Brief reportImplementation of a manual-based training of humor abilities in patients with depression: A pilot study
Introduction
Major depression (MD) is primarily characterized by low mood, anhedonia (the reduced ability to experience pleasure), and a negatively skewed self-perception (Drevets, 2001). Psychotherapy of depression therefore encourages the development of cognitive reappraisal and coping strategies. Among such strategies is the use of humor. The idea that sense of humor has psychological and health-promoting benefits is widely accepted (cf. Martin, 2001).
Empirical data backing up this idea is scarce, however, among other reasons because of widely varying definitions of “humor” and methodological problems: how, for instance, does a subject rate the “funniness” of an intervention. Here, we define “sense of humor” as composed of behavioural patterns (initiating funny behaviour or laughing at the joking behaviour of others), attitudes (a positive attitude towards humor), aesthetic components (the preference of certain types of humor) and coping strategies (the aptness to maintain a humorous outlook on life even in unfavourable situations; Ruch, 1998), i.e. a range of learnable competences.
Patients with depression show cognitive deficits in humor processing (Uekermann et al., 2008), but the affective susceptibility to funny stimuli seems to remain unaffected (Falkenberg et al., submitted for publication). Only the patients' tendencies toward humor behaviour, e.g. laughing at something funny — and their humor abilities, such as the use of coping humor, seem to be impaired. An effort to promote humor abilities in depressed patients, therefore, seemed like a fruitful approach that might broaden their range of coping strategies.
Several programs for the improvement of the sense of humor have been introduced (Goodman, 1983, Ziv, 1988, Anisman-Saltman, 1993, Payo, 1993, Nevo et al., 1998, Salameh, 2007, Ullmann and Kresse, 2008); only very few of these were, however, empirically validated.
Ziv (1988) specifically trained university teachers to improve their sense of humor in teaching. Student courses were then being held by either introducing humor into the teaching process or teaching the same material without humor. In the courses in which humor was used the students obtained better results on the final exam.
Nevo et al. (1998) evaluated a program for the improvement of the motivational, cognitive, emotional, social and behavioural components of humor in four groups of female high-school teachers (n = 101). The four groups received either the full program (1), focussed on passive involvement (2), regularly held social meetings (3) or were only tested before and after (4). Self- and peer evaluation of sense of humor and humor production revealed a significant improvement on measures of humor appreciation and production in groups 1 and 2 after the training and in comparison with groups 3 and 4. However, the mere participation in social group activity also led to an improvement on the sense of humor scales in group 3.
The program by McGhee (1996) is one of the most common approaches in hospital settings. It addresses all of the above-mentioned components of sense of humor and has been validated in a German-speaking sample of healthy subjects (Sassenrath, 2001). In this study 80 participants completed either the whole program (group 1), received the theoretical part only (group 2), discussed socially relevant topics (group 3 = control group), or were assigned to a waiting group (group 4). Sense of humor, coping humor and positive and negative mental states were measured before and after the training and 1 month upon completion. Both short and long-term improvements in all these measures were found in groups 1 and 2 whereas only an unsystematic, short-term improvement in some measures was observed in groups 3 and 4. The most distinct and persistent improvement was found in group 1 compared to group 2. This emphasizes the relevance of transferring theoretical knowledge of humor mechanisms into practical application.
The training has, however, not yet been tested with psychiatric patients. The use of humor in the group therapy of geriatric patients with depression and Alzheimer's disease proved to be helpful (Walter et al., 2007). Hard evidence for the effectiveness of a specific training for the improvement of sense of humor is, however, still lacking.
Given this state of affairs, the aim of this pilot study was to evaluate the practicability of a manual-based training of humor abilities in a group of depressed patients. We modified the program by McGhee (1996) according to patients' needs. The training sessions were shortened and elements which the patients might have considered inadequate, such as the use of disaster jokes or jokes about death were excluded. Furthermore, potential task difficulties due to cognitive deficits were considered and the humor production tasks were kept simpler than those in the original manual. Our first hypothesis was that the patients would be open to trying such an approach. Our second hypothesis was that the patients' use of coping humor would be enhanced after training. Our third hypothesis was that the patients would experience mood elevation in the course of the training sessions as reflected in the pre–post comparison.
Section snippets
Participants
Six inpatients with MD (4 f, Table S1) were recruited in consultation with their attending psychiatrists. Diagnoses according to the ICD-10 criteria as well as other study eligibility criteria were confirmed via semi-structured interviews based on the ICD-10 criteria. The study was approved by the university's ethics committee. Written informed consent from each patient was obtained. Symptom severities corresponded to a mild to moderate depressive episode according to the ICD-10 criteria.
Results
There was no drop-out of participants in the course of training. The patients were willing to get involved in this rather unconventional “therapy” and played an active part during the sessions. Over the course of the training, significant improvement of both state and trait cheerfulness was found. The use of humor as a coping strategy was also significantly improved after the training. There was a significant decrease in both state and trait seriousness and state but not trait bad mood
Discussion
The main result of this pilot study was the observation that humor training was feasible in depressed patients and that most humor-related measures improved over the course of the training although mood improvement, as measured with BDI didn't reach significance. This indicates a specific effect on humor competence that was independent of general health improvement.
After the training, the patients said that they felt more capable of using coping humor and that they were more aware of the
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