The Clinical Supervisor

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Learning to Use Humor in Psychotherapy

Camilo Ortiz PhD

To cite this article: Camilo Ortiz PhD (2000) Learning to Use Humor in Psychotherapy, The
Clinical Supervisor, 19:1, 191-198, DOI: 10.1300/J001v19n01_13

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Published online: 22 Sep 2008.

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 Learning to Use Humor in Psychotherapy
Camilo Ortiz

ABSTRACT. The use of humor in psychotherapy is a controversial

topic, with some therapists supporting its use and others warning
against its risks. For therapists in training, using humor and lightheart-
edness effectively can be particularly difficult because of the anxiety
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that most beginning therapists feel. However, humor can be useful for
trainees precisely because it helps to reduce the self-doubt that is com-
mon among beginners. In this paper I discuss how I used humor to help
a client with obsessive compulsive disorder while at the same time
helping myself to grow as a therapist. [Article copies available for a fee from
The Haworth Document Delivery Service: 1-800-342-9678. E-mail address:
<getinfo@haworthpressinc.com> Website: <http://www.haworthpressinc.com>]

KEYWORDS. Humor, therapists-in-training, OCD, behavior therapy,

psychotherapy, therapeutic bond, lightheartedness

Learning to conduct psychotherapy is both confusing and exhilarating for

a psychology trainee. At the beginning of my second year as a doctoral
student in clinical psychology, I was gently yet forcefully thrust into the
therapy room by my supervisors and told to ‘‘be myself’’ with my clients.
While I now recognize that this experiential type of learning is probably the
best way for a beginning therapist to learn, at the time I felt naked and
incompetent. In response to these feelings I found it difficult to be myself
during sessions. As a result, I closed myself off emotionally to my first few
clients. In sessions I was serious and academic and kept my clients at an
emotional distance. In this paper I describe the process through which I
altered this style of being with my clients. In particular, I discuss the case of

Camilo Ortiz, PhD, is a Postdoctoral Research Associate, Department of Psychol-

ogy, State University of New York at Stony Brook, Stony Brook, NY 11794-2500
(E-mail: cortiz@psych1.psy.sunysb.edu).
The Clinical Supervisor, Vol. 19(1) 2000
E 2000 by The Haworth Press, Inc. All rights reserved. 191
 192 THE CLINICAL SUPERVISOR

‘‘Bill,’’ a man suffering from Obsessive-Compulsive Disorder (OCD), and

the lessons I learned as I let go of my old style. My breakthrough of sorts
involved adopting a more lighthearted and humorous approach to interacting
with my clients. This approach permitted me to open up a bit more to my
clients, which in turn allowed me to better connect with them.
The use of humor in psychotherapy is a controversial topic, with some
therapists supporting its use and others warning against its dangers. Rosen-
heim (1974) referred to the use of humor by therapists as ‘‘indispensable,’’
(p. 590) while Kubie (1971) spoke of it as ‘‘a dangerous weapon’’ (p. 861).
However one feels about using humor in psychotherapy, it is a topic that has
been receiving increased attention recently (e.g., McGuire, 1999; Buckman,
1994; Nilsen, 1993).
Several authors have written about their view of humor in psychotherapy
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by incorporating case examples (e.g., Richman, 1996; Bader, 1993; Haig,

1986; Prerost, 1985). In that respect, my approach in the present paper is not
new. However, I seek to give a perspective on using humor in psychotherapy
from the view of a therapist in training. Therapists in training face a unique
set of obstacles in trying to help their clients. They face the inherent difficulty
of making psychotherapy successful often while dealing with intense feelings
of self-doubt. It is argued by some that using humor may be a particularly
important skill for novices to master, making this topic particularly relevant
to trainees. The present paper is also distinct from most on this topic because
I use a case example of a client treated with behavior therapy for OCD. Most
works on this topic have incorporated cases which involved long-term, in-
sight oriented psychotherapy. As I will describe, the first line treatment for
many clients with OCD, time-limited exposure and response prevention, is
fertile ground for the use of humor and lightheartedness by therapists.
While there are notable exceptions, most writers on this topic espouse the
use of humor in psychotherapy. Haig (1986) sums up many constructive
aspects of humor that have been referred to in the literature, such as fostering
the therapeutic alliance, reducing client anxiety, breaking through resistance,
making interpretations more acceptable to the client, and helping the therapist
to deal with difficult topics. These and other supposed benefits of using
humor that are cited in the literature are based mostly on anecdotal evidence.
In response to the subjective nature of much of the writing on this topic, some
investigators have attempted to settle the question empirically regarding
whether humor should be used in psychotherapy. However, the findings of
such studies are difficult to condense into an unequivocal recommendation.
For one thing, most of these studies were doctoral dissertations that were not
subsequently published in peer reviewed journals. One reason for the paucity
of published empirical studies on the topic of therapists’ use of humor may be
the inherent difficulty of doing such research. Humor is by nature a phenome-
 Special Section 193

