difficult developmental lessons often determine how much each individual will risk humor in interpersonal situations in general. Hence, educators and supervisors must be sensitive to the natural aptitudes and weaknesses of trainees in this area. By way of analogy, self-disclosure in psychotherapy may come more naturally to some therapists than to others. The field of therapy draws a wide range of people to its fold. Some tend to be private and perhaps inhibited; others may be outgoing and expressive. Effective therapists emerge from both ends of that continuum. Similarly, some patients may warm up to the therapist who self discloses, while others may be distanced by such revelations. Both humor and self-disclosure can be broadly subsumed under the heading of authenticity. Where humor is a tool that a trainee naturally possesses and has already refined, using humor may be an opportunity for the therapist's authentic self to enter in. A therapist who can authentically relate to a patient with humor may be able to maintain an alliance with the patient while joking. The therapist who is forcing humor, however, may create a rupture in the therapeutic alliance by appearing inauthentic to the patient. In closing, we return to the question in our title: is it really possible to teach the use of humor in psychotherapy? Our answer is in the affirmative, but with the qualifiers we have noted in the course of this communication. We would stress the following points. (1) Research from diverse sources is expanding our understanding of the use of humor in psychotherapy. (2) “Now” moments involving humor have the potential to be regarded as a component of the therapeutic action in psychotherapeutic treatments. (3) While there is a risk inherent in the use of humor, thoughtful teaching and supervising can minimize the risk and draw attention to humor's potential. (4) The teaching of humor must be carefully placed within the context of the individual learner's natural proclivities. Implications for Educators & Research is expanding our understanding of the use of humor in psychotherapy & “Now” moments are part of therapeutic action & Risks exist, but can be managed, especially through supervision & Teaching should take the strengths of the therapist into account
Implications for Academic Leaders & New research in neurobiology suggests that the effective use of humor may depend on certain capacities of the therapist that may not be present in all trainees. & Supervisors should directly inquire as to trainees' use of humor in psychotherapy. & Some trainees may not be as educable as others in how to use humor, suggesting that a careful evaluation of that capacity by a supervisor may be a useful part of psychotherapeutic teaching.
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