PTSD and Laughter

By Joanne Strawder, MSW, Licensed Clinical Social Worker
and Guy Strawder, MMFT, MHA, USA Lieutenant Colonel (Retired); Resident, Marriage and Family Therapy

Post-traumatic stress disorder (PTSD) describes the psychological distress suffered following an extreme or life-threatening event, with clinical manifestations that include: intrusive thoughts, dreams and flashbacks; avoidance of stimuli (triggering events) associated with the traumatic episode; negative thoughts about oneself and an inability to experience positive emotions; and hypervigilance (American Psychiatric Association, 2013). Individuals suffering from PTSD often fluctuate between moods of depression, anger, and the need to detach from others.

Among combat veterans surveyed following their deployments to Iraq, the majority of soldiers “were exposed to some kind of traumatic, combat-related situations, such as being attacked or ambushed (92 percent), seeing dead bodies (94.5 percent), being shot at (95 percent), and/or knowing someone who was seriously injured or killed (86.5 percent)” (Hoge, 2004, as cited in Department of Veterans Affairs and Department of Defense, 2010, p. 63). Similar results have been identified among service members in Afghanistan with more than 60% of veterans having experienced ambushes, gunfire from enemy forces, and improvised explosive devices (Peterson, Luethcke, Borah, Borah, & Young-McCaughan, 2011, p. 165).

It is important to appreciate that not every combat experience will result in some debilitating psychological state. What has become remarkably apparent from multiple studies of combat-related PTSD is how these events can potentially injure the central structures within the brain responsible for memory and emotional reactivity—namely, the limbic system and the amygdala. When the brain experiences these episodes of emotional trauma, it is a remarkably resilient organ that responds by defending itself from future insults.

In most individuals, the right hemisphere of our brain is the location where our creativity and sensory perception lies, and it is here where we process emotion, insight, intuition, facial recognition, and body language. The left hemisphere of the brain is the domain of our advanced cognitive abilities—e.g., analytical reasoning, logic, speech production and language comprehension. As a protective defense to prevent further insult, the limbic system signals to the right hemisphere of our brains to remain on alert for any stimuli, sign or threat that could be associated with the original trauma.

When this occurs, the right-brain becomes hypervigilant in scanning the environment for nonverbal danger cues in other people’s body language, facial expressions and even their tone of voice for signals of danger and threat. The right-brain, in effect, suppresses the executive decision-making of the left-brain’s ability to think analytically and rationally.

In 2007, the National Academy of Sciences’ Institute of Medicine conducted a thorough review of the psychological literature on the most effective treatment interventions for PTSD, and concluded that only Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) had “enough empirical support” to substantiate their effectiveness as evidence-based practices (Peterson, Luethcke, Borah, Borah, & Young-McCaughan, 2011, p. 168). In my experience, the interventions from both of these therapies are immensely successful. However, it should be immediately apparent from the prior description of this disorder’s effect on the brain that a client will not be prepared for the psychoeducational component of these interventions nor will they have the cognitive predisposition necessary for CPT until their hypervigilant right-brain has been sufficiently calmed.

In the most severe cases, PTSD has been described as a “speechless terror”—with the service member experiencing a painfully hyper-aroused sympathetic nervous system that is unable to effectively access language comprehension and speech production as the basic elements for talk therapy (Curran, 2013, p. 20). It is easy to see how alternating moods of depression, anger and estrangement from others will emerge as the observable clinical presentation for this condition.

Combat veterans need to revisit their memories to rationally process the associated subconscious thoughts and distorted self-perceptions that they may have internalized as shame, guilt, or weakness. Alternatively, it may be that the emotional hypervigilance has not allowed them to mourn the loss of people who were as close to them as their own family. Without the ability to engage the left-brain’s centers for logic and executive decision-making in this process, talk therapy that prematurely targets cognition can potentially re-traumatize the client. The therapist must focus first on cooling and calming the hypervigilant right-brain. This is often accomplished through multisensory guided imagery and mindfulness-based stress reduction exercises. These exercises do not tax the logic and analytical centers of the left-brain, but instead focus on the ability to detach from distracting and disturbing thoughts, and to visualize safe people, safe places, and even pleasant childhood memories.

