Community Ment Health J (2014) 50:737–742
DOI 10.1007/s10597-013-9685-4
ORIGINAL PAPER
Humour-Related Interventions for People with Mental Illness:
A Randomized Controlled Pilot Study
Abraham Rudnick • Paul M. Kohn •
Kim R. Edwards • David Podnar • Sara Caird •
Rod Martin
Received: 3 September 2012 / Accepted: 6 December 2013 / Published online: 12 December 2013
 Springer Science+Business Media New York 2013
Abstract This study explored the feasibility and effects
of humour-related interventions for mentally ill adults.
Twelve, randomly assigned, participated in each of 3
arms—stand up comedy training (the experimental arm),
discussing comedy videos (the active control arm), and no
humour-related intervention (the passive control arm).
Quantitative and qualitative data were collected at baseline,
end of interventions (3 months) and follow up (after
another 3 months). Scale comparisons were largely nega-
tive, although self-esteem marginally increased in the
experimental arm. Interview responses indicated benefits
for the interventions, including improved self-esteem in the
experimental arm. These results, though mixed, justify
further study.
Keywords Coping
Humour
Mental illness

Self-esteem
Stand up comedy
A. Rudnick (&)
Department of Psychiatry, Vancouver Island Health Authority,
The Island Medical Program and University of British Columbia,
642-2334 Trent Street, Victoria, BC V8R 4Z3, Canada
e-mail: abraham.rudnick@viha.ca; harudnick@hotmail.com
P. M. Kohn
Department of Psychology, Faculty of Health, York University,
Toronto, ON, Canada
K. R. Edwards
D. Podnar
S. Caird
Western University, London, ON, Canada
R. Martin
Department of Psychology, Western University, London, ON,
Canada
Introduction
Humor can enhance mental health in the general population
(Martin 2007). It has been suggested that humor-based
interventions may confer mental health benefits on indi-
viduals suffering from mental disorders. However, research
along these lines has been quite limited to date and findings
have been mixed. In a study by Gelkopf et al. (1993),
hospitalized patients with long-standing schizophrenia
watched either comedy movies (n = 17) or serious dra-
matic movies (n = 17) daily for 3 months. Subsequent
analyses revealed that those who had watched the comedy
movies were rated by hospital staff as having significantly
lower levels of anxiety, depression, verbal hostility, and
tension. However, no treatment-related differences were
found on self-rated mood or psychiatric symptoms, physi-
ological measures, or cognitive functioning. In a study of
elderly residents of a long-term care facility, no significant
differences in self-reported mood were found after 6 weeks
of watching humorous (n = 12) versus non-humorous
(n = 12) feature-length movies 3 days per week; both
movie-watching groups showed similar improvements in
mood over the course of the study (Adams and McGuire
1986).
An important limitation of these previous intervention
studies is that participants were only passively exposed to
humorous films, rather than being provided with training in
the creation of humor. More positive benefits may be
obtained with interventions aimed at helping individuals to
develop their own abilities to create humor by taking a
humorous perspective on their personal problems and dif-
ficulties, and communicating this humor effectively to
others. In a recent non-controlled study on humor (Fal-
kenberg et al. 2011), six patients with major depression
participated in an 8-week group training program designed
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to improve humor-creating abilities. There was short-term
improvement in mood and an increase in participant
awareness regarding the use of humor for coping with
stress. We know of no controlled study of such
interventions.
The purpose of our research was to conduct a random-
ized controlled pilot study of the feasibility and effective-
ness of humor-related interventions for people with various
mental illnesses, specifically comparing stand up comedy
training, watching (and discussing) comedy videos, and
treatment as usual. The Health Sciences Research Ethics
Board of the local university approved the study, and
voluntary informed consent was obtained from all the
participants.
Questions and Hypotheses
Quantitative questions of this study concerned comparisons
among the two humor intervention study arms and the
treatment as usual control study arm in scores on a battery
of self-report measures at baseline, at the end of the
12-week interventions, and at 3-month follow-up. In rela-
tion to these questions, we hypothesized that psychiatric
symptoms, stress, functioning, life satisfaction, self-
esteem, self-efficacy, and mood would improve with humor
interventions more than in the treatment-as-usual control.
