Review Article
The Use of Humor in SeriousMental Illness: A Review
Marc Gelkopf1, 2
1Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
2Lev Hasharon Mental Health Center, PO Box 90000, Netanya 42100, Israel
Correspondence should be addressed to Marc Gelkopf, emgelkopf@013.net.il
Received 13 February 2009; Accepted 17 July 2009
Copyright © 2011 Marc Gelkopf. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
There is now a relatively good understanding of the broad range of direct and indirect effects of humor and laughter on perceptions,
attitudes, judgments and emotions,which can potentially benefit the physical and psychological state. This article presents a review
and discussion of the use of humor and laughter in treating people with serious mental illness, distinguishing between clinical
papers on individual and group psychotherapy, and empirical research reports describing humor and laughter interventions. In
spite of the exponential growth of the field over the last 30 years, I conclude that empirical studies are still lacking, the studies that
do exist have major methodological shortcomings, and the field is in dire need of further investigation.
From the laughter of god were born the seven
gods that govern the world . . . When he had
laughed, the light appeared [· · · ]. He laughed
for the second time: everything was water. At
the third laugh appeared Heres; at the fourth,
creation; at the fifth, destiny, at the sixth, time
itself. Then, before the seventh laugh, he took
a great breath, but having laughed so much, he
cried and from the tears sprang the soul.
Anonymous, third century [1]
1. Introduction
Laughter and humor have existed in all societies throughout
the ages, and play an important role in many mythologies
worldwide [2]. Many ancient philosophers, such as Aristotle
and Plato, and later, Descartes, Hobbes, Locke, Kant and
Darwin, as well as modern philosophers such as Bergson,
Jankelevich and Alvin Toffler, have considered humor or
laughter to be a central phenomenon in the lives of people
and societies [3].
The place of humor in mythologies and the attention
it has received by philosophers attests to its importance for
the delicate balance between human well-being, divinity and
society. But the use of humor is not limited to storytelling
and theorizing. The well-known proverb: “a merry heart
doeth good like a medicine” (Proverbs 17:22) has been used
through the ages, and records show that physicians have
been advocating the potentially curative aspects of humor for
hundreds of years.
Although the “science of humor” is a relatively young
field, research from the last 30 years has suggested the
mechanisms through which humor may positively impact
health [4]. Humor seems to have the potential to effectuate
pain relief [5], strengthen immune function [6], improve
positive emotions [7], moderate stress [8–11], dissociate
from distress [11–13] and improve interpersonal processes
[14, 15].
In the wake of the above-mentioned studies, we have seen
the growing application of humor and laughter interventions
with child [16] and adult [17] medical patients, as well as its
use in psychotherapy frameworks [18, 19].
Probably due to what seems to be the therapeutic
potential inherent in humor and laughter, the noteworthy
sense of humor observed in many of the “super-therapists,”
such as Ellis, Perls, Erickson, Satir, Rogers or Whitaker and
the growing use of humor in general hospitals [16, 20, 21],
we have seen an increase in the use of humor in individual
and group psychotherapy and in a number of humor and
laughter interventions within psychiatric institutions and
with individuals with “serious mental illness” (SMI).
SMI is usually used to refer to severe and longlasting
mental disorders such as major depression (MDD),
schizophrenia (SZ), bipolar disorder (BD), obsessive compulsive
disorder (OCD), panic disorder, post-traumatic
2 Evidence-Based Complementary and AlternativeMedicine
stress disorder (PTSD) and borderline personality disorder
(BPD). SMIs are conditions that disrupt a person’s motivation,
thought processes, emotions, mood, interpersonal
relationships and behaviors.
Challenges for these individuals can be very encompassing
and range from regaining meaning in life, self-esteem,
coping with strong anxiety, depressive and suicidal thoughts,
coping with traumatic experiences, coping with strong
hostility and sexual drives interpersonal and intrapersonal
conflicts; including shame and guilt, loss of the ability to
enjoy life, social alienation and internalized stigma as well as
institutionalization [22].
