Author:Paul Gilmartin

Humor in a Therapeutic Setting: A Guest Blog by Jessica Levith M.A.

Make Em’ Laugh

The Power of Laughter in the Therapy Room

Jessica Levith, M.A.


Most of us had lives previous to becoming therapists. After undergraduate in San Francisco, I moved to Los Angeles where I undertook stand-up and comedy writing. I then blinked my eyes, nine years passed, and I was thirty. At my birthday lunch I watched an older friend, who by all accounts had “made it” as a comedy writer, whiskey-nurse his latest out-of-work ulcer. I decided that lunch to go back to school, but I never forgot comedy.


What’s So Funny?

It’s sometimes difficult to picture humor itself as an intervention, but I believe it can be a powerful way to connect with our clients. I openly invite humor into the therapy room, because it often feels like our expected seriousness as therapists paradoxically pushes away our client’s chance for deeper reparative emotional experiences. I chuckle when I think about the archetypal, uber-serious psychiatrist, Dr. Leo Marven, from the 1991 comedy film “What About Bob?” I wonder how safe his clients felt in session with him. He sets up a clear power differential with his cold, lawyer-esque office to convey he’s there to “fix” clients. Of course this hilarious movie purposefully conveys the ridiculousness of Richard Dreyfuss as a self-important psychiatrist, but it also shines a light on the near impossibility for deep therapeutic work when clients fear our clinical stature.

I am not suggesting that we respond to all client tragedies with our best one-liner; humor must be sensitive and thought through.[1] As with any other intervention I rely on clinical judgment when assessing a client’s openness to humor. One day, a long-time client of mine, Rachel, sat across from me in session teary-eyed. She had just spent a solid five minutes weeping over a recent break-up, and I could see that both her body and mind were exhausted. Instead of reaching for my Kleenex box to wipe her face, Rachel pulled from her purse a half-used roll of toilet paper. I watched as she unrolled a solid foot of it. She looked up at me, my head tilted as I watched her with a slight smile on my face. At that, Rachel burst into laughter. I then remarked “I’d like to thank you for your Kleenex Conservation efforts, Rachel. I was running low.” In that exchange, my smile and humor reflected back both an acknowledgement of Rachel’s exhaustion, and prompted her much-needed emotional shift.


Uniform humor is not appropriate across the board however. I would not have used this same intervention with a new client. What if she didn’t have the ego-strength for this sort of acknowledgement? What if her parent had just passed away, or she feared being put on the spot? This joke worked to deepen an already established therapeutic relationship that took time to build. I always monitor for intentionality and appropriateness when integrating humor into sessions. Properly executed, I’ve witnessed humor reduce high levels of depression and anxiety in the room.

With reference to anxiety, I’ve used humor to address some very large elephants in the room. For example, working with traumatized, minority and underprivileged youth, you bet some of these kids size me up at the first meeting. Many of them have been deeply wounded by negative experiences with “The System”, be it the school system, Child Protective Services, or Juvenile Justice. And, to them I am simply a white, privileged extension of this oppressive system. I learned quickly the only way to gain trust and connect with these kids is through authenticity and transparency. I give them both. Once instance, 17-year-old Daryl came into my school-based office for an initial session. He sat down, looked at the ground, and muttered “hey”, pulling his hoodie over his head. His hypervigilence was palpable. After a few shrugs for answers I stopped asking questions and sat back in my chair.

“Daryl”, I said quietly, “I wanna tell you a secret.”

His eyes peered from behind his hoodie with reserved interest.

“Daryl. I’m a short-white-Jewish lady…”

He looked at me incredulous. A moment passed. He then put his fist in front of his mouth, dropped his head, and started laughing.

“No she didn’t”, he said.

“Oh, I totally just did. Are we ok?”

He looked back at the ground. “Yeah, we cool”.

That joke expressed my respect for Daryl by naming the elephants of disparity such as privilege, gender, and race. I modeled owning who I am for Daryl while establishing my humble intent to hear his story.


How Does Laughter Work in the Therapy Room?

Laughter enhances attachment between therapist and client both explicitly (consciously) and implicitly (unconsciously). Explicitly, when we laugh in the room we convey our humanity and humility to clients. We express that we are not thera-bots merely seeking to “fix” them, but instead, like our clients, complex beings with many sides, one of them being silly. I’ve been stunned by how expressing my humanity through a quick quip reduces a client’s need for defense.


