Open access peer-reviewed chapter
Abstract
This paper examines the coping strategy of humor presented by eight adult women aged 26 through 61 in a small clinical practice setting. Each woman had been sexually abused by a variety of family members during childhood. They were seeking therapy for life-phase issues (e.g., divorce, retirement, marital problems, parent/child issues). The reemergence of sexual violence memories and the ways in which these women used humor as a coping strategy to alleviate the effects of childhood sexual abuse (CSA) are presented.
Keywords
- childhood sexual abuse
- trauma
- coping
- recovery
- humor
1. Introduction
The search for meaning and adaptive coping strategies regarding traumatic events [1, 2] extends to survivors of childhood sexual abuse (CSA) [3, 4, 5, 6, 7, 8]. CSA can create psychological and health difficulties that span the life course, disrupting a positive worldview, coping abilities, and adaptive strategies [3, 5, 6, 7, 9, 10]. A significant task for survivors is assigning meaning to the traumatic event and developing a philosophy that assists in developing coping strategies that promote healing and recovery [4].
Types of adaptive coping strategies have been a focus of research and treatment for CSA survivors [3, 4, 5, 11, 12, 13, 14]. Additionally, posttraumatic growth (PTG), assisting the survivor in healing and creating a sense of agency, has been an important area of focus [15].
Studies examining the search for meaning and reframing thinking and coping have furthered our understanding of the recovery process. Yet, the critical survival strategy of humor has been absent in the CSA literature for adult survivors. Do CSA survivors use humor as a method of coping with this traumatic event, and if so, in what ways do they use humor? This chapter presents the treatment issues presented in a small clinical sample of sexual abuse survivors utilizing humor as a coping strategy.
This coping strategy was reported to be foundational as part of their positive recovery. The coping styles of adult CSA survivors employed playfulness and humor and thus assisted in helping them to grow and flourish. Humor as a coping strategy is underrated and not commonly presented as a viable intervention in treatment and recovery. To that end, women who have experienced CSA and their views about humor and its usage to reframe and assuage traumatic events are presented.
2. Incidence and prevalence of childhood sexual abuse
One in five women and one in 13 men report sexual abuse as a child. However, the numbers for male victimization are vastly underreported [16]. Worldwide rates indicate that forced sexual contact occurs for 120 million girls and women under 20 [17]. While our knowledge regarding this crime has grown over the past three decades, childhood sexual abuse remains at epidemic proportions in the United States [5, 18, 19].
The deleterious effects of childhood sexual violence include low self-esteem, difficulty with interpersonal relationships, sleep difficulties and disorders, substance abuse, self-injury, sexual dysfunction, and depression [5, 18, 20, 21, 22]. Teenage pregnancy [23] and eating disorders [24] are also adverse outcomes of CSA. More complex disorders such as dissociative disorders and posttraumatic stress disorder (PTSD) [6, 13, 25, 26, 27, 28, 29] are significant in this population. Physical and oral health issues are also reported health outcomes of CSA for adult survivors [6, 25, 26, 27, 30]. It is significant to note that many of these women will be at risk for sexual revictimization [31, 32].
Disclosure by CSA survivors has been difficult for a variety of reasons such as shame, fear of disbelief, and lack of support [33]. Recent communication changes such as digital platforms, social media, and online communities have increased disclosure in a public forum while increasing social support [34]. This public dialog by CSA survivors also creates a pathway to increase our knowledge regarding the prevalence and experiences of individuals who have been sexually abused during childhood [35].
3. Coping with CSA
Coping strategies, derived from belief systems about the event, and views about how the world works have been an area of research interest for quite some time [7, 14, 36]. Making sense of sexual abuse victimization can be a life-long quest that embodies constant questioning and anxiety without resolution [7].
The ability to cope with traumatic events has focused on managing the demands of stressful and traumatic events while categorizing the event itself and reactions to it [13, 37, 38]. Walsh et al. [8] define coping as “…a range of diverse cognitions and behaviors used to manage the internal and external demands of a stressful or threatening situation” (p. 3).