These conditions often necessitate significant intervention.
But treatment is notably difficult, and interventions
include mainly medication, various therapies and psychosocial
education interventions aimed at rehabilitation. Therapeutic
challenges include the establishment of a positive
working alliance to optimize treatment adherence, working
through strong resistance, instilling hope and a positive
outlook on life, and by working through the strengths of
the client, encouraging him to regain interpersonal and
vocational skills.
Modern practices and orientations in rehabilitation do
not advocate per se the eradication of symptomatology, but
focus upon community integration, improvement in quality
of life through reduction and control of symptoms as well
as client empowerment. Nevertheless many clients regularly
feel helpless to cope with symptoms, and find themselves
hospitalized.
Humor in this frame of reference could be used as an
adjunct to conventional treatment with the goal of helping
clients cope with symptoms, improving rehabilitation
through its emotional, cognitive, social and physiological
impact as well as reinforcing and facilitating therapy and
client empowerment (Figure 1).
In the following paragraphs, I shall present a review
of the literature that presents the theoretical and clinical
background describing the potential benefits of the use of
humor in individual and group therapy for SMI followed by
a review of the empirical studies on the use of therapeutic
humor with different SMI populations.
2. Potential Benefits of Humor and Laughter in
the Treatment of SMI
2.1. Use of Humor and Laughter in Individual Psychotherapy.
The use of humor in psychotherapy with patients with
chronic and seriousmental illness has been widely described.
Advocates of its use have come from all major psychotherapy
orientations, including existentialists [23, 24], dynamic
therapists [25], behaviorists [26] cognitivists [19], paradoxoriented
therapists [27, 28], family therapists [29], Gestalt
therapists [30], provocative therapists [31] and others, and it
has even been presented as an important aspect of supportive
therapy for caregivers of people suffering from SMI [32]. The
techniques used in the many approaches vary widely and
have been described elsewhere [33].
Based upon the aforementioned clinical and research
work, I have made the classification of the potential contributions
of humor to individual therapy for people with SMI
as presented in Table 1.
2.2. Humor in Group Therapy. In his book, The Expression of
the Emotions in Man and Animals, Darwin [49] speculated
that the evolutionary basis of laughter had its function as
a social expression of happiness, and that this rendered a
cohesive survival advantage to the group. More recently, the
understanding of the evolutionary development and social
survival value of humor has been well described [50]. In
support of this theory, laughter has been found to occur
in social contexts over 95% of the time [51]. In addition
to regulating conversation [52], laughter enhances social
relations by producing pleasure in others through simple
contagious processes [53] and by rewarding others’ actions,
thus encouraging ongoing social activities [54]. Studies of the
role of social laughter demonstrate its pro-social benefits, for
example, by increasing group cohesiveness [55].
Therefore, although the use of humor in group therapy
makes the same kind of contribution as in individual therapy,
it has its own distinctive advantages. This is based primarily
on the extent of its impact (e.g., making a group laugh
is different than making an individual laugh), the social
contagion effect (e.g., more opportunities for catharsis) and
the opportunities facilitated by social exchanges in group
format (e.g., working on social skills). The use of laughter
and humor in groups may be especially relevant to the
SMI population because one of the major problems of
this population is the lack of social skills accompanied
with high levels of social alienation. In addition, psychiatric
settings may be especially suited to the optimal use of
social laughter because much if not most of the therapeutic
activities in such settings take place in group format. Based
on the descriptive work of some researchers [25, 56–59], I
suggest the classification of the contribution of humor and
laughter to group psychotherapy in psychiatric settings, as
summarized in Table 2.