What is particularly challenging with combat-related PTSD is the deeply-embedded ethos of strength and determination in the soul of the professional Soldier, Sailor, Airman and Marine. Let’s suspend with political correctness for just a moment to recognize the expectations we have for sustaining the most lethal Armed Force in this history of warfare. As one unit leader from my past days as a paratrooper in the 82d Airborne described us, we were “flat-bellied, beady-eyed, silver-winged doers of death.” That’s the job, and our men and women unapologetically embrace the competencies it requires to be the most feared warriors in the world—willing to kill and die, to suffer extreme hardships, and experience the darkest edge of humanity to protect our freedoms today and the liberties of the generations to come.

It is, therefore, highly counterintuitive for them to initially relax the hypervigilance that they feel protects them—and they often describe these exercises at the outset as making them feel vulnerable, soft and weak. Men, in particular, must often be assured that they can temporarily bend the cultural expectations of both American society and the military while still holding on to their “man card.” These exercises help them to realize that they can become stronger psychologically by confronting emotions and connecting them with rational meaning, rather than the impermanent solutions of avoidance and compartmentalization.

Make no mistake, there are plenty of opportunities in the conduct of these exercises for humor, wit and laughter. Laughter is unquestionably the universal intervention for calming the hypervigilant right-brain (Mobbs, Greicius, Abdel-Azim, Menon, & Reiss, 2003)! It requires no explanation or adjustment on behalf of the client. Although everything in therapy is about timing and the client’s progress in their treatment, humor must always be a mainstay tool used for establishing rapport and for gradually dispelling any extant fear and danger signals. When a client is laughing in a session, I know that definitive cognitive-behavioral therapy for PTSD has truly begun.

Comedy appeals to the right-brain’s emotional perceptions and its desire to feel joy and hope, and it is this desire for the reward of joy where the right-brain permits the left-brain’s awareness and processing power to comprehend the stories and the “punchline.” As the right- and left-brain cooperate, smiles and laughter generate the release of tranquilizing neurotransmitters like dopamine and serotonin. This effect then further activates reward pathways in the brain that can progressively reduce the client’s hyper-aroused emotional state.

Every PTSD case presents as its own puzzle—and each puzzle is as unique as the individual who is seeking treatment. In every case, however, it is necessary to first attune and attend to the combat veteran’s emotional predisposition. Laughter and humor are recognized throughout the medical literature for its positive impact on health, including its ability to increase pain tolerance, enhance the immune system, reduce heart disease, and lower cortisol levels—the very neurotransmitter that is generally overproduced in response to stress!

Laughter enables us to experience joy, and joy feels like a glimmer of hope to the individual who is trapped within the anxious paralysis of PTSD. There are multiple therapeutic routes in individual therapy that can aid in cooling the hyper-aroused right-brain so that it releases its control of our left-brain centers for rational thought, communications, and renewed meaning about our personal experiences. With the possible exception of improved relational attachment, there may be no other intervention more powerful for this purpose than the healing that comes through laughter.

It is for this reason that I so enthusiastically support Laughs for Troops—the mission of this organization is not only deeply committed to raising awareness about PTSD, opening new paths for treatment, and offering financial assistance, but they also provide a tremendously unique resource through comedy events that give respite and healing for the entire family system. Thomas Brown, the organization’s CEO, has an extraordinary vision that seeks to expand current operations towards the development of a resort area for service members and their families that will offer rest, recreational activities, professional therapy and, of course, lots of opportunity for laughter! I have also served alongside some of the distinguished combat veterans and leaders who comprise the Board of Laughs for the Troops. I am proud to serve alongside them again as they genuinely honor the sacrifices of our nation’s military families by their actions—embracing, sustaining and supporting them through the trials they bear with joy, hope and laughter.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Curran, L. A. (2013). 101 Trauma-Informed Interventions. Eau Claire, WI: PESI Publishing and Media.

Department of Veterans Affairs and Department of Defense. (2010). VA/DoD clinical Practice guideline for management of post-traumatic stress. Washington, DC: Department of Veterans Affairs, Department of Defense.

Mobbs, D., Greicius, M. D., Abdel-Azim, E., Menon, V., & Reiss, A. L. (2003, December). Humor modulates the mesolimbic reward centers. Neuron, 40, 1041-1048.

Peterson, A. L., Luethcke, C. A., Borah, E. V., Borah, A. M., & Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war veterans. Journal of Clinical Psychology in Medical Settings, 18(2).