Implicitly, synching up with a client’s nervous system through humor works to reduce anxiety and depression, increasing one’s capacity to feel the pleasure needed for a developing, healthier self-regulation. I base this neuro-psycho-biological power of laughter on, among other sources, the Modern Attachment Theory teachings of Dr. Allan Schore. Dr. Schore consistently provides breaking research on the effects of early attachment trauma on the brain. In his paper, “Attachment and the Regulation of the Right Brain” (2000), he explains that because a baby’s central nervous system continues to develop postnatally, one key early task for a primary caregiver is to co-regulate the child’s nervous system through right-brain-to-right-brain attachment behaviors. This right brain implicit attachment (differing from left brain explicit attachment) must include a capacity to both upregulate the child (create pleasure) and downregulate the child (soothe distress). Ideally over time, the child internalizes this modeling, learning how to self-regulate. If these attachment tasks are not met, that child may be thrown into emotional dysregulation, which compounded over time, leads to many of the mental health issues presented in our rooms. Based in this concept of neurobiological primary attachment trauma[2], one of my goals in therapy is to help repair emotional dysregulation beneath presenting issues. Over time I work with my clients to help repair attachment trauma through conscious and unconscious empathetic connection via syncing up right-brain-to-right brain, helping them hone tools for self-regulation.


Clinicians often focus on downregulating clients when presented with heightened anxiety. Indeed, quick breathing and bouncing knees call for some grounding exercises. Equally as important in co-regulation, however, is a clinician’s ability to upregulate their client’s nervous system. This is where humor comes into play. It works as a chain reaction enhancing attachment between therapist and client, reducing anxiety and depression, which then increases a client’s capacity to experience authentic praise. This praise then works to elevate self-worth, which ultimately reduces presenting issues. In addition to co-regulation, Judith Nelson (2008) explains that humor in the room may provide “clues about attachment style, patterns of affect relation, (and) attachment history (pp. 47)”.


That’s Not Funny. Avoiding Humor in Therapy.

Can humor in the therapy room hurt clients? Any intervention can do this, especially if it’s overused, careless, or inappropriate. One popularized opponent to humor in therapy was the late Psychoanalyst Lawrence Kubie. Kubie (1971) expressed his concern claiming humor may heighten a client’s resistance, muddle therapist-client relationship, and/or encourage a client to mask feelings. I half agree with this idea. I do think inappropriate, thoughtless jokes have the potential to injure clients and I strongly advise against them. However, with or without jokes, therapists make mistakes in the room all the time. Additionally, a client’s negatively distorted perception may twist around anything a therapist says or does (humorous or not) resulting in damaged rapport.


The majority of arguments made against using humor in the therapy room are not against using humor overall, but rather the use of specific forms of humor such as sarcasm or self-defeating humor. Though Albert Ellis was known to promote the use of sarcasm as reality testing in his Rational Emotive Behavior Therapy (REBT), I find that sarcasm is most often used to deride others. Even in everyday life, that style of funny tends to go over poorly. No one is a fan of being mocked.


That’s Only Sort of Funny. When Clients Make Jokes.

I keep my eyes open to all variations of defense, laughter included, when sitting with some of the darkest trauma out there. Most of us have seen and heard this darkness, horror stories our clients have told us with blank or incongruent affect. A client laughs and we wonder what she could possibly be finding funny. My 24-year-old client Ana once sat across from me, describing how she would systematically cut five vertical lines into her leg. She then giggled, adding: “I’ve been thinking of switching it up to four vertical lines with a diagonal slash to indicate five.” I sat in silence with her for a while after that, allowing her space to access the probable despair beneath her masked smile. This would not be a time that I joined in with her humor, but instead a reminder of one of humor’s important functions: Survival.


Viktor Frankl, in his book “Man’s Search for Meaning (1963) describes in dreadful detail his daily life as a prisoner in the Auschwitz Concentration Camp. He poignantly observes the use of humor to survive, explaining that it helped prisoners find a sense of meaning and purpose in their lives even with death and disaster all around them. When faced with trauma and grief we humans try to make sense of the senseless. And when we can’t, we sometimes cope by making fun of it. One of my favorite quotes from Frankl’s book remains: “Humor, more than anything else in the human makeup, affords an aloofness and an ability to rise above any situation, even if only for a few seconds (pp. 54).” A client’s ridiculous exaggeration and mocking of trauma for the purpose of comic relief may be exactly that: a moment of relief as they processes deep pain.


Final Thoughts.

Psychologist Rod Martin (2006) surmises that research on the effects of humor in therapy is limited running the gamut of negative, neutral, and positive results. I’ll add that each clinician’s unique mixture of educational background and clinical style colors any intervention implemented, including humor. As clinicians we get to choose what style of humor to use and when to use it. We must be thoughtful and appropriate with its use and prepared for our clients’ reactions, as well as their dishing it out. If you’ve never thought of using humor in therapy and the opportunity presents itself, consider trying it. It may create a new pathway of both conscious and unconscious empathetic connection. If a joke does go south, as with any therapist-client conflict, your bomb may provide the opportunity for a reparative emotional experience through processing that disconnect.