3. Empirical Studies on Humor-Oriented
Interventions with SMI
3.1. Non-Tailored Interventions. Although interventions “tailored”
to the individual or group would seem to be the
most effective way of using humor, some approaches suggest
that the laughter itself is enough to promote at least shortterm
well being. Indeed, laboratory studies have suggested
increases in positive mood in subjects following forced nonhumorous
laughter [62]. “Yoga laughter” has been used
as an intervention mode in a number of health settings
[63], and today, there are hundreds of “laughter classes”
worldwide, including psychiatric settings, although none has
been investigated scientifically [64].
However, two studies assessed the use of non-tailored
laughter on chronic schizophrenic patients in a psychiatric
hospital [15, 65, 66]. In both studies, humorous movies
were shown twice daily (five times weekly) to 17 and 15
Evidence-Based Complementary and AlternativeMedicine 3
Table 1: Potential contributions of humor to individual therapy for people with SMI.
Diagnostic: In MDD, OCD as well as schizoaffective depressive symptomatology, strong anxiety, aggressive and sexual impulses shame
and guilt may lead to high levels of tension. Given the right therapeutic context this can be expressed through spontaneous laughter or
humor which can then be investigated [29]. Patients’ jokes can also be considered as a projective tool to assess conflicts [34], and laughter
can also be seen as a welcomed and desirable index of the process of therapeutic change itself [30, 35].
Emotional: Strong anxiety are a major aspect of many of the disorders classified under SMI. On the other hand certain disorders such as
SZ and PTSD are at times characterized by emotional numbness. Laughter can both reduce excessive anxiety and facilitate the expression
of emotions [36, 37] such as feelings of hostility [38] that would otherwise become self-defeating. Laughter can also be a mind-relaxing
tool, helping to reach emotional content that the patient is neurotically or psychotically protecting, or as a phase in initiating systematic
desensitization [26].
Cognitive: Distorted cognitions and obsessive rumination are some of the features of many SMI’s. Humor can foster self-observation by
initiating the reorganization of attitudes (e.g., in regard to specific subjects such as sex, ridicule, or the debunking of catastrophe scripts),
and by temporarily suspending taboos and distancing oneself from obsessive thoughts, humor can offer a sense of proportion [33] aswell
as promote different perspectives towards problems [19]. Humor can also facilitate a pleasurable and hedonistic approach to problems,
in stark contrast to depressive or suicidal thinking [33, 39, 40].
Somatic: SMI patients suffer from important physical and mental stress. As a natural tension reducer, humor can be used to relieve somatic
stress and facilitate therapeutic processes [41]. A number of authors have described the importance of a physiological rapport between
therapist and patient [42, 43]. This is especially relevant for SMI patients for whom the establishment of good therapeutic rapport is a
major predictor of successful rehabilitation (ref). In a study assessing skin conductance measures of therapists and patients in videotaped
psychotherapy settings, Marci et al. [44] has suggested empirically that this rapport is strengthened in the presence of laughter.
Potential space: Especially relevant for BPD, humor can promote the use of a potential space of play, where themes can be explored and
shared in a non-defensive way [45].
Dynamic processes of personality: Humor and laughter can release rigid defenses, promoting communication with unconscious processes,
widening the repertory of available coping options and strengthening the ego [46].
Therapeutic relationship: Humor in the therapeutic relationship may help deepen the therapeutic alliance, as the use of humor can
strengthen the feeling of acceptance, enhancing empathy and a sense of belonging [33]. Therapists can show their humanness and break
down barriers that often exist within the therapeutic context—especially within psychiatric institutions [37]. The therapist’s spontaneous
laughter can improve the patient’s trust in the therapist and therapeutic process [47].
Therapist-related processes: Outside of the therapeutic context, humor can help the staff in the psychiatric institution deal with frustrating
sessions, the processes of institutionalization, and difficult-to-treat chronic patients that may affect burnout [48].
Table 2: Potential contributions of humor to group therapy for people with SMI.
Diagnostic: The way individuals use humor in group situations can, in certain cases, be an indicator of inadequate social coping means,
or can be explored as a positive coping skill that can be generalized to other social situations. Analyzing the timing of laughter may also
help understand certain dynamic group processes.