Several authors have addressed the attributions of sexual abuse survivors and their attempts to make sense of the event [7, 14, 36] and their attempts to cope [39]. For instance, CSA survivors can employ a range of coping strategies such as self-blame, avoidance, and cognitive restructuring. Characterological self-blame (I am the reason this happened) and behavioral self-blame (my behavior – which I can change – is the reason this happened) have been studied with a variety of populations [40, 41]. Behavioral self-blame has been viewed as a better strategy because behavior is changeable (“I won’t walk in that neighborhood again”). However, several authors have challenged this notion, positing that all kinds of self-blame, despite its use as an adaptive strategy, have negative consequences [42, 43, 44, 45].
Other coping strategies such as avoidance, cognitive restructuring, or the way one thinks about events that are happening, have happened, or will happen, can also have adverse outcomes. Avoidant strategies, for instance, attempt to avoid any interaction with the abuser and may impact normal attachment development [14, 18, 20, 31, 46].
Several models postulate why some victims will experience negative sequelae while others develop coping skills that help them organize positive rationales and philosophies about the experience and life in general [12, 47, 48, 49]. Mediational models have examined coping strategies, cognitions, attribution style, interpersonal conflict, and psychological distress that mediate poor outcomes for sexual abuse survivors. Barker-Collo and Read [39] state.
The author’s go on to cite Draucker’s [12] findings.
Mediating (intervening) and moderating (tempering) variables influence coping ability [8]. These include the type of abuse that occurred and by whom, the severity of the abuse, the frequency and duration of the abuse, and support systems that could and did not intervene [8]. In addition, temperament, familial environments, and organizational responses such as schools, Family courts, and the legal system influence coping styles [4].
Until recently, the CSA field has focused on debilitating and harmful outcomes for survivors [51, 52, 53, 54] and how to ameliorate them. Understanding this aspect for the CSA survivor is critical to healing and recovery. Newer models, however, focus on resilience, posttraumatic growth, and positive cognitions and coping strategies employed by trauma survivors [15, 51, 53, 55, 56]. More recent research has identified that CSA survivors can develop coping strategies that assist them in leading productive lives [4]. Graham et al. [4] identified several critical factors in coping strategies that promote successful outcomes: reframing the event/s, taking control of the traumatic memories, and thinking about it differently.
4. Humor and trauma
Humor has been viewed as a way of coping since time immemorial [57, 58]. Humor increases the quality of life and is an effective tool in dealing with stress and health issues [57, 59, 60, 61, 62]. The benefits of laughter – direct physical benefits – and humor, which indirectly improves physical status and mediates mood and cognition [63, 64] are now widely recognized by a variety of mental health disciplines [15, 65, 66, 67, 68, 69, 70]. Positive humor and playfulness improve positive self-concept [71] and overall happiness [60, 72].
Humor has been studied with a diverse set of trauma populations, including veterans, individuals who experience severe medical conditions, and older adults [73, 74]. As a result, different humor interventions have been developed, such as Laugh Yoga and Medical clowning [75].
The idea or notion that humor can be introduced or utilized in the throes of trauma presents an oxymoron. On the one hand, the person is cognitively and emotionally challenged in dealing with a traumatic event and suffering; at the same time, they are cognitively and emotionally challenged with a visual or auditory depiction of something playful or humorous [61].
Yet, humor and playfulness serve dual primary purposes: to distract and provide a sense of hope. The first aspect, distraction from painful affect and cognition, creates cognitive dissonance, the premise that an individual cannot hold two competing thoughts simultaneously [21, 64, 76]. On the other hand, laughter creates a sense of relief – usually from stress – both mentally and physically, thus giving way to a sense of hope.
Several authors have addressed the benefits of incorporating humor and playfulness within psychotherapeutic treatment and how to do so [21, 61, 68, 77, 78]. An individual’s sense of humor is an important aspect of coping, and the clinician needs to be mindful of both the client’s and their own “Humor Quotient” [79].
While the field has been slow to adopt the importance of humor in the treating room the use of humor either by the client or the clinician is now viewed as beneficial [4, 80, 81]. Several issues such as timing, the purpose of humor within the session, the type of humor, cultural differences, gender, language, and client diagnosis [60] should be considered when incorporating humor as part of the treatment process, either by the clinician or the client.
