Humor utilized in the practice of forensic mental health nursing might seem incongruous, given the usually serious situations surrounding the admission and detention of forensic mental health patients. Yet recent studies have indicated that the use of humor is an element of staff interactions with forensic mental health inpatients, one that warrants further investigation (Gildberg et al., 2010, 2012). International research literature relating to forensic mental health and the use of humor is sparse; however, if humor does indeed play a significant role in the interactions between staff and patients (whether positive or negative), researchers and staff members alike need to be aware of this in order to further develop and evaluate existing nursing knowledge in this regard.
Humor is a phenomenon that exists not only in forensic mental health care but also is an important part of social interactions between humans everywhere (Fine & Soucey, 2005). Humor in itself can have many functions, from venting aggression to pure entertainment, in addition to gallows humor and sarcasm, to predictors of relational development (Graham, Papa, & Brooks, 1992; Sayre, 2001). The use of humor in staff–patient interactions appears evident in existing mental health literature more generally (e.g., Koehn & Cutcliffe, 2007; O’Brien, 2000; Repper, Ford, & Cooke, 1994) and is being viewed by some as an integral part of everyday nursing at the ward level (Mason, Lovell, & Coyle, 2008; Rask & Aberg, 2002; Sumners, 1990). Humor is important to the establishment of trust in mental health nursing interactions as well as to the development and maintenance of the nurse–patient relationship (Dziopa & Ahern, 2009; McCann & Baker, 2001; Scanlon, 2006; Struthers, 1999; Yilmaz, Josephsson, Danermark, & Ivarsson, 2008). However, such relationships, although of central importance (e.g., when it comes to gaining insight into patient’s problems, perceptions, and situations), are not without pitfalls in regard to staff use of humor. Humor has the potential to be misunderstood and may lead to conflicts (Gildberg et al., 2012). On the other hand, humor also has the potential to have a positive impact on patients’ experiences of health (Gelkopf, Sigal, & Kramer, 1994; Minden, 2002), reduce patient stress (Scanlon, 2006; Schoppmann & Luthi, 2009), and increase perceptions of environmental support (Gelkopf et al., 1994). It may also be seen as a survival mechanism, be it by staff diverting attention from their perceived seriousness of patients psychopathologies (Aiyegbusi, 2009) or to survive ideologically and/or psychologically as a patient confronted with stigmatization (Cardena, 2003). It seems clear that humor has a role to play inside the area of mental health care more generally, but the characteristics of the use of humor, the intentions behind its use, and the impact of its use inside the area of forensic mental health are as yet underdiscussed.
The aim of this study was to critically review the existing international forensic mental health research literature on humor to investigate (a) what characterizes forensic mental health staff–patient use of humor and (b) what significance humor holds within the forensic mental health setting.
The search was conducted in June 2013, with an open time frame, and utilized a variety of databases most likely to provide access to appropriate literature on the subject. Scopus, CINAHL, PubMed, and PsychINFO were searched using “psychiatric and forensic” and “mental health and forensic” combined with “humor” (and “humour”). Humor was simply operationalized as an empty category, only defined by the search terms allowing the content of the term to be defined by the literature. This limited the search by excluding concepts (e.g., laughter) not associated with the term “humor.”
As indicated, the search set out to find articles that combined keywords/phrases with the search variables. First, the search in each database was undertaken and duplications were removed. The remaining article abstracts were then read through and sorted for inclusion in the study by using the following criteria:
- a. be peer reviewed;
- b. be written in English, Danish, German, Norwegian, or Swedish;
- c. state an aim, method, results, and a conclusion; and
- d. report, investigate, or contain results relating to the aim of this literature review.
In order to try to ensure high-quality outcome, the above Criterion a (peer reviewed) and Criterion c (include the aim, method, results, and conclusion) were chosen as a minimum research benchmark in order to identify and judge the quality and coherence of the research reported in the articles (Cleary, Hunt, Horsfall, & Deacon, 2012; Sollaci & Pereira, 2004). Articles included were then read and sorted in regard to the above criteria compiled from each database, and duplications were again removed. Identified articles were then analyzed using a thematic approach (refer to Table 1).