Emotional: Due to the social contagion effect of laughter, the potential of emotional catharsis in groups is great. Furthermore, using humor
as an outlet for hostility and fear in a group situation may enhance the acceptance of these feelings and the pleasure of making people
laugh may boost their expression.
The contagion effect of laughter in groups can lead to both loud and strong laughter and in some instances to “fou rire” or uncontrolled
positive laughter, effecting both physical and emotional catharsis and relaxation.
As one major problem for patients with SMI is the deficit in the ability for emotional self-regulation, group humor may be a good setting
in which to learn this, due to positive up-regulation of emotions within the group. Indeed, a recent study has shown that humor can serve
as a potent cue for emotional up-regulation [59].
Therapist-related aspects: The therapist, as a model figure, displays behaviors, including humor, that the patient may imitate [60], and
adopt as a coping mode.
Cognitive: As in individual therapy, humor within a group context may enable and facilitate the development of a sense of proportion, and
may help overcome exaggerated seriousness that often serves as a defense against ambiguity. The presentation of one’s life in a humoristic
manner may often help patients accept certain difficult situations in a more existential way, accepting life’s absurdities and quandaries.
Social: Patients’ use of humor may strengthen interpersonal skills, social confidence and reduce social phobia very often present in SMI’s.
In gender- or ethnic-specific groups within psychiatric contexts, humor can be used to strengthen the gender or ethnic identity of the
participants [58] and as such foster community integration.
Group-related aspects: The use of incongruity and surprise bymeans of humormay stimulate the group, evoke curiosity, overcome defenses
and provide a cue for remembering and internalizing insights more readily than verbal interpretations. Humor in a group context can
help the self-disclosure process, thereby contributing to emotional catharsis and strengthening group belonging. It can promote a sense
of intimacy, attachment and friendliness in the group, improving cohesion and morale. This aspect is paramount in institutional settings
and with patients with SMI, who are often socially alienated.
Institutional aspects: Group humor may be especially beneficial in that it sets aside institutional rules to facilitate dialogue between clients
and professionals [61]. If humor is used in large groups or in regular ward meetings, its impact may generalize to the larger therapeutic
setting of the ward or the clinic.
4 Evidence-Based Complementary and AlternativeMedicine
Aspects of humor:
Cognitive
Emotional
Social/interpersonal
Physiological
Therapy processes:
Medication adherence
Therapeutic alliance
Psychotherapy work
Aspects of recovery:
Bigger social network
More social satisfaction
More social integration
Less symptoms
Better symptom control
Less negative and
distorted thoughts
Less anxiety and depression
Less shame
Less mental stress
Instilment of hope
Improvement in quality of life
Less physical stress
Better physical health
Client empowerment
Figure 1: Potential ways in which humor can contribute to recovery.
SZ patients, respectively, in wards, over a 3-month period,
and “regular” movies (including 15% humorous) were
shown to control wards. These were assessed both before
and after, using well-established self- and clinician-rated
questionnaires. These studies suggest that the use of this kind
of intervention may reduce psychiatric symptomatology,
anxiety, depression, verbal hostility and aggression, anger,
and improve social support and social competence. On
the other hand, this intervention did not improve physical
health-related measures, nor did it improve the therapeutic
relationship with the therapist. Interestingly, the first study
[67] showed no relationship between any improvement
between any of the measures, and a patients’ ability to enjoy
humor, supporting the suggestion of Falkenberg et al. [68]
that such interventions may be beneficial for many of the
patients, regardless of their ability to enjoy humor. The
first study, where the staff had the opportunity to watch
the movies with the patients also showed an improved
relationship between staff and patients [15], and based
upon qualitative ward observation, an improvement in ward
atmosphere. However, the second study showed that the
impact of this intervention was not mainly due to its social
aspect, because in the second study improvements could be
observed on both psychiatric symptomatology, depression
and anxiety, as well as social competence without the staff
watching the movies, and without any improvement in the
relation with the staff, nor any change in ward atmosphere.
