Would a homeopath try to commit suicide by underdosing?

Therapeutic humour

Homer Simpson says to an alternative healer: “My little girl’s stomach hurts. Do you have anything to stop her complaining?” Well, it made me laugh as do M*A*S*H, Outnumbered, my foster sons, my ‘jokes’ that no-one else finds amusing…. Loads of things, most of the time.  

This is a quick scamper through therapeutic humour. Like all other forms of therapeutic interventions, this is not neutral (it can be healthful or harmful), nor uncontroversial. But at least it’s guaranteed to generate more laughs than colonic hydrotherapy, although The Complete Enema Recipe Handbook has definite humorous potential.

1. Introduction

First off, it helps achieving humour geek status if you have no difficulty in differentiating between terms for 'funny stuff' that tend to get used interchangeably:

·      Comedy – the Homer gag above is comedy, something that is intentionally constructed to be humorous. Jokes are one, quick, comedy format

·      Humour – something that makes people amused

·      Sense of humour – the ability to experience or appreciate humour – although it’s often used to comment on how funny someone is thought to be

·      Therapeutic humour – applying humour to promote health

·      Laughter – the most obvious but definitely not the only way of responding appreciatively to humour

·      Happiness – pleasure, only sometimes connected to humour

Having clarified that, what makes things funny?

Incongruity, juxtaposition of opposites or surprising combinations

·         Absurdity, ludicrousness, or ridiculousness

·         Exaggeration and understatement

·         An unexpected twist

·         “Getting it” and resolution

·         Looking back at a stressful situation and appreciating the humour within it

·         Familiarity with the scenario, identifying with the person

·         Irony and satire

 2. Primum non nocere 

 To be Hippocratical about it, but at least in English, "First, Do No Harm". Although the concept of humour seems oxy-moronic, stuff that’s funny can also be deeply wounding either inherently (eg teasing, insulting, humiliating), insensitive to the emotional experience of the receiver) or stylistically (eg sarcasm used as a put-down).

 Happily, it’s unusual for humour to be used cruelly by staff with patients, and I’ve been surprised to find as an inpatient how seldom it’s resorted to among us patients. (I felt that the morning I spent barricaded in my bedroom was a much more courteous method of achieving distance. The staff didn’t quite see it like that….) 

The risk of inadvertently causing further distress to patients is one of the main constraints on the ward experience of humour – and conversation. This is a complex area given patients’ levels of distress, the function of the ward to reduce this distress and the incredible diversity of patients’ life and emotional histories, cultural use of humour, and not least their particular taste in humour.

But there’s a very simple and swift way of judging whether a humorous comment could unintentionally upset or disturb someone. The ‘target’ of the humour needs to be carefully considered:

  1. humour aimed at ourselves is more likely to be healthful
  2. humour aimed at others is more likely to be harmful.
  3. humour aimed at situations falls in between these two extremes.
 The Italian film Life is Beautiful is an exceptional comedy achievement, especially an agonisingly funny scene with a father, his young son and a Nazi guard. The art of finding humour in excruciating situations is to steer well clear of trivialising the situation and instead focus on one small aspect, ideally one which undercuts the power of the tyrant.

 3. Mental illness and humour 

Those who do not know how to weep with their whole heart don’t know how to laugh either. Golda Meir, late Prime Minister of Israel

With the fearful strain that is on me night and day, if I did not laugh I should die. Abraham Lincoln, very late President of USA

I never would have made it if I could not have laughed.  It lifted me momentarily out of this horrible situation, just enough to make it liveable. – The psychiatrist Viktor Frankl talking about how he survived concentration camp.

 “Lighten up Homer. You’re making Happy Hour bitterly ironic.” Barman in The Simpsons

 Most of us have experienced the sheer pleasure and relief of a good laugh in the midst of something really traumatic. Although at the time I found nothing even potentially humorous about being sectioned, subsequently I could laugh at some of the particularly absurd aspects of the deeply scarring process. As well as the obvious benefits of humour in terms of emotional uplift, bonding etc, humour involves the use of techniques which are particularly relevant in coping with being mentally ill. Taking the example of jokes, they can help with:

  1. Developing different, often wildly contrasting perspectives
  2. Increasing mental agility, eg through constructing a gag or listening to and imagining/analysing the narrative and punchline
  3. Disrupting very entrenched and/or rigid ways of seeing a situation
  4. Experiencing dilution of intensity
  5. Practising ‘mentalising’ or mind-awareness, through imagining what’s happening in the minds of the people in the gag
  6. Connecting with other people through shared experience. When we laugh at the same things, there's an immediate, recognized bond.
  7. Practising tension relief – our own and others’
The good thing is that we don’t need to be Julian Clary or Eddie Izzard, or even gay, to be able to improve our appreciation of humour. ‘Seeing funny’ can be learned. The key is to practice seeing funny, especially by noticing multiple layers of meaning. As well as noticing and enjoying humour and humorous potential in the course of our daily lives, we can also actively seek out humour, especially of the shareable variety. The obvious sources are comedy TV and radio programmes, books, films, cartoons, websites, witty friends and colleagues. 

