Why So Serious: Humor and its Association with Treatment Measurements Process and Outcome (2024)

Abstract: Humor is an important social construct with various roles in human communication, yet clinicians remain divided on its appropriateness and effectiveness. Despite its importance, empirical research on humor in psychotherapy is limited. This study explores the theoretical concept of “humor” by examining the operational variable of “laughs” within psychotherapy. Method: We analyzed transcriptions from 872 psychotherapy sessions involving 68 clients treated by 59 therapists. Clients self-reported their symptoms and state of well-being before each session, while both clients and therapists provided self-reports on their therapeutic alliance after each session. Through text analysis, we extracted the number of laughs and words for each session. We investigated the within-client associations between laughs and symptoms, well-being, therapeutic alliance, and clients’ number of words. Results: We found concurrent session-level associations between laughs and well-being, symptoms, and the number of words. However, no significant associations were observed between laughs and the therapeutic alliance, either from the perspective of the therapist or the client.

## introduction humor offers numerous benefits in everyday life and is often employed to diffuse tension, particularly during intense conversations, such as those in psychotherapy sessions @xcite . @xcite identified humor as one of the character strengths and virtues that contribute to psychological well-being. additionally, humor can be viewed as an emotion, as recognizing something incongruous with one's expectations can evoke feelings of pleasure. over the past four decades, the medical community has increasingly acknowledged the healing power of humor and the positive emotions it fosters @xcite . not everyone has agreed on the beneficial role of humor in therapy. @xcite cautioned that a psychiatrist's use of humor could be potentially harmful to the therapeutic relationship, suggesting that it might lead clients to feel their concerns are not being taken seriously. additionally, freud argued that certain uses of humor reflect underlying aggressive and sexual impulses @xcite . as such, humor can sometimes function as a defense or resistance mechanism @xcite and might be misused by therapists to manage their own anxieties or as a display of narcissistic showmanship @xcite . in a recent review of humor in psychotherapy, hussong and micucci (2020) noted that many therapists continue to believe in humor's therapeutic benefits. for example, humor's capacity to encourage new interpretations or perspectives can help clients reframe the issues that led them to seek therapy @xcite . from a cognitive standpoint, humor may aid in reducing depression by facilitating "rapid perceptual-cognitive switches in frames of reference" @xcite . additionally, humor can be valuable for fostering insight @xcite and promoting cognitive flexibility @xcite . another crucial aspect of psychotherapy, the therapeutic alliance, has been linked to the use of humor, as evidenced by clinical experience. @xcite argues that humor's primary contribution lies in strengthening the therapeutic relationship. he references @xcite , who suggested that humor is closely associated with a strong therapeutic alliance, allowing therapists to demonstrate their humanity and reduce barriers between clients and psychotherapists. poland also noted that humor enables therapists to bridge the gap between themselves and their clients. similarly, @xcite hypothesizes that humor helps clients to open up and engage with their therapist, fostering a bond and reducing the atmosphere of rivalry, threat, and dependency. in line with this, psychoanalyst bader (1993) presented clinical cases showing that a ther-apist's humor can reveal aspects of their internal thoughts, thereby cultivating a sense of safety and confidence in the therapeutic relationship. additionally, @xcite presents intriguing findings suggesting that humor might be an indicator of a healthy therapeutic relationship. in her thesis, she reports that most participants considered their therapists' humor to be beneficial to their therapeutic process. she found a positive correlation between the alignment of clients' and therapists' senses of humor and the overall ratings of their therapeutic relationship. furthermore, she identified a positive correlation between clients' perceptions of the helpfulness of their therapists' humor and their evaluations of the therapeutic relationship. in summary, limited studies suggest a connection between the use of humor in therapy and the enhancement of therapist-client relationships. empirical studies have consistently shown a link between the use of humor in therapy and improved treatment outcomes or reductions in pathological symptoms. for instance, @xcite explored the relationship between humor and various therapeutic outcomes in psychotherapy clients, finding a strong positive correlation between the presence of humor during therapy sessions and their effectiveness, as perceived by both clients and therapists. another study demonstrated that watching humorous movies led to a reduction in psychopathology, anger, anxiety, and depression symptoms, although it did not affect therapeutic alliance scores @xcite . similarly, @xcite found that listening to humorous audio tapes resulted in decreased depression severity among participants. despite humor's potential to enhance therapy, it remains underemphasized in psychotherapy training, and there is a scarcity of empirical research supporting its use as an intervention @xcite . this lack of focus may contribute to some therapists' ambivalence about incorporating humor into their practice. in this study, we aim to expand the current understanding of humor in psychotherapy. while previous research, such as @xcite , has highlighted various methods for measuring humor, the challenge of quantifying humor, particularly in psychotherapy, might explain the limited empirical studies on the topic. nonetheless, it is widely acknowledged that