One major criticism of these studies is that they did
not assess “laughing” itself thus it is possible that some
other aspect of comedy viewing, such as social expectation
or positive emotions, may be responsible for the effect.
Furthermore, no “dose effect” could be observed in patients
who watched more versus those who watched fewer movies,
suggesting it may be a general “positive atmosphere” affecting
the wards, and not specifically the laughter itself.
3.2. Humor Groups in the Psychiatric Setting. A number of
interventions have been set up with the declared aim of
using humor as a therapeutic tool to improve the quality
of life of mental health clients. The best known is probably
Stand Up for Mental Health [69], which uses stand-up
comedy, including training and public performances to
enhance self-competence, sense of control and self-worth, as
well as reducing self-stigma, and uses the performances to
educate the public about stigma. Although these and others
are noteworthy, only a handful of interventions have been
empirically assessed.
Witztum et al. [70] performed an empirical 6-month
intervention in a psychiatric ward with 12 schizophrenic
patients. Based upon the paradoxical ad absurdum principle,
described by Frankl [23], Titze [27] and Whitaker [28],
with the aim of creating paradoxical scenarios which would
obviate judgment errors and the irrationality of behavior
patterns on the part of the patients, all 12 patients were
offered humorous renderings and interpretations of their
most prominent complaints, which had been prepared in
advance to debunk the alleged symptoms. This 3-month
humor intervention was scheduled after a 3-month version
of Ellis’ Rational Emotive Therapy (RET). The humor
approach was more efficient in reducing psychopathological
symptoms than the RET, as assessed by the Brief Psychiatric
Rating Scale (BPRS) for the same patients.
Minden [71] described 4 years’ work in an open group
that provided patients with a mirthful place for respite and
shared laughter. The intervention was held as an “open
group” in the psychiatric wards, where each patient was
offered to participate in six to eight 1-h sessions. Each weekly
session included an introduction, which was conducted in a
playful manner and set a jovial tone for group interaction.
The “call for jokes” served as a springboard for more
spontaneous humor, provided an incentive to prepare ahead
of time, and gave more introverted participants a concrete
focus. Next, a “humorous activity” engaged members in a
variety of games, songs, dances, skits or relay races that
emphasized cooperation. This activity was followed by a
discussion that encouraged members to share concerns
and plan for future sessions and was a safeguard against
humor’s divisive or destructive potential. Finally, there was
an “enlightenment” component, which often took the form
of an instant replay of some funny group occurrence and
ended the session on an upbeat note. After each session, a
Evidence-Based Complementary and AlternativeMedicine 5
debriefing was held in which the students and the instructor
critiqued the group process and developed strategies for
improvement. A total of 66 sessions were held, involving
129 patients. Interviews conducted with 13 patients revealed
several themes suggestive of the group’s therapeutic value.
The participants viewed the group as a place in which was
a sense of connection developed, communication improved
and social skills were learned. They also learned to regulate
thoughts and feelings, attain new perspectives, reduce
stress and enhance coping, find respite and relaxation, and
laugh with others at oneself. A similar intervention was
also described by the same author [72] within a forensic
psychiatric setting. This was performed in a naturalistic
setting without a control group or systematic data gathering.
Walter et al. [40] compared the impact of pharmacological
medication and humor group therapy (n = 20)
to standard medication treatment alone (n = 20) in
elderly patients with late-onset depression and Alzheimer’s
disease. The Humor group received 1 h therapy once every
2 weeks. During each the moderator acted as a stimulant
for humor, smiling and laughter using verbal techniques.
After an initial phase, the moderator told or read humorous
stories or suggestive funny anecdotes. The aim was to
trigger the patients’ reactions, observations or comments
by way of personal associations. Where appropriate, the
moderator intervened with provocative or slapstick humour.
Furthermore, happy biographical episodes and memories
were also addressed later on with the aim of creating shared
laughing or smiling. The focus of the humor therapy was the
accentuation of an exhilaration milieu in the group and the
encouragement of everyone’s sense of humor.