In addition, it was expected that an active humor inter-
vention (standup comedy training and performance) would
improve these outcome measures more than a passive
humor intervention (comedy DVD watching and related
discussion). Finally, we predicted that the more positive
uses of humor (i.e., self-enhancing and affiliative humor,
used, respectively, to cope with stress and enhance rela-
tionships with others) would be associated with better
outcome scores whereas the more negative humor styles
(i.e., self-defeating and aggressive humor, used, respec-
tively, to make others laugh at one’s own expense and to
make fun of others) would be associated with worse out-
come scores.
Qualitative questions of this study were: (1) What is the
experience of people with mental illness participating in
active (standup comedy training) and passive (comedy
viewing and discussion) humor-related group interven-
tions? (2) What are participants’ behaviors during such
interventions?
Methods
Design and Sample
This was a randomized controlled pilot effectiveness study
with a mixed—quantitative and qualitative (primarily
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Community Ment Health J (2014) 50:737–742
focused ethnography)—methods evaluation approach
(Creswell 2007). Participants were recruited from the
community by advertising in local mental health care
organizations (hospitals and community agencies) and
were then randomly assigned to a group of 12 participants
with diagnosed mental illness in each of the 3 study arms
(with one participant moving from the passive control arm
to the experimental arm early on due to an error; possible
contamination from which was not noted): (1) Experi-
mental arm—stand up comedy training with a public per-
formance at the end of training (the experimental arm),
facilitated by a professional comedian who is also a pro-
sumer (mental health care counselor who also has a mental
illness) and who provided this training by smart board via
Skype weekly other than in person once a month. The
training consisted of learning how to generate and perform
effective jokes using the facilitator’s published approach
(http://www.thehappyneurotic.com) with feedback from
the facilitator and the other members of the group; (2)
Active control arm—watching and discussing comedy
videos (the active control arm), facilitated weekly by a
graduate student in psychology. During the initial group
session, participants were asked to rate a list of well-known
comedy videos based on which ones they believed were
most likely to make them laugh. The video selections were
then rank-ordered by popularity, which served as the basis
for weekly selection. In addition to discussing the comedy
videos, the discussion portion also involved commentary
regarding how participants used humor as a means of
coping; and (3) Passive control arm—treatment as usual
without any humor-related intervention. Both humor-rela-
ted interventions were provided for 3 h weekly for
3 months, with a meal break during each session. All
participants, including those in the passive control arm,
could continue to receive standard mental health care of
their choice.
Data Collection
Data were collected from all 3 arms at 3 points in time—at
baseline, after 3 months (end of interventions), and after
another 3 months (follow up). Evaluation at all 3 points in
time consisted of severity of mental symptoms, stress,
functioning, life satisfaction, self-esteem, self-efficacy,
mood, and humor style (state). Psychiatric diagnoses and
humor style (trait) were evaluated at baseline, and attrition
and qualitative experience of the interventions were eval-
uated at end of interventions and at follow up. Standardized
measures, and semi-structured individual interviews (based
on our de-novo interview guide, available upon request),
were used to collect these data, and direct observation was
guided by our de-novo observation guide (also available
upon request) and conducted by research staff who
Community Ment Health J (2014) 50:737–742
documented their observations in field notes weekly during
the interventions.
The semi-structured interviews were audio-recorded and
transcribed and validated for qualitative analysis. They
consisted of open-ended questions such as these: Please
describe to me how humor affects your life; Please tell me
what do you feel about taking part in group programs;
Please tell me how this program did or did not meet the
expectations you had when you registered for it; Please tell
me what you feel about being in a group situation.
The following standardized measures were administered
to all assessed participants in all 3 study arms at all 3 points
in time: the Personal and Social Performance (PSP;
Morosini et al. 2000) Scale, modified for self-report; the
Hopkins Symptom Checklist 21 (HSCL 21; Deane et al.