Articles identified in the literature matrix (see Table 1) were critically evaluated using a thematic analysis approach (Dey, 1993; Gildberg et al., 2010; Zoglowek, 1999). First, emerging themes were noted by reading through the articles with the intention of creating an overview of the text elements and an immediate marking of thematic headlines (Zoglowek, 1999). These themes were derived from answering the question “what is this text about?” The purpose was to identify overriding structures and themes, concepts, and structure in the text (Blumer, 1986). Subsequently, the article text was coded using two questions to frame the analysis:
- 1. What characterizes forensic mental health staff use of humor in interactions with forensic mental health patients?
- 2. What significance does humor hold within the forensic mental health setting?
The material was then condensed, interpreted, labeled, then categorized into themes, merged with the emerging themes from the first reading, and then condensed into a coherent text (Dey, 1993; Gildberg et al., 2010; Zoglowek, 1999). Finally, the material was recontextualized by testing it against the original text and the outcomes of the first reading (Blumer, 1986, p. 28).
Results of the Search Strategy
From the total initial hits (n = 156), identical reoccurring articles (duplications) from each of the individual databases were removed (n = 16) and the remaining articles were sorted by evaluating the abstract according to the inclusion criteria. This reduced the number of total hits by 96. Applying Criterion c (i.e., inclusion of an aim, method, results, and conclusion) and Criterion d (i.e., report, investigate, or contain results relating to the aim of this literature review) proved particularly difficult to achieve.
As shown in Table 1, the articles were then read and sorted again in relation to the inclusion criteria, and this time Criterion c reduced the total by 24. By compiling the results from each database search into one, recurring identical articles were eliminated (n = 3); thus, remaining articles totaled 11. One article was added by going through article reference lists (Moore et al., 2002), bringing the total search result up to 12 articles. The result from this search procedure was categorized by publication year and presented in the literature matrix (Garrard, 2006). Refer further to Table 1.
As shown in Table 2, the material for the thematic analysis was made up of 12 articles with different methodological approaches: four articles using qualitative methods, four articles using quantitative methods, two literature reviews, and two articles using mixed methods. Four of the articles could possibly report on results evident in other articles. Two literature reviews used in the analysis hold the potential for including other articles used in this literature review (Gildberg et al., 2010; Muir-Cochrane & Mosel, 2008), and two articles reported from the same study (i.e., Mason, Coyle, & Lovell, 2008; Mason, Lovell, et al., 2008). On the other hand, the reoccurrence of results in the included review articles did not have any significance in regard to the results of this article, as this was taken into account in the presentation of the results. Also, the two articles reporting from the same study were included because they were reporting different perspectives on the same data material. Looking at the material used in the thematic analysis, it becomes clear that most of the articles report on studies using only staff as participants. Three studies include both staff and patients, but none of the studies include the patient perspective alone; hence, further research in this area would be welcome.
Result of Thematic Analysis
The analysis of the literature listed in Table 2 resulted in three themes: “humor as staff skill,” “humor as a relational tool,” and “the impact of humor on patients.”
Humor as Staff Skill
Humor as staff skill is represented by literature indicating that staff found humor to be important as a staff skill or trait. As a staff skill, the use of humor among and between staff is seen as an important skill or strategy for coping with stress and negative feelings derived from clinical practice (Sandhu, Rose, Rostill-Brookes, & Thrift, 2012). Boumans, Egger, Souren, Mann-Poll, and Hutchemaekers (2012) point out that staff use of humor influences decision-making in regard to the use of seclusion. However, it remains unclear as to exactly how (Boumans et al., 2012). The theme is somewhat tenuous as most of the literature merely mentions humor as a skill and does not go on to explain how, when, and what kind of humor is used. However, this analysis of international research literature shows that forensic mental health staff consistently identify humor as an important skill in forensic mental health nursing (Carver & Morrison, 2005; Mason, Coyle, et al., 2008; Mason, Lovell, et al., 2008; Moore et al., 2002).
