Evaluation of a Humor Training for Patients with Chronic Pain: A Randomized Clinical Trial

Figures & data

Figure 1 CONSORT flow diagram of the trial for primary outcomes.

Table 1 Overview of the Humor Training

Module	Title	Aim	Content
1	Allowing yourself to laugh	Encouraging the expression of joy and cheerfulness; overcoming potential inhibitions	Elaboration of functions and physical effects of laughter; practices to experience laughter; playful exercises to “let yourself go”
2	What humor can do	Imparting knowledge about the positive effects of humor; enhancing the motivation to use humor as a coping strategy	Elaboration of the variety of positive effects of humor on well-being; discussion about the limits of humor and inhibiting believes
3	Rethinking	Fostering the ability to see and evaluate situations in new and humorous ways	Creative, practical exercises to overcome habits and to look at situations from a more humorous point of view
4	Giving humor more space	Embedding the content of the training in everyday life; overcoming hindering emotions	Individual “humor anamnesis“; discussion about inhibiting emotions; creating individual plans for implementing positive and humorous activities

Table 2 Means, Standard Deviations, and Effect Sizes of Primary and Secondary Outcomes for Training and Control Group

		Pre		Post		Pre-Post
	n	M	SD	M	SD	d
Current pain intensity (NRS)
Training group	58	6.41	2.04	4.66	2.37	0.79
Control group	63	6.25	2.05	5.10	2.21	0.54
Depression (DASS-D)
Training group	61	8.15	5.30	6.13	5.29	0.38
Control group	64	8.81	5.80	6.52	5.32	0.41
QLIP
Training group	57	28.91	6.83	21.23	9.74	0.90
Control group	63	27.87	7.88	22.52	9.75	0.60
Cheerfulness (STCI-S)
Training group	51	2.20	0.72	2.52	0.78	0.43
Control group	52	2.17	0.59	2.57	0.64	0.64
Seriousness (STCI-S)
Training group	51	2.71	0.49	2.58	0.57	0.24
Control group	52	2.74	0.58	2.59	0.62	0.26
Bad mood (STCI-S)
Training group	51	2.23	0.74	1.86	0.71	0.52
Control group	52	2.33	0.75	1.86	0.68	0.66
Self-enhancing humor (HSQ-SE)
Training group	52	3.97	1.29	4.27	1.30	0.23
Control group	52	4.15	1.39	4.14	1.33	0.01

Note: Differences in noccur as not all scales have been completed by every participant. As the scales for secondary outcomes STHI-S and HSQ-SE were not included in the German Pain Questionnaire and were handed and filled out separately, a smaller sample resulted for these outcomes. Participants that only had completed secondary outcomes (n = 7) were not included in the quantitative analyses.

Abbreviations: DASS, Depression, Anxiety, and Stress Scales; HSQ-SE, self-enhancing subscale of the Humor Styles Questionnaire; NRS, Numeric Rating Scale; QLIP, Quality of Life Impairment by Pain Inventory; STCI-S, State-Trait-Cheerfulness Inventory – state version.

Table 3 Main Effects and Group by Time Interaction for Training vs Control Group

		Group		Time		Group by Time
	df	F	η^2p	F	η^2p	F	η^2p
Current pain intensity (NRS)	1, 119	0.17	0.00	58.03***	0.33	2.45^†	0.02
Depression (DASS-D)	1, 123	0.36	0.00	27.03***	0.18	0.11	0.00
QLIP	1, 118	0.01	0.00	63.16***	0.35	2.03^†	0.02
Cheerfulness (STCI-S)	1, 101	0.01	0.00	27.51***	0.21	0.28	0.00
Seriousness (STCI-S)	1, 101	0.00	0.00	7.96**	0.07	0.06	0.00
Bad mood (STCI-S)	1, 101	0.14	0.00	38.86***	0.28	0.48	0.01
Self-enhancing humor (HSQ-SE)	1, 102	0.01	0.00	1.70^†	0.02	1.90^†	0.02

Notes: ^†p ≤ 0.10,**p < 0.01, ***p ≤ 0.001 (one tailed).

Abbreviations: DASS, Depression, Anxiety, and Stress Scales; HSQ-SE, self-enhancing subscale of the Humor Styles Questionnaire; NRS, Numeric Rating Scale; QLIP, Quality of Life Impairment by Pain Inventory; STCI-S, State-Trait-Cheerfulness Inventory – state version.

Table 4 Means and Standard Deviations of Feedback Items for Participants of the Training Group (n = 52)

	M	SD
General evaluation of the training
Enjoyment of the training	5.62	1.55
Doing the training’s homework	4.76	1.89
General benefit from the training	5.31	1.49
Anticipation of positive effects of the training before	4.69	1.58
Recommendation of the training to other pain patients	5.50	1.77
Training’s impact on the use of humor
More use of humor in different situations	4.94	1.46
Greater knowledge of the effects of humor	4.84	1.76
Less hesitation to laugh openly	4.50	1.79
Less doubt about making fun of things	3.96	1.71
Training’s impact on perspective change
Changed perspective on life in a positive way	4.73	1.67
Changed perspective on symptoms in a positive way	4.55	1.63
Easier humorous reframing of situations	4.55	1.54
Viewing pain in a more humorous manner	4.29	1.84
Training’s impact on the future
Long-term positive effects on overall quality of life	4.69	1.52
Intention to apply the strategies in everyday life	5.02	1.50

Notes: 1 = totally disagree, 7 = totally agree.

Table 5 Codings for Answers on Open Feedback Questions by Participants of the Training Group (n = 43)

	Number of Codings in Category
Positive aspects of the training (n = 40)	55
Effects of the training	11
Laughter and silliness during the training	10
Content of the training	9
Characteristics of the trainer	9
Everything	6
Group (atmosphere and communication)	4
Setting	2
Hardly any	2
Others	2
Negative aspects of the training (n = 26)	28
Content of the training	10
No negative aspects	4
Group (communication and constellation)	3
Time/duration of the sessions	3
Characteristics of the trainer	2
Practicability	1
Premises	1
Others	4
Potential improvements of the training (n = 27)	35
Content of the training	12
More humor/laughter/playfulness	4
Better premises	4
More sessions	3
Other time of day/duration	3
No need for improvement	3
Larger group size	1
Others	5

Notes: Statements of all participants that had visited one or more training sessions and filled out the feedback questionnaire were included in qualitative analysis. Only one of them was excluded as this patient had participated in the study before. N = 32 visited at least three sessions of the training.