5. The clinical sample
This chapter examines how humor is utilized as a coping strategy in a small, clinical practice setting by eight women aged 22 through 61. These women had been sexually abused during childhood and adolescence by various family members (father, grandfather, stepfather, brother, uncle, and mother’s boyfriend). It should be noted that none of these women presented with diagnoses that consisted of personality disorders or the range of dissociative disorders. Initial treatment centered on significant life-phase issues, including marital issues, remarriage, divorce, parent/child issues, and children going to college and retirement. During treatment, previous memories of sexual abuse were triggered and emerged as a focus of attention. The CSA consisted of rape, sodomy, and fondling. Four women reported that the abuse was further traumatizing by the abuser’s constant statements that the cause of the abuse rested with her (“You always tempt me to behave this way”). All of these women had previously been in treatment for their sexual abuse issues before entering treatment with this author. The women’s current developmental crises had triggered previous abuse memories and therefore cases for examination were selected for their use of humor and playfulness as coping strategies in a) dealing with the sexual abuse and b) recovery responses were part of their treatment discussion. The themes regarding their use of humor as a coping strategy are included here. While the following comments and data are anecdotal, they nonetheless represent a previously unexamined area of coping for this population. Women whose comments are utilized in this paper gave permission for their use.
6. Different ways CSA survivors utilize humor
6.1 Vulnerability and powerlessness
Several CSA survivors reported feeling vulnerable and powerless during childhood, adolescence, and young adulthood due to the abuse, and humor was utilized as a tool. They reported that being funny – comedic- served to keep the abuser at bay – even for a little while. Additionally, their sense of humor assuaged their sense of powerlessness.
The clinician should note, however, that utilizing humor to point out vulnerability or powerlessness should be a focus of attention, drawing light on the fact that while the client is presenting situations or feelings about vulnerability in a funny way, it also highlights the pain and sorrow of victimhood.
6.2 Distracting in playful ways
Humor can be described as a distraction from painful events or memories has always been recognized as an important foundational aspect in the use of humor. Several women identified the use of funny movies, television series or jokes as a useful coping mechanism that distracts from painful memories or emotions.
6.3 Life is absurd
Thinking differently about the CSA has been identified as one way to develop a coping strategy that minimizes negative emotions and thought processes [4]. Several women reported their use of humor to be more reserved, i.e., in their “head,” using humor or absurdity as an approach to thinking differently about the abuse itself, the offender, or life in general. Part of this humor approach involves the notion that if something is ridiculous, how can it be threatening [21, 82].
7. Humor, jesting, and playfulness in the treating room with CSA survivors
Clinical work addressing trauma is generally phase-based, tailored to symptom presentation [83], and incorporates practice elements that create an environment for healing. A host of symptom reduction interventions such as emotional regulation, cognitive restructuring, stress management, and improving interpersonal skills are employed to create safety and set the stage for change [61, 83]. “Second line” strategies are mindfulness and meditation strategies [64, 83]. Additionally, understanding the support system available and the cultural context are vital to successful treatment [61, 84].
Humor, jesting and playfulness, although not stand-alone interventions, are generally not considered within the context of trauma treatment despite the potential to increase the therapeutic alliance while bolstering a sense of safety [61, 73, 85]. Garrick [73] reminds us, “…our neurological responses to laughter and general happiness, as well as the nature of humor, represents an asset to therapy” (p. 171). The therapists’ style and sense of humor are also significant factors in determining the employment and usefulness of playfulness and humor in the treating room [78]. It should be noted however, that humor should be a well-thought-out consideration and not just a random, tongue-in-cheek intervention utilized with trauma survivors.
Important considerations appear below.
8. Cautions and considerations on the use of humor with CSA survivors
8.1 The clients use of humor
While safety and the development of rapport are essential to establish the foundation of conducting trauma-responsive work, attunement between the clinician and the client should also be established in terms of sense of humor. For example, a clinician who has a strong sense of humor matched with a client who has a low sense of humor should use caution in employing humor in the treating room, in general, but when trauma is the topic, in particular.