In this pilot study, it has been shown that although
the humor intervention reduced depression symptoms,
improved mood, daily living activities and quality of life
for a group of 10 depressive patients, it did so as much
as the standard medication treatment group. In addition,
none of the interventions had any effect on any of the
measures for the Alzheimer group. This study suffered from
many shortcomings, mainly a very heterogenic population
regarding cognitive ability, and that participants participated
in 2–12 sessions thus rendering comparisons impossible as
well as what seems to be an unregulated post questionnaire
administration.
Roller and Lankester [73] described how an open-ended
group for clinically depressed out-patients worked, using
both humor and paradoxical intent during 100–120 1 h
sessions. This intervention was found to be successful for
most of the 80 group participants who succeeded in overcoming
depression symptoms, as determined by achieving
some success in either the discontinuation of medication,
obtaining a job or establishing a positive relationship or
friendship. In this study no control group was used, and
assessment was done on the basis of files only.
3.3. Medical Clowns. Historically and culturally, clowns
have been associated with the well-being of society and
the healing arts. Since the late 1980’s, several clowning
approaches have entered general hospitals with the basic
aim of providing empowerment, a supportive relationship
and the opportunity for play, especially for children, but
also for adults. The techniques used vary widely, not only
between approaches (e.g., clown doctors, therapeutic clowns,
therapeutic play) but also depend upon the clown’s own
abilities.
Although medical clowning is now widespread and in
use in thousands of general hospitals worldwide, very little
research has studied its impact both in pediatric [16] and
cancer [17] ward settings. A literature search, as well as
informal networking, found only two studies assessing the
impact of such an intervention on psychiatric wards.
In a 6-week intervention pilot project involving 27 older
patients with SMI, with affective and psychotic diagnoses,
and 22 staff members, Wild et al. [74], found a positive
change of attitudes regarding the helpfulness of clowns for
improving emotional states in patients. The intervention
included six visits of two clowns in the psychiatric ward
where they both gave a “personal” show (which averaged
8min) for each patient as well as a 30-min group intervention
for 21 of the 27 patients. Six patients refused
any contact with the clowns. The patients were questioned
using a structured nine-item questionnaire developed for
that study, regarding their acceptance of the clowns and
the personal benefit they experienced. In general most of
the 21 patients appreciated the clowns, and their appreciation
grew over time. Nevertheless no control group was
used, the questionnaire only queried the appreciation of
clowns, and not the impact it had on well being, and
the questioning of patients happened at different time
points for each patient making it difficult to assess any real
impact.
A study by Higueras et al. [75] described the implementation
of a bi-weekly clown intervention during two
3-month periods, in a 29-patient closed SMI psychiatric
ward, to assess its impact on disruptive behaviors ranging
from aggression towards self and staff and attempts to
escape the ward. Each session began with warm-up exercises
(marching in different directions in time to a set rhythm,
stretching and dancing), followed by group activities led by
the clowns, and consisting of games, psychomotor expression
exercises, activities based on imaginary situations (imitation
in front of a mirror, charades, playing with an imaginary
ball, visits to an imaginary planet with zero gravity, games
based on invisibility, games based on curiosity). Humor was
an element in all activities, which took place in a setting
of controlled tolerance. At the end of the session, quieter
games were usually played to lower the level of excitement.
Results suggest an overall reduction of disruptive behavior
on all measures assessed. Blind assessments were made
based on standard reports of disruptive behaviors during
the intervention period (n = 101), and comparisons were
made with the period prior to the intervention (n = 83).
There was a significant reduction in the number of disruptive
behaviors during the experimental period. A closer look at
the results showed that fewer people attempted to escape the
ward; there was less agitation, less aggression towards staff,
less self-injury, less fighting and less non-cooperation in the
ward.