1992); the Perceived Stress Scale (PSS; Cohen et al. 1983);
the Positive and Negative Affect Scale (PANAS; Watson
et al. 1988); the Satisfaction with Recent Life Scale
(SWRLS; adapted from Diener et al. 1985); the state ver-
sion of the Humor Styles Questionnaire (HSQ-S; Puhlik-
Doris 2005); the Rosenberg Self-Esteem Scale (RSES;
Rosenberg 1965); the Personal Functioning Inventory (PFI;
Kohn et al. 2003); and the General Self-Efficacy Scale
(GSES; Jerusalem and Schwarzer 1992). The Structured
Clinical Interview for DSM Disorders (SCID; American
Psychiatric Association 1994; First and Gibbon First and
Gibbon 2004; Mowry 1998) and the trait version of the
Humor Styles Questionnaire (HSQ; Martin et al. 2003)
were administered to all assessed participants at baseline.
Participant retention/attrition was monitored from start to
end of study.
Data Analysis
Data analysis consisted primarily of Fisher’s exact test and
repeated measures analyses of covariance (ANCOVA) for
quantitative data and of comparative thematic analysis
(Boyatzis 1998) for qualitative data. Comparisons between
study arms to examine baseline matching on demographic
and clinical variables were done via one-way between-
groups ANOVA for age, years of education, length of
psychiatric illness and number of psychiatric hospitaliza-
tions, whereas those for gender, marital status and psy-
chiatric diagnosis were done via fisher’s exact test (FET)
because of too many low expected cell frequencies, i.e.
more than 20 % under 5. Corrections for the multiplicity of
comparisons across our several dependent variables were
not conducted because of the exploratory nature of the
study. Comparative thematic analysis involved word-by-
word coding and, from that, identification of emerging
themes within and across study arms. Trustworthiness/
credibility of qualitative data analysis was facilitated by
triangulation of interview data with direct observation data
739
and by peer debriefing of the first author with a collaborator
who is also experienced in qualitative research. Saturation
was reached for all qualitative themes for both intervention
arms.
Results
Matching of Study Arms
The three study arms showed no significant demographic
or clinical (diagnostic and other) differences at baseline
(F (2, 32) = 1.01, p = 0.375 for age; F (2, 32) = 1.16, p =
0.325 for years of education; F (2, 32) = 0.80, p = 0.459 for
length of psychiatric illness; F (2, 32) = 0.680, p = 0.514
for number of psychiatric hospitalizations; FET = 4.53,
p = 0.114 for gender distribution; FET = 12.24, p = 0.059
for marital status; and FET = 8.68, p = 0.967 for
diagnosis).
Quantitative Outcomes
There was no significant difference in attrition between the
study arms (FET = 3.77, p = 0.183). Reliabilities of all
outcome measures were satisfactory, ranging from 0.80 for
the HSCL 21 at Time 2 to 0.94 for the RSES at Time 3.
There were no significant differences between study arms
for any of these measures at Time 1 (multivariate F (16, 52) =
0.68, p [ 0.80; Univariate F ranging from 0.05 to 1.24,
with p [ 0.05 in all cases), attesting to the success of
random assignment in producing comparable study arms at
baseline. Because the retention of participants in the active
control arm was unacceptably low, they were eliminated
from the remaining quantitative analyses reported here
(only 5 of 12 remained in the active control arm in Time 3,
compared to 8 of 13 in the experimental arm and 9 of 11 in
the passive control arm). Attrition from intervention did
not entail attrition from standard mental health care.
Repeated measures ANCOVAs were conducted to compare
scores on each of the outcome measures at end of inter-
vention (Time 2) and at follow up (Time 3) within and
across the experimental and passive control arms, con-
trolling statistically for baseline scores. There was a mar-
ginally significant interaction effect of study arm and time
(T1 vs. T2 vs. T3) for self-esteem scores (F (1, 14) = 4.53,
p = 0.051). That is, the passive control arm showed an
initial increase in self-esteem from Time 1 to Time 2 but
this increase largely dissipated by Time 3 (T1, M = 29.33;
T2, M = 31.12; T3 M = 29.89); in contrast, the experi-
mental arm exhibited very little change from Time 1 to
Time 2, followed by an increase in self-esteem at Time 3
(T1, M = 29.0; T2, M = 29.12; T3, M = 31.62). This
interaction effect of time and study arm was substantial,
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accounting for 19 % of the variance in participants’ self-
esteem scores. All other inferential statistical analyses
yielded non-significant results.
