Behdad Bozorgnia, MD, MAPP (Photos by Graham Perry)

What lessons can comedy offer to psychiatry?

By Rachel Ewing

If you’ve been to a psychiatrist, or even just watched a therapy session on TV, you’ve probably had a moment of wondering what exactly that clinician is thinking about while quietly taking notes as a patient spills their innermost thoughts. Behdad Bozorgnia, MD, MAPP, a fourth-year and chief resident in Psychiatry at Penn Medicine, is prepared to tell you: “The thing I spend the most time thinking about as a psychiatrist is how to appear contemplative without appearing constipated,” he says.

That’s a joke.

Bozorgnia, who has performed stand-up comedy in the past and continues to hone his funny bone through humorous writing, will be the first to tell you that joking, especially as a doctor, isn’t easy. But if you make the effort, he argues, comedy has some valuable lessons for the practice of psychiatry.

Words Matter

In one of Bozorgnia’s earliest classes in the subject, he recalls, the instructor advised that psychotherapy requires merely “saying the exact right thing at the exact right time.” While that task is far from a simple one, the same challenge applies in comedy, Bozorgnia says—getting the wording just right to set up the context of a character, tell a story, build anticipation. “It's a lot about understanding the subtleties and effects of words,” he says. “The deeper I get into psychiatry the more I realize that. Words have a lot of power. You have to think about how it's going to change the particular relationship you have with someone.”

Rooted in Relationships

Comedy is rooted in relationships for Bozorgnia. After his family emigrated from Iran to the U.S. when he was a child, he used his penchant for entertaining as a way to fit in: “I realized, as a second grader, these Americans like to laugh, and I've got to win them over, so if I can know how to make them laugh, I can make more friends.” He practiced his jokes, reworking the ones that fell flat, and watched a lot of stand-up comedy as he grew up. In college, at Wesleyan, a friend encouraged him to get into stand-up, and they formed a troupe called Punchline that performed frequently on campus venues. After graduating, he found a few more opportunities to perform—an open-mic night in South Carolina where he “wasn’t booed off the stage but wasn’t received very well, either,” and a performance or two at the Laugh Factory in Philadelphia, where he says the best joke during his time on stage was one made by the next comedian coming on to follow his set. (And it was at his expense.) Now, Bozorgnia mainly expresses his comedic interest through writing.

The Penndulum Swing

What drew Bozorgnia to writing, and to psychiatry itself—he initially favored family medicine—was storytelling. In psychiatry, the patient’s narrative of their behavior is part of their illness and part of their treatment. In writing, Bozorgnia tells his own stories, such as an essay about the shock of his first experience working on an inpatient psychiatric unit. In such stories, he likes to build in punchlines to keep things engaging and light. “It's helpful in psychiatry because we have to deal with a lot of dark themes,” he says. “I think having a sense of humor both helps you explore that and also kind of protects you from having to live through that all the time.”

The same is true of Penndulum, a literary magazine he co-founded and edits with his best friend, Lisa Jacobs, MD, GME’17. Comedy isn’t one of its main selling points. Originally conceived as a magazine by residents, for residents, Penndulum now draws submissions of writing and art from medical students and physicians at all levels, nurses and other health care providers, and even patients, from across the country. The publication tackles heavy subjects that are often hidden and hard to talk about—burnout, mental anguish, and all the difficult points of conflict in medicine.

“One of the things humor allows people to do is be really honest about what makes them uncomfortable,” Bozorgnia says. “That's I think what Penndulum tries to do, too, to get people to be really honest.”

Conflict in Comedy

There’s a problem with comedy in medicine. It’s often pretty bad. But it’s bad for a good reason.

One of Bozorgnia’s favorite punchlines in medical school was just the phrase “classic doctah humah”—that’s “classic doctor humor” said with a thick affected New York accent—to punctuate the silence after anyone in his vicinity made a bad or corny joke. “Doctor humor is often very, very dry and based on puns and things like that,” he says. “It's hard to be really funny and a doctor at the same time because there are a lot of expectations of professionalism.”

Using the kind of sharp honesty that underlies a lot of humor (other than puns), while being careful not to wield it as a weapon that causes patients harm, is a difficult balancing act.  “We're constantly trying to work through that dynamic,” Bozorgnia says. “I'm trying to work through it right now as I'm talking.”

The Lesson of Surprise

Despite these challenges, for Bozorgnia, there are lessons to learn from comedy that help with the practice of psychiatry. It’s a learning process he plans to take with him as he completes his residency this summer and moves on to his new role as an attending psychiatrist with the Veterans Administration.

“It's sort of a verbal sleight of hands,” he says, of comedy. You lead people in one direction and set up an expectation of some serious statement—and then you puncture it with something totally unexpected, a punchline. There’s a formula: Expectation, surprise, laugh, feel good.

“Psychiatry is a lot about a similar thing, sometimes defying people's expectations,” Bozorgnia says. As he sees it, patients who are caught in an unhealthy pattern of behavior are paving their own well-established path of expectations, acting out a script that evokes a predictable response from each person they encounter. A psychiatrist’ job, then, is to deviate from the path and change those expectations. If a patient is trying to anger him, instead of taking the bait, Bozorgnia observes, calmly, “It seems like you’re trying to make me angry.” That unexpected response can surprise the patient and, sometimes, open the door to insight into their own behavior.

The trick is understanding the comedic formula and adapting it to a new purpose: Expectation, surprise, reflect, and start to behave differently.

“I think that psychiatry and comedy are ultimately about getting people to confront uncomfortable truths in a way that doesn't feel too painful,” Bozorgnia says. “Or at least also feels enjoyable as well as painful.”

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