Some authors have identified clients’ use of humor in the treatment process as undermining the serious nature of therapy [86, 87], while others have stated that it is a defense that deflects from issues at hand [88, 89].
Timing and phase of treatment are also important considerations when employing humor and playfulness in the treatment process. The clinician must assess if the use of humor by the client is utilized to deflect painful and difficult conversations, delay trauma processing, minimize negative sequelae, or keep the therapeutic alliance in a static condition so that further work cannot commence. These are important variables that need to be applied when considering the use of humor in the treating room. These aspects needs to be evaluated and addressed with the client so that the use of humor and playfulness is clearly understood.
8.2 Humor as a defense mechanism
Sexual violence such as CSA “represents profound violations of an individual’s body and emotions” ([68], p. 1). Given this fact, a survivor may have been likely to employ defense mechanisms that assisted in adapting to daily life, especially if the abuse is ongoing; humor may have been part of the equation. Additionally, humor may be “employed” as a defense mechanism to thwart discussions that address serious or traumatic material. Approaching this content with empathy is fundamental, with the additional caveat of understanding how and why this defense is being utilized. The clinician may need to adapt their use of humor to the changing treatment issues and explore with the client how their use of humor may be changing. Several questions should be employed such as is humor part of denial regarding the abuse or significant impact? Is humor utilized as a coping strategy in particular situations that “benefit” the client? Is it a way to delay discussions about the abuse? Is humor used in a self-denigrating manner?
Trauma-responsive work entails the foundational approach of strength-based interventions [90]. While clients may employ a coping strategy that veils anger and low self-esteem behind self-demeaning, denigrating humor, it’s the clinician’s task to address how that may impede positive self-worth, posttraumatic growth, and the recovery process overall. The overarching component is how and why a client is using humor, the timing of its use, and the rationale for how the clinician responds to this humor usage. Assisting the client in understanding how the use of humor helps or hurts processing the sexual violence is just one aspect in the arsenal of healing and recovery.
Although not the topic of this chapter, the clinician will want to pay close attention to those individuals who present with personality disorders and/or the range of dissociative disorders and the use of humor and playfulness. As mentioned, the women in this chapter are from a general group of CSA survivors separate from those individuals who experience personality disorders and/or the range of dissociative disorders. Dissociative CSA clients may rely on separate personalities who use humor to deflect painful memories at the expense of the whole personality. Caution should be exercised by the clinician, who needs to be attuned to the client’s use of and response to humor throughout the course of treatment.
8.3 The clinician’s use of humor
Working with individuals who have been sexually violated, particularly during childhood, is difficult work at best. This type of clinical work has the potential to stir strong emotions and reactions within the clinician, and some even suggest that trauma work can be considered an “occupational hazard” [91, 92].
The clinicians’ prior experiences, countertransferential reactions, and reasoning for the use of humor needs to be examined, particularly how it will enhance treatment and assist the client in the recovery process. How the clinician’s “agenda” may enhance and impede treatment needs to be examined regarding humor, just as any intervention in the therapeutic context. An example of both the client’s use of humor and the clinician’s countertransferential reactions appears below.
Susan, twenty-six, had been sexually abused as a child by her stepfather for over 5 years before disclosure. Viewed as an optimistic child, she was outgoing and funny. She entered treatment to address her grief over a failed marriage and her inability to maintain employment. She viewed her comedic persona as a gift and fancied becoming a comedy writer and stand-up comic.
However, her constant comic presentation in session thwarted addressing her presenting issues, yet she would infer a great deal of anger toward men and her previous traumatic sexual abuse.
Sessions centered on how her deflection through “entertaining” the therapist through laughter did not assist her recovery but rather kept us from addressing her issues. This author shared with S. that the author’s love of laughter made her hilarious presentations attractive but kept us from the serious discussions that were essential to her recovery. In one of these discussions we addressed her use of humor as “the shield” that not only protected her from serious discussions but kept people at a distance through the laughter. We also addressed that while she was a naturally funny person, her constant humorous presentation may not have served her well in other situations such as employment and previous treatment. The painful discussions that humor masked her trauma and anguish were indeed difficult, but she was able to reflect on her use of humor, her timing, and the humor’s goal. While the intent was not to extinguish her use of humor it was more to understand its purpose.
