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] as well 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].