Humor as a Relational Tool
The second theme, “humor as a relational tool,” may offer an explanation as to why forensic mental health staff identify humor as an important skill. This theme is characterized by staff as the use of humor by staff in order to engage patients on a relational level. Minden (2002) states that humor is perceived as disarming from a relational perspective by both staff and patients, whereas at the same time some staff members perceived the humor group intervention as challenging to the institutional order in regard to their own position in the ward hierarchy (Minden, 2002). However, Gildberg et al. (2012) indicate that, when used in informal everyday practice, staff tend to use humor as a way of building and maintaining relationships with the forensic mental health patient (Rask & Aberg, 2002), in that it holds the potential to create communicational bonds between humans (Talerico, 2012). From a relational perspective, staff use humor with the intention of creating something positive in the staff–patient relationship. According to staff, humor is connected to the establishment of a trusting relationship by reducing severity and showing a more human side of staff. At the same time, the use of humor would seem to presuppose trust and a sense of what would be appropriate use of humor in the unique relationship in order to counter for misunderstandings, which, according to staff, potentially can escalate into conflicts (Gildberg et al., 2010, 2012; Tetlie, Heimsnes, & Almvik, 2009). The use of humor by staff appears connected to the informal purpose of establishing and maintaining relationships with forensic mental health inpatients but may also be used in the interaction with the unarticulated intention of observing the patients reaction to humor in order to observe patients’ ability to understand that humor (Gildberg et al., 2012).
The Impact of Humor on Patients
According to forensic mental health staff, the use of humor can be used to minimize potential conflicts, but at the same time, staff point out that misunderstood humor may lead to confusion and may indeed escalate into conflict with the patient (Gildberg et al., 2012; Minden, 2002). Also from the point of view of staff, the literature suggests that humor directed toward paranoid patients and in conflict situations should be avoided because of potential conflict escalation and misunderstandings (Gildberg et al., 2012; Minden, 2002). Why this is and what kind of humor leads to confusion or conflict is unclear because of a lack of detail in the results reported in the article. On the positive side of humor impact, humor can be used as positive reinforcement in regard to physical activity (Tetlie et al., 2009) and used as a tool for reducing absconding behavior (Muir-Cochrane & Mosel, 2008). However, this is only mentioned in passing in the literature, and no explanation is offered as to how humor can be used proactively to reduce absconding behavior. Humor is also reported as having a positive impact in getting patients to relax and open up, and supporting patients to relate to their surroundings (Gildberg et al., 2010; Minden, 2002). Minden (2002) reports that humor as a group intervention has a positive effect on patients’ perceived mental, social, physical, and spiritual dimensions of health. One hundred percent of the participants in Minden’s (2002) study experienced a positive effect on the mental dimensions of health, and 77% experienced a positive effect on the social dimensions of health. These findings are limited by a number of confounders, and the author claims no causality between humor and health but points out that humor used in humor groups has a positive impact in regard to the patient experience.
Normally one could expect that a review and analysis would present a substantial result, where the questions asked could be answered from different perspectives, with similarities and differences in findings strengthening themes. This unfortunately is not the case; the themes presented are not substantial in this regard and need to be regarded as “emergent,” because of the limited literature in regard to the subject under study. Consequently, the results make it clear that more research concerning humor and forensic mental health is warranted.
Although humor described in the existing literature would seem important for staff and the staff–patient relationship having a positive impact on patients, one could argue that the use of humor also presents a pitfall for misunderstandings, leading to conflicts and perhaps violence (Gildberg et al., 2012). On the other hand, if that is so, why would staff use humor in clinical practice to begin with? One of the reasons for using humor, according to mental health staff, is to establish and maintain relationships (Gelkopf et al., 1994; Gildberg et al., 2012; Struthers, 1999; Sumners, 1990). However, as well as holding the possibility of creating a sense of togetherness, the possible misunderstanding of humor or the insensitive use of humor can lead to hurt feelings and thereby damage the relationship (Astedt-Kurki, Isola, Tammentie, & Kervinen, 2001).
To belong to and to be accepted by a group is important for most people. Humor has multiple functions and can be a key for opening up interpersonal relationships. Just as conflicts can tend to separate people, humor and shared laughter hold the potential power to unite people (Ziv, 2010). Examining humor from a social group perspective can also be used as a way to exclude strangers from participation. This is mainly due to a tendency to develop a “private” understanding and use of humor. Private jokes reflect group norms and experience; hence, if a person cannot laugh with the group, the person does not belong and consequently the person may be marginalized from the group (Ziv, 2010). Humor used by mental health staff in the interaction with the patient could be seen as a way of consolidating the asymmetry in the relationship between staff and patients (Gelkopf, 2011; Hampes, 1992; Struthers, 1999).
