Most of us had lives previous to becoming therapists. After undergraduate in San Francisco, I moved to Los Angeles where I undertook stand-up and comedy writing. I then blinked my eyes, nine years passed, and I was thirty. At my birthday lunch I watched an older friend, who by all accounts had “made it” as a comedy writer, whiskey-nurse his latest out-of-work ulcer. I decided that lunch to go back to school, but I never forgot comedy.
What’s So Funny?
It’s sometimes difficult to picture humor itself as an intervention, but I believe it can be a powerful way to connect with our clients. I openly invite humor into the therapy room, because it often feels like our expected seriousness as therapists paradoxically pushes away our client’s chance for deeper reparative emotional experiences. I chuckle when I think about the archetypal, uber-serious psychiatrist, Dr. Leo Marven, from the 1991 comedy film “What About Bob?” I wonder how safe his clients felt in session with him. He sets up a clear power differential with his cold, lawyer-esque office to convey he’s there to “fix” clients. Of course this hilarious movie purposefully conveys the ridiculousness of Richard Dreyfuss as a self-important psychiatrist, but it also shines a light on the near impossibility for deep therapeutic work when clients fear our clinical stature.
I am not suggesting that we respond to all client tragedies with our best one-liner; humor must be sensitive and thought through.  As with any other intervention I rely on clinical judgment when assessing a client’s openness to humor. One day, a long-time client of mine, Rachel, sat across from me in session teary-eyed. She had just spent a solid five minutes weeping over a recent break-up, and I could see that both her body and mind were exhausted. Instead of reaching for my Kleenex box to wipe her face, Rachel pulled from her purse a half-used roll of toilet paper. I watched as she unrolled a solid foot of it. She looked up at me, my head tilted as I watched her with a slight smile on my face. At that, Rachel burst into laughter. I then remarked “I’d like to thank you for your Kleenex Conservation efforts, Rachel. I was running low.” In that exchange, my smile and humor reflected back both an acknowledgement of Rachel’s exhaustion, and prompted her much-needed emotional shift.
Uniform humor is not appropriate across the board however. I would not have used this same intervention with a new client. What if she didn’t have the ego-strength for this sort of acknowledgement? What if her parent had just passed away, or she feared being put on the spot? This joke worked to deepen an already established therapeutic relationship that took time to build. I always monitor for intentionality and appropriateness when integrating humor into sessions. Properly executed, I’ve witnessed humor reduce high levels of depression and anxiety in the room.
With reference to anxiety, I’ve used humor to address some very large elephants in the room. For example, working with traumatized, minority and underprivileged youth, you bet some of these kids size me up at the first meeting. Many of them have been deeply wounded by negative experiences with “The System”, be it the school system, Child Protective Services, or Juvenile Justice. And, to them I am simply a white, privileged extension of this oppressive system. I learned quickly the only way to gain trust and connect with these kids is through authenticity and transparency. I give them both. Once instance, 17-year-old Daryl came into my school-based office for an initial session. He sat down, looked at the ground, and muttered “hey”, pulling his hoodie over his head. His hypervigilence was palpable. After a few shrugs for answers I stopped asking questions and sat back in my chair.
“Daryl”, I said quietly, “I wanna tell you a secret.”
His eyes peered from behind his hoodie with reserved interest.
“Daryl. I’m a short-white-Jewish lady…”
He looked at me incredulous. A moment passed. He then put his fist in front of his mouth, dropped his head, and started laughing.
“No she didn’t”, he said.
“Oh, I totally just did. Are we ok?”
He looked back at the ground. “Yeah, we cool”.
That joke expressed my respect for Daryl by naming the elephants of disparity such as privilege, gender, and race. I modeled owning who I am for Daryl while establishing my humble intent to hear his story.
How Does Laughter Work in the Therapy Room?
Laughter enhances attachment between therapist and client both explicitly (consciously) and implicitly (unconsciously). Explicitly, when we laugh in the room we convey our humanity and humility to clients. We express that we are not thera-bots merely seeking to “fix” them, but instead, like our clients, complex beings with many sides, one of them being silly. I’ve been stunned by how expressing my humanity through a quick quip reduces a client’s need for defense.
Implicitly, synching up with a client’s nervous system through humor works to reduce anxiety and depression, increasing one’s capacity to feel the pleasure needed for a developing, healthier self-regulation. I base this neuro-psycho-biological power of laughter on, among other sources, the Modern Attachment Theory teachings of Dr. Allan Schore. Dr. Schore consistently provides breaking research on the effects of early attachment trauma on the brain. In his paper, “Attachment and the Regulation of the Right Brain” (2000), he explains that because a baby’s central nervous system continues to develop postnatally, one key early task for a primary caregiver is to co-regulate the child’s nervous system through right-brain-to-right-brain attachment behaviors. This right brain implicit attachment (differing from left brain explicit attachment) must include a capacity to both upregulate the child (create pleasure) and downregulate the child (soothe distress). Ideally over time, the child internalizes this modeling, learning how to self-regulate. If these attachment tasks are not met, that child may be thrown into emotional dysregulation, which compounded over time, leads to many of the mental health issues presented in our rooms. Based in this concept of neurobiological primary attachment trauma , one of my goals in therapy is to help repair emotional dysregulation beneath presenting issues. Over time I work with my clients to help repair attachment trauma through conscious and unconscious empathetic connection via syncing up right-brain-to-right brain, helping them hone tools for self-regulation.