non that is subject to individual/personality differences and also dependent

on the situation. Conducting humor research with high internal validity, such
as by having some therapists use a lighthearted tone while others do not,
invariably leads to problems with external or ‘‘real life’’ validity. Therefore,
this paper will not rely heavily on empirical data in its analysis of humor in
psychotherapy. Readers interested in such a discussion are urged to read
Shaughnessy and Wadsworth, (1992) and Saper (1987).
Despite the difficulty of empirically supporting the value of therapists’ use
of humor, many therapists strongly encourage its use. For instance, Albert
Ellis and many therapists who practice Rational Emotive Behavior Therapy
(REBT) often use humor with their clients. This tendency to use humor
comes from the belief that clients often unknowingly exaggerate the serious-
ness of their problems and of life in general. Clients are urged to take ‘‘a
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serious but humorously ironic attitude to life’’ (Ellis & Dryden, 1997, p. 28).
In fact, REB therapists sometimes have their clients sing humorous songs
poking fun at their own irrational beliefs with the hope that as clients see the
absurdity of their beliefs they will adopt more rational ones.
In Marsha Linehan’s Dialectical Behavior Therapy (DBT), therapists use
so called ‘‘irreverent communications.’’ These are humorous and offbeat
statements that are made in order to get clients to see things in a totally
different way. These statements are particularly useful when a client and
therapist feel stuck in their work to overcome a particular problem. For
example, she suggests that for clients who use ‘‘diversionary dysfunctional
traumas’’ when confronted with anxiety-provoking topics, an appropriate
irreverent communication might be ‘‘Do you want help with your real prob-
lems or not?’’ or ‘‘Oh, no! Another soap opera’’ (Linehan, 1993, p. 396).
Linehan is careful about using these strategies, suggesting that they must
always be couched with validation and genuine concern to avoid the impres-
sion that the therapist is being rejecting.
During my own training as a therapist in a clinical psychology Ph.D.
program, I was often encouraged to take a more cheerful approach toward
helping my clients. At the start of my training I had been under the impres-
sion that therapy was a completely serious endeavor and that a therapist
should be straight-faced whenever possible. I quickly realized that this ap-
proach was making most of my clients uncomfortable, which was reducing
the effectiveness of their treatment. I also came to understand that I was using
this style of interacting with my clients in part because I felt protected behind
a façade of seriousness. Without this ‘‘act’’ I felt that my clients would see
through me and conclude that I was incompetent, and a phony. After much
thought I came to the conclusion that I had to force myself, in a self-imposed
behavioral flooding of sorts, to let down my guard in order to improve as a
psychotherapist. I realized that I would be initially more uncomfortable than
 194 THE CLINICAL SUPERVISOR

if I continued with my current style, but that in the long run, I would be a
more effective therapist.
The case example that follows describes my initial attempt to adopt a more
lighthearted and humorous tone, thereby allowing myself to use a fuller range
of expressed emotion with my clients.

THE CASE OF ‘‘BILL’’