humor can elicit laughs and promote happiness @xcite . in this study, we measure the use of humor in therapy by annotating instances of laughs during sessions. this approach assumes that laughs are clear, identifiable events that can often be traced back to humor. although not all laughs are directly linked to humor, it is generally considered a reliable indicator of humor-related responses. ## method we utilize a dataset of 872 psychotherapy session transcripts from 74 different therapist-client dyads (pairs), constructed by 68 clients and 59 therapists. see the appendix for more details about the participants, treatment, transcriptions, and ethical concerns. within these transcripts, we extracted a total of 10,454 laughs (mean per @xmath0.98, @xmath1. the extraction process involves analyzing the transcribers' comments regarding paralinguistic events using a specialized paralinguistics lexicon "joy". this lexicon includes terms such as "laughs," "amused," "with humor," "giggling," etc. that transcribers used to describe what they hear @xcite . 1 before each session, clients self-reported their functioning using the ors questionnaire @xcite which is considered to be an indicator of treatment progress, and selfreported their symptoms using the hscl questionnaire @xcite which represents the global symptomatic level experienced by the client over the past week. after each session, therapists and clients reported their perspectives on the relationship quality during each session, measured by the wai questionnaire @xcite ; see the appendix. ## results for each session, we extracted the (1) number of laughs, and (2) number of client's words. the means, standard deviations, and ranges for all the variables are presented in because the data had a multilevel structure (sessions nested within treatments; bolger and laurenceau, 2013), we used multilevel models (mlm, using r lme4 library (bates, 2010), using function lmer) also known as hierarchical linear models. these models allow estimation of two levels, a within-treatment level, and a between-client level, and accommodate non-balanced data @xcite . to examine the concurrent within-treatment associations between the laughs variable (laughs) and session-level treatment measures: outcome measured by ors (hypothesis 1a) symptoms measured by hscl (hypothesis 1b), therapeutic alliance measured by wai (hypothesis 1c), and the number of client's words (hypothesis 2), we applied a multilevel model predicting the session level treatment measure (client mean-centered) by the number of laughs used by the client and therapist in the session. the mixed-level equation was as follows: t reatment_m easure d s for a dyad d in session s is predicted by the sample's intercept (γ 0 0 ), by dyad d's deviation from this intercept (u d 0 ), by the average (i.e., fixed) effects (γ 0 1 ) of the predictors, by this client's deviation from the fixed effects (i.e., the random effects: (u d 0 , u d 1 )), and by a level-1 residual term quantifying the session's deviation from these effects (i.e., the random effect at level 1, e d s ). the results of the multilevel model summarized in ## discussion laughs were associated with better treatment outcomes, aligning with @xcite . while we cannot establish a causal relationship, this suggests that laughs during therapy may contribute to improved client functioning. we propose that laughs may indirectly enhance social competencies, thereby boosting interpersonal skills @xcite . in this way, laughs in therapy-distinct from laughter therapy-can serve as a social tool that clients learn in therapy and later apply in their social lives. this potential benefit is reflected in ors, which assesses social functioning. laughs were associated with lower levels of the client's symptoms. the current study does not allow us to determine whether it is laughs that lower the level of symptoms or a low level of symptoms that increases the amount of laughs. previous studies support the conclusion that laughs may help reduce symptoms of mental disorders such as anxiety and depression @xcite . this may indicate that laughs provide a release for the client, as supported by medical and psychological studies on the psychophysiological effects of laughs @xcite . no association was found between laughs and the therapeutic alliance. this finding does not correspond with @xcite ; @xcite . however, the findings are compatible with the study of @xcite , which found no significant associations between the effect of humorous movies and the therapeutic alliance. to the best of our knowledge, there has not yet been any empirical study that examines the associations between laughs in psychotherapy and therapeutic alliance. laughs in treatment were associated with higher verbalization among the clients. this finding corresponds with providing assumptions in the literature that humor helps the client open up @xcite , and feel more comfortable with the therapist @xcite . @xcite claimed that previous research in laughs and psychotherapy has focused almost exclusively on the client. this study examined the role of laughs in general (of both therapist and client) in treatment. to gather evidence on whether the therapist's use of humor is positive and beneficial, further research is needed. in a future project, we aim to investigate whether the therapist influences the client's degree of laughs, whether humor increases throughout treatment, and how it relates to treatment outcomes. ## limitations the current work acknowledges that laughs can arise from various emotions beyond humor, such as nervousness, embarrassment, and other emotional states. however, laughs were annotated regardless of whether they occurred due to humor. we used "humor" as a motivation for the study but did not address the implications of humor in the present study. we limited our findings to "laughs" only. future work is needed to determine how frequently laughs might occur due to non-humorrelated reasons, and how this could potentially impact the results. specifically, how these alternative sources of laughs might influence the conclusions and associations drawn regarding humor.