Clinicians often focus on downregulating clients when presented with heightened anxiety. Indeed, quick breathing and bouncing knees call for some grounding exercises. Equally as important in co-regulation, however, is a clinician’s ability to upregulate their client’s nervous system. This is where humor comes into play. It works as a chain reaction enhancing attachment between therapist and client, reducing anxiety and depression, which then increases a client’s capacity to experience authentic praise. This praise then works to elevate self-worth, which ultimately reduces presenting issues. In addition to co-regulation, Judith Nelson (2008) explains that humor in the room may provide “clues about attachment style, patterns of affect relation, (and) attachment history (pp. 47)”.
That’s Not Funny. Avoiding Humor in Therapy.
Can humor in the therapy room hurt clients? Any intervention can do this, especially if it’s overused, careless, or inappropriate. One popularized opponent to humor in therapy was the late Psychoanalyst Lawrence Kubie. Kubie (1971) expressed his concern claiming humor may heighten a client’s resistance, muddle therapist-client relationship, and/or encourage a client to mask feelings. I half agree with this idea. I do think inappropriate, thoughtless jokes have the potential to injure clients and I strongly advise against them. However, with or without jokes, therapists make mistakes in the room all the time. Additionally, a client’s negatively distorted perception may twist around anything a therapist says or does (humorous or not) resulting in damaged rapport.
The majority of arguments made against using humor in the therapy room are not against using humor overall, but rather the use of specific forms of humor such as sarcasm or self-defeating humor. Though Albert Ellis was known to promote the use of sarcasm as reality testing in his Rational Emotive Behavior Therapy (REBT), I find that sarcasm is most often used to deride others. Even in everyday life, that style of funny tends to go over poorly. No one is a fan of being mocked.
That’s Only Sort of Funny. When Clients Make Jokes.
I keep my eyes open to all variations of defense, laughter included, when sitting with some of the darkest trauma out there. Most of us have seen and heard this darkness, horror stories our clients have told us with blank or incongruent affect. A client laughs and we wonder what she could possibly be finding funny. My 24-year-old client Ana once sat across from me, describing how she would systematically cut five vertical lines into her leg. She then giggled, adding: “I’ve been thinking of switching it up to four vertical lines with a diagonal slash to indicate five.” I sat in silence with her for a while after that, allowing her space to access the probable despair beneath her masked smile. This would not be a time that I joined in with her humor, but instead a reminder of one of humor’s important functions: Survival.
Viktor Frankl, in his book “Man’s Search for Meaning” (1963) describes in dreadful detail his daily life as a prisoner in the Auschwitz Concentration Camp. He poignantly observes the use of humor to survive, explaining that it helped prisoners find a sense of meaning and purpose in their lives even with death and disaster all around them. When faced with trauma and grief we humans try to make sense of the senseless. And when we can’t, we sometimes cope by making fun of it. One of my favorite quotes from Frankl’s book remains: "Humor, more than anything else in the human makeup, affords an aloofness and an ability to rise above any situation, even if only for a few seconds (pp. 54)." A client’s ridiculous exaggeration and mocking of trauma for the purpose of comic relief may be exactly that: a moment of relief as they processes deep pain.
Psychologist Rod Martin (2006) surmises that research on the effects of humor in therapy is limited running the gamut of negative, neutral, and positive results. I’ll add that each clinician’s unique mixture of educational background and clinical style colors any intervention implemented, including humor. As clinicians we get to choose what style of humor to use and when to use it. We must be thoughtful and appropriate with its use and prepared for our clients’ reactions, as well as their dishing it out. If you’ve never thought of using humor in therapy and the opportunity presents itself, consider trying it. It may create a new pathway of both conscious and unconscious empathetic connection. If a joke does go south, as with any therapist-client conflict, your bomb may provide the opportunity for a reparative emotional experience through processing that disconnect.
A good starting position on your clinical humor journey is having a solid idea of what therapeutic humor is. The Association for Applied and Therapeutic Humor created a great definition: “…any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life's situations. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, or spiritual (2014)”. Essentially, don’t be a stick in the mud. Life can be funny and it’s ok to laugh when it is. Using this base, connect with your authentic self as a clinician, have fun, and laugh.
Shifting away from the comedy world was challenging; any life transition typically is. I cannot deny the feelings of intoxication brought on by audience laughter. However for me, it felt like empty validation. Only a caricature of myself was connecting with an audience hardly visible though stage lights. Laughing with my clients now, I’m not pulling laughs. I’m sharing them. It just feels more satisfying. 
Jessica Levith currently runs a private practice in Oakland, CA. For more information or to set up an appointment, you can contact her at 510.883.3074 or east-baytherapy.com.
Association for Applied and Therapeutic Humor [Website]. (2000). Retrieved (2014) from http://www.aath.org/general-information
Frankl, V. E. (1963). Man's search for meaning: an introduction to logotherapy, pp. 54. New York: Washington Square Press.
Kubie, L. S. (1971). The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 127(7), pp. 861–866.
Martin, R. (2006) The psychology of humor: An integrative approach, pp. 346- 349. Burlington, MA: Academic Press.
Nelson, J. (2008). Laugh and the world laughs with you: An attachment perspective on the meaning of laughter in psychotherapy. Clinical Social Work Journal, 36, pp. 41-49. doi: 10.1007/s10615-007-0133-1
Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2, pp. 23–47.
 CAMFT lawyers remind me of this.
 For the unabridged super-complicated brain-jargon masterpiece, see referenced article.
 Only one clinician was harmed in the writing of this article. Me. Editing can be brutal.