Qualitative Outcomes
The results of the qualitative analysis of data from both
intervention arms are presented in relation to 4 themes that
we found (with some inevitable overlap between themes);
obviously, intervention-related data were not collected from
the passive control arm so that data from that study arm
cannot be presented in this section. There were similar
qualitative findings across the 2 intervention arms, although
satisfaction, benefits and challenges (such as intervention-
induced anxiety) related to the intervention were more
prominent in the experimental arm. Observational data
corroborated important aspects of the interview data (spe-
cifically, the field notes upheld participants’ satisfaction
from the interventions and their view that humor is some-
times—but not always—helpful). That being said, although
the field notes did not contradict the interview data, they
showed an issue that did not arise prominently in the inter-
views, i.e., the distinctions among different types of humor.
Theme 1: Satisfaction from the Interventions
Participants in both intervention arms reported satisfaction
from the intervention, especially enjoying themselves, expe-
riencing humor, feeling supported and comfortable (some-
times even relaxed), and generally having a positive
experience. Participants from the experimental intervention
arm also reported satisfaction (particularly having fun) from
their performances at the end of their standup comedy train-
ing. Participants’ quotes per group are found below to illus-
trate this theme.
Active Control: … I really enjoyed the program… I just
had a lot of fun… I was laughing at everyone else… I
think it exceeded my expectations…! I got a lot out of
it…. I liked being in the group… it was non-judgmen-
tal… it’s a really great program… it’s a wonderful
experience
Experimental Group: ... momentous event... Really
impressed... material was funny... really good... It was
a supportive audience... a wonderful celebration...
Theme 2: Challenges of the Interventions
Participants in both intervention arms reported challenges
related to their participation, ranging from technical chal-
lenges (such as some uncomfortable chairs) to substantive
challenges (such as diversity of the group in relation to
humor preferences, some anxiety and not always finding
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Community Ment Health J (2014) 50:737–742
humor in the interventions, particularly in the active con-
trol arm). Participants’ quotes per group are found below to
illustrate this theme.
Active Control: … I didn’t make a long-term rela-
tionship with anybody there… anxiety provoking
every time…
Experimental Group: … it made me step out of my
comfort zone… I was scared to death…
Theme 3: Benefits of the Interventions
Participants in both intervention arms reported improvement
in use of humor, in mood, in activity and energy, in positive or
at least more positively balanced thinking, in self-confidence
and in social interaction and befriending. They also reported
more happiness and less stigmatization of people with mental
illness (presumably including themselves). Participants’
quotes per group are found below to illustrate this theme.
Active Control: … it helped me to understand that I
have an escape… I think I’m more aware of it now…
I still got something because I heard other people’s
perspectives… when people would talk about how
they used humor in their life…
Experiment Group: … it boosted my confidence… a
lot more happy… helps you a lot with your self-
esteem… I just kinda laugh it off… I liked it better
Theme 4: The Impact of Humor
Participants in both intervention arms reported advantages
as well as challenges of using humor, such as its mood
elevating effect in some circumstances but not in others
(e.g., they reported it is helpful for stress but not during
severe depression). They also reported an influence of
background factors, such as the role of early (presumably
childhood) exposure to humor in the family in relation
to their ability to use humor. This referred to both self-use
and use of humor by others. Participants’ quotes per group
are found below to illustrate this theme.
Active control: …humor is a way of venting …
everything can be taken lightly and not so seriously…
I think I need to laugh. I think it is important. I think
it is healthy…
Experimental Group: …it alleviates a lot of the
stress… its survival… its just a tool in the toolbox…
Discussion and Conclusion
We found that it is feasible to study humor-related inter-
ventions (standup comedy training, and comedy video
Community Ment Health J (2014) 50:737–742
watching and discussion) for people with various mental
illnesses, although there was much attrition from the video
arm, and that participants were overall satisfied with these
interventions. There were challenges (such as in relation to
the mixed clinical population) as well as benefits (such as an
increase in self-esteem of participants in the stand up arm by
follow-up) of the interventions, and the use of humor more
generally was considered to have mixed effects. For exam-
ple, participants reported humor to be effective in coping
with anxiety but not in coping with severe depression, which
may not be surprising as severe depression does not respond
as well to structured coping enhancement such as cognitive
behavioral therapy (Haby et al. 2006).