A good starting position on your clinical humor journey is having a solid idea of what therapeutic humor is. The Association for Applied and Therapeutic Humor created a great definition: “…any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life’s situations. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, or spiritual (2014)”. Essentially, don’t be a stick in the mud. Life can be funny and it’s ok to laugh when it is. Using this base, connect with your authentic self as a clinician, have fun, and laugh.


Shifting away from the comedy world was challenging; any life transition typically is. I cannot deny the feelings of intoxication brought on by audience laughter. However for me, it felt like empty validation. Only a caricature of myself was connecting with an audience hardly visible though stage lights. Laughing with my clients now, I’m not pulling laughs. I’m sharing them. It just feels more satisfying. [3]


Association for Applied and Therapeutic Humor [Website]. (2000). Retrieved            (2014) from

Frankl, V. E. (1963). Man’s search for meaning: an introduction to logotherapy, pp. 54.             New York: Washington Square Press.

Kubie, L. S. (1971). The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 127(7), pp. 861–866.

Martin, R. (2006) The psychology of humor: An integrative approach, pp. 346-  349. Burlington, MA: Academic Press.

Nelson, J. (2008). Laugh and the world laughs with you: An attachment perspective             on the meaning of laughter in psychotherapy. Clinical Social Work Journal, 36, pp. 41-49. doi: 10.1007/s10615-007-0133-1

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment &            Human Development, 2, pp. 23–47.


Jessica Levith currently runs a private practice in Oakland, CA. For more information or to set up an appointment, you can contact her at 510.883.3074 or and

Supervised by Karen Pernet LCSW# 23635 Oakland, CA

ã 2014 by Jessica Levith, MA. All rights reserved.

[1] CAMFT lawyers remind me of this.

[2] For the unabridged super-complicated brain-jargon masterpiece, see referenced article.

[3] Only one clinician was harmed in the writing of this article. Me. Editing is painful.


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Scar Tissue by Paul Gilmartin

Scar Tissue


I’m sitting here at my favorite coffee place wondering why I didn’t wear looser pants.  My junk is swollen.  Not with pleasure; with bruising and stitches and a Band-Aid.

I had a vasectomy yesterday and like many of the twelve operations I’ve had, they were more complicated than expected.   The doctor told my wife when he finished he felt like he needed a drink.

I had to be put under general anesthetic.  Two years ago, the doctor tried to use a local while I was awake but because of some previous operations there was too much scar tissue and it was beyond painful.  He told me he had done several thousand of these and never experienced this.  I felt that familiar wave of shame.

Shame around my junk.

My wife and I had been talking for years about me getting one.   We both knew we didn’t want children and she’d like to go off the pill soon.  But I still woke up this morning feeling a pang of sadness.   It’s now official.   I will never reproduce.

My problems with my junk started when my testicles didn’t descend like they’re supposed to and at ten and eleven I had operations to lower them.

I’m not sure if the procedure is any more kind than it was back then but they attached an elastic string to the testicle and the other end to a leg cast.  I think Mengele invented it when he was in his bluegrass phase.  It was painful and embarrassing but in hindsight really not the worst part of the whole experience.

I’ve written ad-nauseam about this, especially on previous blogs, and I kind of want to apologize because I’m afraid of looking weird or obsessive about these issues and memories, but I figure nobody is making you read this.

Some of my most painful scar tissue is the feeling of being helpless, exposed, prodded and abnormal; the doctor informing my mom nonchalantly that I will never have kids and her taking him out into the hallway to rip him a new asshole (I didn’t understand at the time why she was making such a big deal even though I felt a wave of shame when he said it, I mostly felt numb); the multiple doctor visits, laying completely naked (they didn’t offer me a gown) on the table while he handled my body like I was a piece of meat; the time he walked in with a half-dozen interns in tow and talked about my body like I was a defective freak and I tried not to cry; my mom passively letting this happen; me feeling myself leave my body;

I buried how I felt about that experience until two years ago.  I suddenly realized how abandoned and unprotected I felt by my mom.   What kind of a mother wouldn’t sense her son feeling cold, frightened, exposed?  I felt the buried rage and sadness.  Why didn’t my mom try to get something to cover me up? Why didn’t she say anything when the doctors came in with a herd of people without warning?  Why she didn’t say anything afterwards, ask how I was?  Hug me?