6 Evidence-Based Complementary and AlternativeMedicine
4. Discussion
The therapeutic use of humor has grown exponentially over
the last two decades. An abundance of professional and nonprofessional
articles and books have been written on the
subject, interventions have been developed and many websites
are actively promoting this therapeutic modality. The
Association for Applied and Therapeutic Humor (AATH)
includes psychotherapists, psychiatrists, counselors, teachers,
nurses and other health professionals, many of who actively
promote the use of humor in psychiatric settings. A major
conclusion of previous reviews on the general effects of
humor [4, 6, 18] is that humor has a broad range of effects
on perceptions, attitudes, judgments and emotions, which
may mediate directly or indirectly to benefit the physical and
psychological state.
Although a plethora of studies have described its theoretical
underpinnings and its potential use in psychotherapy,
empirical studies regarding the potential therapeutic
use of humor are scant, especially those assessing its
impact on SMI. The studies that have been published have
significant methodological flaws; they either lack control
groups [70, 75], use non-standardized assessment tools
with non-standardized measurement periods [71, 75] or
very small samples [65, 66]. Finally, most studies do not
have an adequate “emotion-evoking” control stimulus for
distinguishing between the effects uniquely attributable
to humor and those attributable to positive emotions in
general.
Humor or laughter is an easy-to-use, inexpensive [66],
natural therapeutic modality that could be used within
different therapeutic settings, with a multi-professional staff
whose impact could, at the least, temporarily alleviate some
of the daily distress experienced by the seriously mentally ill.
It is, therefore, surprising that it has not been widely applied
and researched in psychiatric settings, especially since this
population ismost in need of cost-efficientmeans to improve
quality of life.
The first reason behind the relative lack of development
of humor-related therapeutic intervention in this population
may be the history of professional socialization in psychiatry,
where the focus on emotional distancing, conformity and
hierarchy does not encourage the “risk taking” involved in
humorous encounters with clients [76]. Another reason may
be rooted in the fact that schizophrenic and populations with
SMI have traditionally been considered as impaired in their
ability to enjoy humor, although unjustifiably so [77]. They
have also been perceived as more vulnerable to the anxietyevoking
aspects of humor, thus disliking humor in general
[69, 78] as well as therapeutic interventions incorporating
humor [79]. Another reason may originate in the fact that
humor is not considered “mainstream,” has a “new-age”
unscientific connotation, and may find difficulty receiving
financial support for either an intervention or a scientific
study. Thus, most humor interventions are applied on a
small scale, in “amateurish” ways, and without any scientific
assessment.
A further reason may lie in the emotional potential of
humor to negatively affect a person. Indeed, many therapists
are conscious of the dangers that may accompany the
inappropriate use of humor with SMI patients [36, 37],
as humor (like all therapy) must be used with skill and
sensitivity. For example, in the Stand-Up for Mental Health
intervention, it is important to ensure that patients’ comedy
routines do not become a form of “self-defeating” humor,
and this requires implementation by a skilled clinician (and
not just a comedian).
A final reasonmay originate inWestern European history
of the Middle Ages, when the unholy trinity—the devil, folly
and laughter—were to be burned at the stake [2]. Foucault
[80] observed, in his history of mental illness, that in the
middle ages, the laugh of the madman was the laughter of
death. It is possible that the shrill sounds of the witches’
laughs still echo within our scientific minds.
Therapeutic humor is, therefore, a unique field in that
it is characterized by a discrepancy between clinical practice
and scientific research. On the one hand, a plethora of
therapeutic approaches has been developed, such as the use
of medical clowns, stand-up, paradoxical humor-oriented
approaches, humor training and yoga laughter, and many
leading and innovative therapists have openly advocated and
made use of it and institutionalized it; but on the other hand,
only a handful of studies have been published assessing its
potential for the seriously mentally ill, a population that is
potentially in dire need of life-uplifting experiences.
The present review thus suggests developing empirical
research projects to assess the potential use of these
modalities with mental health clients, and in institutional
settings.
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