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Story of a Smile — Therapeutic Uses of Humor
By Scott Janssen, MSW, LCSW

Tears pour down Jacquie’s face as she rocks back and forth in the wooden chair where we sit talking. Pain is etched into her face; her respirations are constricted and her hands are shaking rapidly.

Her partner had called me Monday morning to let me know Jacquie’s mother, Charlene, had died over the weekend. Charlene had been a patient in hospice, and during that time I’d developed a good connection with Jacquie. Her partner was at a loss about how to help. “She’s been crying and having panic attacks,” she’d said. “I don’t know what to do.”

During the preceding week, Charlene had been feeling good. In fact, the symptoms of cardiac disease had been so well controlled that she and Jacquie had planned to go to a local pancake house Saturday morning. Unfortunately, something happened on their way there—a stroke, cardiac arrest, it wasn’t clear. Charlene died in the back seat of the car.

Jacquie was inconsolable. Attempting to help her process the experience cognitively was going nowhere—she was too overwhelmed. I’d already tried walking her through some somatic strategies for helping her settle, but these had likewise been unsuccessful.

Suddenly Jacquie shouts in anger, “She didn’t even get to have her pancakes.” Bowing her head, she begins repeating the phrase: She didn’t even get to have her pancakes.

“Well thank God for that!” I say loudly.

The comment jars her. Her head snaps up and she looks me in the eye. “What did you say?”

“I said thank God she didn’t get any pancakes,” I say warmly.

Jacquie shakes her head, confused, not sure what to say.

“You know how busy that pancake place gets on Saturday morning, don’t you Jacquie?”

She nods.

“It’s a mad house. It takes forever to find parking. Then you lug her portable oxygen into the lobby and wind up waiting an hour for a table. When you finally get seated your mom’s energy is shot and it’s so loud you have to yell at each other just to hear.”

I’m relieved when Jacquie starts nodding her head. “The waiter is so stressed out,” I continue, “he gets your order wrong. And you know how poor your mom’s appetite was. When she finally gets her pancakes—she takes two bites and feels stuffed. The whole ride back she’s feeling horrible and wondering why she wanted those pancakes in the first place.”

Jacquie is wiping her tears with a tissue, interested in where this is headed. I remind her how excited her mother had been the week before as she anticipated going out for pancakes and asked, “Jacquie, when would you rather die? On the ride back when you’re feeling let down and thinking about how bad those nasty pancakes feel in your belly? Or on the ride over when it’s all ahead of you, when you’re full of joy and excitement thinking, ‘Oh boy, I’m going to get me some pancakes?’”

This seemingly strange intervention offers Jacquie another way of understanding the events of her mother’s death and helps her shift from a painful emotional state into one of reflection. Within minutes her breathing is normal and she’s talking about the thoughts and feelings that have been swirling inside her without getting overwhelmed. At one point she gives a faint smile and starts laughing, “That place sure can be crazy on Saturday morning.”

Humor and Its Nuances
Using humor in the context of psychotherapy or crisis counseling can be tricky. Issues around content, timing, safety, and trust can make thoughts of injecting a bit of levity into such serious work a nonstarter for many social workers. If used insensitively, humor can rupture the therapeutic relationship, intensify a client’s suffering, and even reinforce negative emotions or beliefs. If used to deflect from a social worker’s own anxiety, it can shut down conversation. If a client senses, rightly or not, that humor is at their expense or is laced with judgment, it can intensify pain or defenses originating in having been stigmatized, bullied, or abused.

As a hospice social worker, I avoided humor for years, convinced that injecting playfulness would be out of synch with the seriousness of what patients and caregivers were facing. But as I assessed how patients coped with adversity and invited them to share important memories and reflect on what was important to them, time and again they spoke about laughter and having a sense of humor.

For many patients, humor gave a welcome break from troubling emotions or thoughts and brightened the monotony of long days in a hospital bed. Laughing with others generated a sense of connection and countered beliefs about being a burden or that life had lost its meaning. For patients looking back on their lives, humor helped them to make peace with regrets and missed opportunities and to better accept their imperfections.

Psychological Benefits
Laughing while facing the challenges of dying seemed to connect patients and their loved ones with reserves of inner strength and resilience. Laughing at something that is painful or frightening can loosen its power; stepping back and viewing one’s circumstances from a humorous angle can reinforce a healthy coping resource and introduce an element of mindfulness.

Though it’s wise to use caution, for social workers who are comfortable with humor and able to use it sensitively, it can be a positive factor in work with clients. Reflecting on humor in social work practice, Gitterman (2003) suggests that, when used well, humor “puts people at ease during initial contacts, as they enter an unfamiliar situation and meet a professional stranger for the first time. Shared laughter serves as a social bridge and facilitates engagement and rapport. Laughing together softens the power differential, reduces social distance, normalizes the helping process, and advances the therapeutic relationship.”

Burns (2003) notes that it is possible “to use humor and humorous experiences as a way of communicating a salient therapeutic message that may be relevant to the client’s desired outcome—in fact, in humor it may be possible to say something to your client that you may not choose to do directly.”

Research by Panichelli, Albert, Donneau, D’Amore, Triffaux, & Ansseau (2018) found a strong positive correlation between humor and increases in “therapy effectiveness, therapeutic alliance, perceived hope, and pleasure in participating in therapy sessions.” According to Dziegielewski, Jacinto, Laudadio, & Legg-Rodreguez (2003), “Within therapy, humor can be utilized to break a client’s resistance, reduce tension, generate catharsis, and increase trust in the client/therapist relationship.”