I have always felt invaded by my mother’s eyes; like she drinks me in.   It’s like the doctor visits were the perfect opportunity for her to get what she wanted.   I don’t know if this is the truth or not, but that’s how I feel and I know from years of therapy that it’s not about blame it’s about processing our experience.  She never once asked me if I’d like some privacy.  It was quite the opposite. I remember the few times I tried to cover myself up she chided me saying “it’s nothing I haven’t seen before” or “I saw it before you did”.

After the first failed vasectomy I decided, maybe I don’t even need one.  Maybe that childhood doctor was right.  I got a sperm motility test.   For almost two years I avoided making the phone call to find out the results.  I don’t know why.   Maybe I was afraid of revisiting that feeling of shame when the doctor said I would be sterile.  Clearly I was afraid of something.  I finally called and because it had been so long I had to talk to about nine different people and leave multiple messages, feeling like even more of an oddity that I would wait so long.

The doctor informed me my sperm number is about a million.  I was impressed.  Then he said, that’s basically sterile, but there is still a remote possibility of getting my wife pregnant.   A million sperm and those are the odds?  Now I know how parents feel whose forty-five year-old still lives in the basement.

I think the emotional scar tissue is much worse than the physical.

When I had my testicles lowered I was terrified my classmates would find out.  It didn’t even occur to me how shitty it was that my dad’s train home from work would pass right by a stop at the hospital and he didn’t visit.   I remember pretending to be happy blowing out the candles on a birthday cake in the cafeteria and just feeling numb.   I coped by going to a place in my head where I didn’t feel.  I checked out.   I disassociated from my body.  I never once talked about what I was feeling.  I was never asked.  I buried it for the next forty years.

I have one fond memory of that time; a nurse from Philadelphia who would sing to me.  She looked like Liza Minnelli.  I liked her perfume. She would sweep into the room smiling and cracking jokes.  I loved it.  I felt like she was the one person who understood what I felt; who felt me.   I didn’t feel uncomfortable being naked in front of her, because I felt like more than a body to her.  To this day when I’m in the care of a compassionate nurse I want to ask them to hug me.  I want to cry on their shoulder.  Not because I’m still sad.  I’m not sure why.  Maybe because they feel like the mom I always wish I’d had and I know what a difference their kindness can make in someone who is feeling shame or fear.   Like most childhood trauma it has also left me with sexual fantasies around nurses and being cared for.  Yes, there are some videos online, most are terrible and miss the emotional point of the fantasy.

Back to my renegade testicles.  I was told after one operation that I shouldn’t ride a bike for a while.  I thought they meant peddling.  They didn’t say it was because it was about avoiding sitting on the seat and having your legs hang down.   I had my brother chauffer me on his bike, which was even worse and it screwed up the operation of one of my testicles, leaving it higher than the other.   I was sure no woman would ever be able to overlook this.  I now know, thanks to feedback from my wife and other women I’ve shared this information with they’re not big scrotum fans to begin with.    Very few get the newsletter.   Last year’s convention was cancelled.

Why am I sharing all this?  I don’t know.  Maybe I’m one of those people that have to share every personal detail of their life.  Maybe I need to let this out.  Maybe I want to know that other people have been through something similar or are working to overcome an adversarial relationship with their junk.  I started the podcast to help other people feel less alone, but I didn’t write this to help other people.  It didn’t even occur to me when I sat down (gently) to write this.  That’s how “unique” I feel even though I know realize as I type this how crazy that is.   I’ve read the body shame surveys on the website.  But most of the self-hatred shared there has to do with feeling fat.   Very few people share about their junk.   I know there is an epidemic of girls growing up hating the size of the labia.  I hate to say this but when I first heard of this it made me feel better.   That’s so selfish but it made me feel less alone.   I guess that’s how toxic body shame can be.

When I’m showering after a hockey game and I see guys with “normal” looking junk I think to myself “I wonder if they appreciate that?”

I’m normal sized when “in action” but not so impressive back at the barracks.  In fact it looks like I’m in my bunk with the covers pulled over my head.   Every time I get undressed after a game, there’s even more shrinkage and I’m reminded of all of this stuff. Almost like I’m waiting for someone to razz me.   I know it’s crazy, but emotional scar tissue isn’t always based in reality.  Lots of my teammates don’t shower.  Maybe they’re dealing with shame too. I feel like my genitals are an annoying neighbor and neither of us are going to move.

So here I sit for about the sixth time (I also had two hernias and a benign tumor) looking like my groin was hit by a baseball bat.

I’m not sure what to write next.   So I’ll wrap this up like it’s a documentary on A&E being voiced by Bill Curtis.

Scar tissue has been around since the dawn of man.  It carries with it the reminder that life is inherently dangerous on this rocky planet.  Much like the early cave drawings, they bear testament not only to where we’ve been…but what we’ve fought.  



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