The quantitative results do not provide strong support for
the effectiveness of standup comedy training as an inter-
vention except in relation to self-esteem; the enhancement of
self-esteem was corroborated by the qualitative data. How-
ever, there are a number of limitations of this study which
make the refutation of this intervention’s effectiveness pre-
mature: First, the sample size was small; indeed, by Time 3,
the active control arm had too few participants for inclusion in
inferential statistical analyses. Second, choice in an activity
such as learning stand up comedy may affect its effectiveness
and resemble more real-world conditions (in which individ-
uals can choose whether to participate in a particular pro-
gram); hence, a quasi-experimental design based on self-
selection may be more appropriate for such research than an
experimental design based on random assignment like the
one used here. Third, training in stand up comedy may be very
effective with some people and much less so with others; e.g.,
it may be more effective with people who are anxious than
with people who have depression, particularly if the latter is
severe and hence associated with considerable—if tempo-
rary—learning difficulty; the effectiveness of such interven-
tions may be enhanced if they are selectively chosen,
depending on the particular mental illness of the participant as
well as on other factors, such as previous positive or negative
exposure to humor and humor style. Fourth, it is possible that
the stand up intervention would demonstrate more benefit if
studied over a longer time span than just 6 months and if it
involved more performances, as the performance seemed to
encourage participants. Fifth, video-conferenced stand up
training, which was the primary mode of stand up training in
our study, may be less effective than face-to-face training.
Sixth, the considerable attrition from the active control arm
did not allow for quantitative comparison with it, thus lim-
iting our ability to distinguish effects of humor-generation
from effects of humor-exposure. Seventh, standard treatment
received by all participants may not have been consistent
within and across study arms, which could confound results;
e.g., if during the study most participants in the experimental
arm were treated with psychotherapy and most participants in
the passive control arm were not, self-esteem may have been
741
higher at the end in the experimental arm due to the psy-
chotherapy rather than to the stand up comedy training; still,
although we did not control for possible differences in stan-
dard treatment, it is unlikely that such standard treatment
could make much of a difference during the study period,
particularly in self-esteem (which was the only quantitative
outcome to show significant benefit from standup-comedy
training). Finally, some of the measures used may not be the
most suitable to evaluate change for such research (although
in our study they were fairly diverse and seemingly relevant
to mental well-being).
In spite of the limitations of our study, and its largely
negative quantitative findings, it suggests that humor-
related interventions, particularly training in stand up
comedy, may be helpful for people with mental illness.
More research is required to better understand the role
humor can play in the lives of people with mental illness,
and how to harness it for their possible benefit.
Acknowledgments Thanks are due to David Granirer from British
Columbia, Canada, who created and conducted the training program
in stand up comedy for people with mental illness (Stand Up for
Mental Health), and allowed us to use his services to study it. Thanks
are also due to research staff and others who assisted us in this study,
particularly Marnie Wedlake who provided input on the study design
and the qualitative data analysis. This project was funded in part by
the Consortium for Applied Research and Evaluation in Mental
Health (CARE-MH), which was funded in turn by the Canadian
Institutes of Health Research (CIHR), and by AstraZeneca.
Conflict of interest The writing of this manuscript was not spon-
sored; nor did any of authors receive any financial payment for the
work. The authors certify that they accept responsibility for the
content of this article. All authors helped write this manuscript, and
agree with the decisions about it. All the authors meet the definition of
an author as stated by the International Committee of Medical Journal
Editors, and they have seen and approved the final manuscript.
Authors can attest that the content of this manuscript and any essential
part of it, including tables or figures is not published elsewhere nor is
it being considered by another publication. The authors declare
no relevant conflict of interests.
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