Distilling the work of others (Reynes & Allen, 1987; Goldin & Bordan, 1999; Goldin, Bordan, Araoz, Gladding, Kaplan, Krumboltz & Lazarus, 2006) psychotherapist Laura Johnson (2009) identified several potential benefits of incorporating humor and playfulness into clinical work including the following:

• strengthening the bond between client and counselor;
• facilitating communication and helping clients focus;
• making the therapy process more interesting;
• better assessing clients’ psychological functioning;
• helping clients develop a more useful perspective by seeing the world’s absurdities;
• offering clients less painful ways of understanding difficult problems;
• enhancing clients’ coping skills and personal resources; and
• reducing stress and tension during the therapy session.

Physiological Benefits
In addition to psychological benefits, humor can bring positive physiological effects. According to the Mayo Clinic (2019), laughter does the following:

• enhances the intake of oxygen; stimulates the heart, lungs, and muscles; and increases the brain’s release of endorphins;

• activates then relieves the stress response, resulting in a feeling of relaxation;

• reduces the tension and physical symptoms of stress by stimulating circulation and increasing muscle relaxation;

• improves the functioning of the immune system by increasing positive thoughts that can cause the body to release neuropeptides that help fight stress and illness; and

• relieves pain by causing the body to produce its own natural painkiller.

Humor’s Value and Risks
In therapeutic terms, humor can be used to facilitate psychological and emotional processing, break through painful behavioral patterns, and reinforce the power of important relationships. It can also be used to shift a client out of negative patterns of thinking or seemingly intractable feeling states.

As with Jacquie, humor can help clients shift from a narrative that is causing pain by introducing a new one that stimulates curiosity and is associated with positive and/or empowering feelings and beliefs. If a patient or client is anxious, is guarded, has trouble putting emotions into words, or has cognitive impairment, gentle humor can send verbal and nonverbal messages of safety, attunement, and care.

Whether using a humorous story or joke, or finding joy in irony, absurdity, or playful exaggeration, social workers in almost any setting will find opportunities for using humor. Such opportunities, of course, should be guided by an intention to use humor in a way that brings clients insight and is consistent with their goals as well as the social work Code of Ethics. Social workers should also be sensitive to a client’s values, communication style, and social history, as well as their particular preferences and style of humor.

Gladding & Drake Wallace (2016) suggest using only what they call “positive humor,” such as puns, anecdotes, and the playful use of clichés. They differentiate this from negative humor, which social workers should generally avoid with clients, e.g., sarcasm, teasing, and morbid/dark humor.

Using humor as an adjunct to clinical intervention is a choice. Social workers should feel no pressure to force it into their practice. Those who wish to incorporate humor would do well to consider its potential uses, as well as contraindications, within the unique context of each client relationship.

I had a strong connection with Jacquie, for example, and we had used humor frequently on prior visits. When I chose to use it in an acutely stressful situation, there were risks. I was confident, though, that if my attempt at using humor to reframe her experience backfired, our connection would allow us to get back on track without exacerbating the likelihood that Jacquie might walk away with complicated bereavement or long-term psychological trauma.

Kierkegaard, Suffering, and Transcendence
One of the stories I occasionally share with patients is from the 19th-century Danish philosopher Søren Kierkegaard. He tells a metaphorical tale about being swept into a transpersonal realm where he meets a pantheon of gods who offer to grant him a single wish. He ponders, then says, “I choose one thing: always to have the laughter on my side” (Kierkegaard, 1992).

The implication is clear. The ability to cultivate a humorous outlook and laugh amidst life’s trials is a transcendent power—a power that can serve not only clients but social workers as well, as they enter the lives of people who are suffering or feeling hopeless or overwhelmed.

— Scott Janssen, MSW, LCSW, is a hospice social worker with UNC Health Care Hospice, and member of the National Hospice and Palliative Care Organization’s trauma-informed care work group.

References
Burns, G. (2003). 101 healing stories: Using metaphors in therapy. New York: John Wiley & Sons, Inc.

Dziegielewski, S. F., Jacinto, G., Laudadio, A., & Legg-Rodreguez, L. (2003). Humor: An essential communication tool in therapy. International Journal of Mental Health, 23(3), 74-90.

Gitterman, A. (2003). The uses of humor in social work practice. Reflections: Narratives of Professional Helpers, 9(2), 79-84.

Gladding, S. T., & Drake Wallace, M. J. (2016). Promoting beneficial humor in counseling: A way of helping counselors help clients. Journal of Creativity in Mental Health, 11(1), 2-11.

Goldin, E., & Bordan, B. (1999). The use of humor in counseling: The laughing cure. Journal of Counseling & Development, 77(4), 405-410.

Goldin, E., Bordan, T., Araoz, D. L., Gladding, S. T., Kaplan, D., Krumboltz, J., & Lazarus, A. (2006). Humor in counseling: Leader perspectives. Journal of Counseling & Development, 84(4), 397-404.

Johnson, L. (2009, June 25). Humor in psychotherapy. Positive Psychology News. Retrieved from https://positivepsychologynews.com/news/laura-lc-johnson/200906252693.

Kierkegaard, S. (1992). Either/or: A fragment of life. (p. 15). New York: Penguin.

Mayo Clinic. (2019, April 5). Stress relief from laughter? It’s no joke. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-relief/art-20044456.

Panichelli, C., Albert, A., Donneau, A. F., D’Amore, S., Triffaux, J. M., & Ansseau, M. (2018). Humor associated with positive outcomes in individual psychotherapy. American Journal of Psychotherapy, 71(3), 95-103.

Reynes, R. L., & Allen, A. (1987). Humor in psychotherapy: A view. American Journal of Psychotherapy, 41(2), 260-270.