However, a problem seems to arise when humor is brought into use in clinical practice as an unspoken way of judging the levels of “insanity” and social norms (Kidd, Miller, Boyd, & Cardena, 2009; Struthers, 1999). If the use of humor is situated in the context of forensic mental health care and the power defining normality only belongs to staff and not to patients (Gildberg et al., 2012), the use of humor holds the potential for a hidden relational alienation. As such, a patient who does not understand humor used by staff may become a matter of “insanity” in the eyes of staff (Kidd et al., 2009). Because this judgment, passed by staff, remains unarticulated in the presence of the patient, it simply removes the possibility for the patient to explain their reaction or lack thereof. Different kinds of humor and use outside mental health care may very well also involve defining powers over the concept of normality, but it could be argued that it has no consequences for the one whose reaction to humor is deemed insane outside “the walls” of mental health institutions. Whereas the hospitalized patient’s response to humor could be argued to represent a risk of being misinterpreted and thus influence the grounds of mental evaluation inside the walls of a mental health institution, simply because concepts of normality and abnormality may be constrained in such a setting (Kidd et al., 2009).
However limited, findings of this review indicate that humor used in the interaction between forensic mental health staff and patients can be perceived as a staff skill and a relational tool. From a broader perspective, the positive effects of humor should be acknowledged in that, for example, humorous movies are reported as having a positive effect on hostility, anxiety, and the experience of staff support (Gelkopf, Kreitler, & Sigal, 1993) and may reduce levels of psychopathology and at the same time improve patients social competence (Gelkopf, Gonen, Kurs, Melamed, & Bleich, 2006). The findings also illustrate that the area is sparsely represented in forensic mental health research literature. Looking more broadly across mental health literature, Gelkopf (2011) argues for the importance of humor in relationship building and maintenance (Dziopa & Ahern, 2009; Scanlon, 2006), but also that humor should be used with sensitivity and skill in order to counter “self-defeating” (Gelkopf, 2011, p. 6) use of humor. Astedt-Kurki et al. (2001) also argue that humor therefore must be client-centered, drawing to attention that the nurse and patient should laugh “with” and not “at” each other. Whereas laughter is a universal phenomenon, humor is individual disposition, and what makes people laugh is therefore not universal (Astedt-Kurki et al., 2001).
Implications for Clinical Forensic Nursing Practice
Because of the sparse research in the area on which this article was based, the development of extensive implications for forensic mental health nursing would be stretching findings too far at this time. However, in light of the outcomes of this literature review, humor is considered an important staff skill but also plays a role in the building of staff–patient relationships. Therefore, clinical awareness should be centered on how to avoid the potential pitfalls of social exclusion, risk of alienation, and pathologization of patients. Consequently, clinical forensic nursing theory and practice should continue to develop the debate as to how humor is to be used as a relational and social attribute within forensic settings. This being said, it would seem that humor is not an area that can be reduced to a scientific formula and “applied” (as one would apply pressure in order to stop bleeding) but should perhaps be viewed as a necessary integral constituent of clinical and situational awareness within the everyday practice of forensic mental health staff.
The results of this review are limited by articles being solely peer reviewed (i.e., no “gray literature” considered) and written in English, Danish, German, Norwegian, or Swedish. This decision to exclude articles written in other languages was made for pragmatic reasons, that is, the language fluency of the reviewers. A significant number of articles (n = 87) were excluded by reading abstracts and removing articles that did not state an aim, method, results, and a conclusion or did not report, investigate, or contain results relating to the aim of this literature review (see Table 1). Utilizing the structure known as IMRAD (Introduction, Method, Results, and Discussion) as a model for building up scientific papers was chosen as a standard for research articles, not only because it has been used widely since 1940 but also because the elements of IMRAD are needed in order to identify and judge the quality and coherence of the research reported in the articles (Sollaci & Pereira, 2004). The choice however means excluding a large portion of literature that potentially could hold a deeper insight into the characteristics and impact of humor in forensic mental health, and this should be taken into account.
The literature search resulted in 12 articles relating to the characteristics and significance of humor used within the forensic mental health setting. The result of the thematic analysis identified that the use of humor according to literature is characterized by three themes:
- • “humor as staff skill,” that staff found humor to be important as a staff skill or trait;
- • “humor as a relational tool” with the purpose of establishing and maintaining relationships with the forensic mental health inpatients;
- • “the impact of humor on patients,” describing both positive and negative impacts on conflicts, dimensions of health, and motivation.
The results of the analysis are however limited, mainly because of the limited number of published articles addressing humor in forensic mental health staff–patient interactions. As a consequence, the results presented must be considered as “emergent” and indicative of the need for further investigation to take place.
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