After a thorough assessment, I concluded that ‘‘Bill,’’ a 25-year-old, Euro-
pean-American man suffered from Obsessive Compulsive Disorder. Bill felt
highly anxious when he was around people or things that he considered
‘‘dirty.’’ Bill also felt a high degree of anxiety when objects around him were
not arranged symmetrically. To relieve this anxiety Bill would spend several
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hours each day performing rituals. For example, he would take up to six
showers a day and avoid contact with people and things that he considered
dirty. He would also arrange his belongings in ways that were highly sym-
metrical and orderly, spending large amounts of time sorting his clothes by
size, color, and texture. Bill recognized the irrationality of his behaviors, yet
felt powerless to stop performing them.
I began treating Bill with exposure and response prevention. In response
prevention, the client makes an agreement with the therapist to stop ritualiz-
ing as a means of relieving the anxiety associated with the client’s obsessions.
Nothing funny about that! In exposure the client is gradually exposed, in vivo
or with imagery, to the things and situations that cause the client anxiety. The
client is then supported and encouraged to cope with the anxiety in a more
constructive manner than by ritualizing. For Bill’s in vivo exposure, he and I
developed a hierarchy of things and situations that made him feel anxious,
and I assigned him ‘‘homework’’ to do between our sessions that involved
facing these fears. For example, I would ask Bill to mix up the order in which
he hung his clothes, mixing colors, sizes, and textures. I would also ask Bill
to walk outside on the grass barefoot in order to get his feet dirty. Bill and I
also did imaginal exposure in which he and I developed scenarios of situa-
tions that made him very anxious in real life. I would have Bill close his eyes
and I would describe these scenarios back to him. He would sit with his
anxiety until it declined naturally, without the aid of rituals.
Using humor with clients who suffer from Obsessive Compulsive Disor-
der is common (e.g., Riggs & Foa, 1993; Steketee, 1993). Steketee (1993)
observed that humor can be used to put the client at ease about facing the
objects and situations that cause the anxiety associated with OCD. For many
clients with OCD, laughing at their fears is an important step in being able to
conquer them. There are, however, two main cautions to keep in mind about
using humor in exposure situations. First and most importantly, since the goal
of exposure is to habituate clients to the feared object or situation, anything
 Special Section 195

that distracts clients from focusing on the feared stimulus can reduce the
effectiveness of the therapy (Rodriguez & Craske, 1995). Therefore, if the
humor is unrelated to the task at hand, the humor probably will not be
effective. Second, clients with OCD are often embarrassed and ashamed
about their disorder, making them highly sensitive to the reactions of others.
There is a danger that they may feel that the humor is in some way meant to
disparage them. Steketee (1993) suggests that humor may best be used at the
start of treatment. In the later stages of therapy, when clients are facing the
most anxiety-provoking objects or situations on their fear hierarchy, the use
of humor should be minimized and empathy and support should be increased.
During Bill’s treatment there were ample opportunities for the construc-
tive use of humor. We often used humor when deciding on the homework Bill
would attempt between sessions. Specifically, Bill and I would play ‘‘detec-
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tive’’ surrounding his anxiety and resistance over completing the homework
assignments. Bill, like many people who suffer from OCD, was very good at
finding loopholes in the agreements he made to avoid rituals. For example, he
might declare to himself that, because of the special numerical properties of
the current month, getting dirty would be allowed on the second Monday of
the month. This kind of thinking would allow him to comply with homework
assignments, while still behaving compulsively in order to relieve himself of
anxiety. Bill and I would try to anticipate what loopholes he might try to use
to get out of doing his homework. This detective work took on a humorous
and collaborative tone as Bill would let me in on his many ‘‘tricks,’’ and I
would compliment him on his honesty and creativity in finding ways out of
the homework.
Incorporating humor into the exposure images was also helpful. In fact,
inserting humor into exposure exercises has been suggested in the OCD
treatment literature (Riggs & Foa, 1993; Steketee, 1993) as well as in the
treatment of other psychological problems (e.g., Prerost, 1985). The process
of constructing these scenarios was anxiety provoking for Bill, and humor
made the process more bearable. During exposure, humor is often used to
help clients deal with feared stimuli that initially seem too difficult to face.
By using humor, clients can also be shown that they can face the most anxiety
provoking situations. This gives them the confidence to face less fearsome
situations.
In one set of scenarios we focused on Bill’s fear of associating with people
whom he considered to be ‘‘unclean’’ or ‘‘shady.’’ Bill believed that such an
association would begin a vicious cycle whereby he would become shady
himself. When we were in the process of constructing the anxiety provoking
scenarios to battle this particular obsession, I would say to Bill with a smile,
‘‘OK, let’s think of the shadiest, slimiest, corniest people you can possibly
imagine.’’ He would smile back wryly and start describing these characters in
 196 THE CLINICAL SUPERVISOR