A particular consideration of using humour with mentally ill people is being sensitive to each individual’s experience of their illness eg:

·         Symptoms:
o          Severity
o          Manifestation especially re: content/nature of voices/messages whether experienced inside or outside of their own head

·         Self-esteem

·         Impact on their life

Alongside this, staff sensitivity is increased when they are aware of the individual’s humour preferences. I’m not suggesting that in the middle of a conversation with a patient, a nurse excuses herself and rushes off to look at the patient’s notes before making a gentle quip about the weather. But where they have a substantial relationship with a patient or humour has emerged as an issue for the patient, it can help to know:

  1. that the more an individual uses humour in healthful ways the more receptive they are likely to be to humour interventions.
  2. about the role humour plays in the patient’s life, for example by finding out what humorous films, programmes, comedians etc they enjoy.

4. Talking therapies

Freud kicked it all off at the beginning of the last century with his not exactly rib-tickling Jokes and Their Relation to The Unconscious. More recently, some types of psychotherapies have been developed which include humour explicitly. Albert Ellis wrote of the Rational-Emotive Therapy he created: “Human disturbance largely consists of exaggerating the significance of the seriousness of thing, and the ripping up of such exaggerations by humorous counter-exaggeration may well prove on of the main methods of therapeutic attack.” And if therapists on the attack appeals to you, you’ll love Provocative Therapy. A benevolently humorous approach is central to Provocative Therapy, as a way of starkly challenging what the therapist regards as a client’s very distorted or dysfunctional beliefs. PT uses reverse psychology, eloquently illustrated by Mr Simpson:

Homer's Brain: Use reverse psychology.
Homer: Oh, that sounds too complicated.
Homer's Brain: Okay, don't use reverse psychology.
Homer: Okay, I will!

Humour in therapy can be powerful but is risky. Kubie is the best-known anti-humour in therapy hardliner, believing it makes patients so vulnerable to actual or perceived attack by the therapist that it shouldn’t be in the therapist’s repertoire. But Kubie doesn’t have much company in the Relentlessly Serious Therapists’ Corner. Much more representatively, Killinger concluded that `the use of humour seems in most instances to stimulate positive client discussions of the topic, and positive client feelings towards the therapist predominate'. The main reasons given for the benefits of appropriate, healthful humour in therapy are that:
·      It creates an unusual, egalitarian instance of the patient and therapist sharing the same or similar experience/power/feelings between them.

·      This co-construction of meaning can significantly strengthen the therapeutic alliance

·      Humour can sometimes reach and activate important emotions which a patient has shielded from therapeutic intervention (‘getting through to blocked affect’)

·      It can be a particularly unthreatening, unaggressive, warm technique for diluting the intensity and pain of some of the issues being probed in therapy 

Of course, to achieve these and avoid hurt, it helps if the therapist is not only sensitive and wise, but also funny.

The most targeted use of psychotherapeutic humour I’ve come across is
The Humor Group created by Pamela Minden, which used humour as the focal point of treatment. This group therapy had a very tight structure, including the central element of a "humorous activity" each session, engaging members in a variety of games, songs, dances and skits. The group’s ambitious objectives were to:

·         provide pleasurable ‘respite’ and relaxation

·          cultivate humour in patients’ lives

·         develop a sense of connection

·         improve communication and social skills

·         learn to manage thoughts or feelings

·         get new perspectives

·         reduce stress and enhance coping

·         laugh with others at oneself

·         enjoy therapy if traditional formats are experienced as threatening

 Despite the group’s popularity with its members and its effectiveness, it was a short-term project. But Laughter Clubs throughout India have been not only sustained but also replicated around the world. Participants experience ‘stimulated laughter’ – eg breathing techniques combined with chuckling, snickering, snorting, chortling, and giggling. It works on the basis that ‘faking it leads to making it’. 

5. Good for body as well as soul

 Humour is said to be good for:

·         Increasing muscular and respiratory activity

·         Stimulating the cardiovascular system, and the muscular and skeletal systems

·         Increasing antibodies

·         Increasing pain tolerance

·         Decreasing levels of stress hormones

·         Decreasing heart rate  

6. Practical ideas for making mental health wards funnier

Wards are already organising lots of different activities which are humour spreading. Like the Humor Group and Laughter Clubs, they are happy to contrive humorous opportunities, which have lots of additional benefits for patients and staff.

·         funny board and other games eg Pictionary, Twister

·         cooking funny designs eg on pizzas and cakes

·         books – joke books, humorous books, comics, novels,

·         comedy films, TV and radio programmes, poetry, music, drama….

·         themed days – whether Abba or Halloween

·         religious festivals tend to be rather serious, if not gloomy, but there are some which are particularly good fun, such as the Jewish festival of Purim

·         comedy outings – eg films, plays and of course comedy clubs

·         pets. Dogs in particular can be very funny, as can meerkats and aye-ayes but these are even less likely to slip under Infection Control’s penetrating radar

 Making things more fun for staff is not only good for them but makes them more able to engage humorously with patients. The sorts of things which teams can try include having a fun noticeboard in the staff room, starting ward meetings, staff meetings, handovers etc. with a joke and ensuring there’s some humour in training, conferences and other events. All these can of course be adapted for use with patients.