As for the clinician’s part, this author found S. very funny and loved the laughter that she created but recognized that we were not getting “work” done. The realization that the therapeutic work at hand was difficult, accompanied by “why can’t I have a chance to laugh?” was part of the hard task of trauma work. Supervision assisted in analyzing this quagmire and provided this author with the opportunity to resolve the issues that then helped to move S.’s treatment forward.
These cautions notwithstanding, the client’s use of humor can create a sense of control and empowerment while also distracting from obsessive thoughts and negative self-talk [59, 61, 73]. When people play, they are not scanning for danger and, thus, not feeling vulnerable [21]. Creating enough safety that assists a person to feel open and free enough to play, e.g., vulnerable, creates an environment where growth is possible. While one may have a good or strong sense of humor, it is important to understand the timing and the employment of empathy while using humor in a therapeutic context.
9. Discussion
Using humor in therapy is beneficial to the therapeutic encounter [21, 68, 77, 78]. However, it is not clear how often and in what ways CSA survivors utilize humor and playfulness as a coping strategy that promotes their recovery process. Anecdotal, clinical information, and information emerging from social media suggests that the old adage: “If I didn’t laugh, I’d cry,” is valid for this population. Utilizing humor deflects the tragic and traumatizing aspects of a childhood filled with violent, sexualized brutalization. These women discussed the issues of vulnerability, powerlessness, and fear that were moderated through humor and playfulness. Several CSA survivors reported feeling powerful when viewing the abuser and/or situation differently, such as absurd situations.
As demonstrated with this small cohort, a sense of hope and resilience is imbued with the use of humor and playfulness [60]. The clinician needs to understand the importance of this coping strategy in the therapeutic context, particularly the issues of sensitivity and timing. Other important issues are to address the client’s use of sarcastic or demeaning humor and gently challenge when they do [60].
Humor and playfulness can assist in continually building the therapeutic alliance [21, 61, 68, 77, 78]. Clinicians should carefully monitor countertransferential issues and contraindications of humor in the therapeutic context [60].
Assessing if humor is a thought-out strategy, part of the individual’s temperament or resilience skills, or a combination of variables will assist in understanding humor as a coping strategy. Moreover, how humor enhances or impedes – or both – positive outcomes furthers our understanding. Further research will assist in developing therapeutic techniques and approaches for this population, just as the medical clowning field and other humor researchers have developed approaches that have increased our awareness of humor as a vital tool in recovery.
This small clinical sample is an exploration of how humor and playfulness are utilized as a coping strategy by CSA survivors; while it cannot be extrapolated to the general population of CSA survivors, it warrants further investigation. Exploration and enhancement of humor in the therapeutic encounter add to the repertoire of positive coping strategies of CSA survivors. Further investigation of this coping strategy will increase clinical awareness and the arsenal to improve the recovery processes of CSA survivors.
Future research will also need to investigate how humor is utilized by CSA survivors with personality disorders and/or the range of dissociate disorders. How humor is addressed for CSA survivors by the clinician, humor utilization at different stages of treatment (both clinician and client) and contraindications on the use of humor still need to be researched.
10. Conclusion
This chapter presented the use of humor and playfulness as a coping strategy by a small group of CSA survivors in therapy. While humor is seen as a productive and helpful way to reduce stress and improve mood, it has not been widely viewed as a coping strategy in the recovery process of childhood sexual abuse. Clinicians’ attention to how humor is being utilized within the treatment setting and as a coping strategy for CSA recovery will assist in understanding the utility of this approach. Clinicians will need to understand the timing of humor utilization, self-denigrating humor, humor as a defense, and countertransferential reactions when using humor with this population. Research is needed to understand how humor is utilized by both CSA clients and clinicians, particularly with populations with personality disorders and a range of dissociative disorders. Understanding the use of humor as a coping strategy in trauma treatment has the potential to improve the therapeutic alliance and recovery processes for CSA survivors.
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