great detail. The construction of the scenario went from a potentially difficult
and unpleasurable experience to a kind of contest in which Bill was chal-
lenged to use his vivid imagination to describe the most outlandish people he
could imagine. On one occasion Bill described a tall and lanky man dressed
in two-foot wide bell-bottom jeans and a thin yellow polyester shirt with a
collar that stretched from shoulder to shoulder. This character also wore
mounds of costume jewelry and foot-high platform shoes, and he had an
outlandish hairdo four feet across. He described the man dancing very badly
while trying to pick up equally outlandishly dressed women. Bill and I had a
good laugh at the fantastic image he had proposed. For Bill the ability to
laugh at what made him anxious was a major step in mastering and coping
with his anxiety in a way that was less destructive than were his compulsions.
I think that this type of therapy would have been unbearable for Bill had I
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persisted in handling it in a completely serious manner. Therapy might also

have been too difficult for Bill had my use of humor not been couched with a
great deal of empathy. I think that if I had been lighthearted without commu-
nicating to Bill that I also understood his terror at facing these anxiety pro-
voking situations, I would have lost the collaborative nature of our work.
The tenor of these sessions, as well as Bill’s humorous examples, helped
him with his OCD and also helped me with my own anxiety. I was able to let
go of my rigid efforts to remember all the ‘‘rules’’ of therapy, as I was
learning to be myself. I was better able to better connect with Bill and
empathize with how difficult constructing these scenes was for him. Some
have argued (e.g., Kubie, 1971) that humor, particularly for beginning thera-
pists, is dangerous precisely because of the anxiety that novices tend to feel
about conducting psychotherapy. Kubie states that therapists may use humor
to deny the anxiety that they themselves feel and to express hostility and
aggression toward their clients.
I can understand how a beginning therapist might use humor to express
unconscious hostility toward clients. However, as Coleman (1971) points out,
a therapist who is overly solemn with clients may be acting out aggression
and hostility as well. In my case, as I discussed above, I had been using
solemnity as a defense against my own nervousness. Using humor facilitated
a decrease in my nervousness which proved to be liberating for both myself
and my client.
For similar reasons, Coleman (1971) suggested the use of humor to the
therapists whom he trained. He proposed that when therapists are humorous
and use banter with their clients, the therapists are freed ‘‘to deal spontane-
ously and flexibly’’ with their clients (p. 119). Likewise, Bader (1993) points
out that a solemn therapist may, for some clients, ‘‘reinforce certain patho-
genic expectations and fantasies rather than help the patient face and work
through them’’ (p. 43). In other words, clients who have been hurt by with-
 Special Section 197

holding people may, according to Bader, relive those injuries with a stern
therapist, perhaps leading to increased resistance or dropout.
I have come to several important realizations during the process of becom-
ing more emotive with my clients. First, I realize that although beginning
therapists may try desperately, we cannot avoid our own feelings of terror and
incompetence when we confront our first clients. These feelings of nervous-
ness are so common in fact that Shapiro (1995) coined a mock psychological
disorder to describe this phenomenon called ‘‘fledgling therapist disorder.’’
This ‘‘condition’’ is characterized by such symptoms as ‘‘fear of being ex-
posed for the fraud she or he is, excessive beliefs that she or he was accepted
to graduate school in an accident involving the cosmos, the United States
Postal Service, and the registrar’s office of one’s undergraduate institution,’’
or ‘‘inability to function as a therapist without one or more of the following:
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white lab coat, clipboard, pencil (previously categorized as Untherapeutic

Item Dependence)’’ (Shapiro, 1995, p. 459). Following my experience with
Bill, I came to realize that these ‘‘symptoms’’ are not the hallmarks of a poor
therapist. Rather, I think that a therapist’s inability to explore feelings of
anxiety and inadequacy and adjust one’s behavior accordingly are the mark-
ers of a mediocre therapist.
Second, with regard to humor, I concluded that in the correct context,
humor can significantly improve the therapeutic alliance. Humor, when used
sensitively and selectively, can also enrich the therapy and help clients put
their problems into perspective. Finally, for trainees in particular, taking a
more lighthearted attitude can lower their own anxiety while allowing them
to be more effective therapists.
In summary, while the risks of using humor should always be kept in
mind, incorporating a sense of lighthearted warmth in clinical work can
enhance the characteristics of sensitivity and humanness associated with
being a good, effective, and caring therapist.

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Haig, R. A. (1986). Therapeutic uses of humor. American Journal of Psychotherapy,
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 198 THE CLINICAL SUPERVISOR

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