An Overview of the Science and Practice of Humor—HA!
Authors: Neil Shulman, MD, Humorist, Associate Professor, Emory University School of Medicine, Atlanta, GA; and Zoe Haugo BA, Clown Ministry, Atlanta, GA.
Editor’s Note— "I have good news and bad news,’ the doctor said. The good news is you have less than twenty-four hours to live.’ If that’s the good news,’ exclaimed the patient, what’s the bad?’ The doctor replied, I couldn’t reach you yesterday.’"1
Due to the tremendous explosion of knowledge in medicine, the hospital/clinical setting has become infused with stress. Because there is such a vast array of tests that can be done and medicines that can be prescribed, the diagnosis and treatment of disease has become more complicated. Health care professionals are under enormous pressure to keep up with the technological advances and ever-increasing paperwork. This limits the time they can spend with patients. An average patient visit is 2 minutes,2 and there are as many as 98,000 fatal mistakes made in American hospitals each year.3
The stress of illness or injury is often compounded by the stress of treatment expenses, inability to understand the medical procedures or technical language, and frustration with the impersonal system of health care delivery. There is an urgent need to improve doctor-patient rapport. Humor can improve communication with patients and can help prevent health professionals from experiencing burn-out and stress-related illnesses.4 Humor also has therapeutic value on a physiological level, in that laughter can ease pain, boost the immune system, and provide cardiovascular exercise. A humor agenda may prove to be an indispensable part of the health care package for both the receivers and providers of medical care! The following article will include some effective examples of how to turn glum into fun.
Humor: Definitively!
The Oxford English Dictionary defines "humor" as "that quality of action, speech, or writing which excites amusement; oddity, jocularity, facetiousness, comicality, fun." In psychological terms, humor includes cognitive, behavioral, psychophysiological, emotional, and social elements. Humor can refer to "a stimulus (eg, a comedy film), a mental process (eg, perception or creation of amusing incongruities), or a response (eg, laughter, exhilaration)." Laughter is "a respiratory-vocal-behavioral pattern" that produces a certain set of psychophysiological responses, and an emotional state of exhilaration."
Theoretically, humor has therapeutic value. While the positive effects of laughter are readily measured, it is more difficult to evaluate the benefits of humor to date because of the many variations in definition and the resulting inconsistencies in methods of research. Further studies with better controls are needed to resolve the sometimes inconclusive or anecdotal results of the existing studies.5 Regardless of strategic difficulties in evaluation, humor does unquestionably create a positive and healthy atmosphere for patients and doctors.
Humor Therapy: A Historical Perspective
"A good laugh and a long sleep are the two best cures."—Irish Proverb1
The word humor is derived from the Latin root "umor," which means fluid or liquid. In the Middle Ages, humor was thought of as an energy that determined one’s health and emotional state, and was related to one’s body fluid. A sanguine humor, for example, was a cheery disposition associated with blood, while a choleric humor was an angry temper associated with bile.6
The healing properties of joy and mirth have been valued throughout history. In biblical times, it was believed that "a merry heart doeth good like a medicine" (Proverbs 17:22; [King James Bible]). In the early 13th century, there were a handful of physicians and philosophers who claimed that laughter provided physical exercise to both the muscles and inner organs of the body, improved digestion, increased respiration, enriched the blood, and improved circulation.5 Henri de Mondeville, a professor of surgery in the 1300s, proclaimed, "Let the surgeon take care to regulate the whole regimen of the patient’s life for joy and happiness, allowing his relatives and special friends to cheer him, and by having someone tell him jokes."6 Dr. Thomas Sydenham, a 17th century physician was convinced that, "The arrival of a good clown exercises more beneficial influence upon the health of a town than of twenty asses laden with drugs"7 (see Figure 1). Florence Nightingale wrote in the 1860s that the fears suffered by patients in hospitals concerning their physical condition and confinement were "far better dismissed by a real laugh."8
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| Figure 1 |
The Beginnings of Clinical Research
The first clinical laughter research in the United States was conducted in the 1930s by Dr. H.A. Paskind, who examined how laughter affects muscle tone, closely followed by Dr. E.L. Lloyd’s documentation of its respiratory benefits. In 1953, Dr. William Fry began researching the emotional, psychological, and physiological effects of laughter. One of his important findings was that it enhances alertness, learning, creative thinking, and memory.5
The modern medical community did not start seriously exploring the validity of humor therapy until the 1970s. Norman Cousins’ 1976 book, Anatomy of an Illness, inspired a dramatic acceleration in laughter and humor research. The book described his self-treatment for ankylosing spondylitis, a progressive degenerative disease of the collagen tissue. Cousins initiated his own laughter therapy program of viewing amusing films, and discovered that 10 minutes of belly laughter provided him with 2 hours of pain relief. He found that he was able to sleep comfortably without analgesia or sedation after a good bout of laughing, and he also discovered a decrease in his rate of sedimentation, which correlated with a reversal of the inflammatory response.4 In medical parlance, this is called a "sed rate" or ESR, which stands for erythrocyte sedimentation rate. It is a general measure of inflammation in the body and a nonspecific way to tell if somebody has an inflammatory illness or is improving once the diagnosis is made. It is like a fever in that respect since it does not help with diagnosis, but it is a good tool to tell if somebody is ill. After recovering, Cousins spent his final years of life conducting studies at UCLA’s Department of Behavioral Medicine doing research in this area. He started the Humor Research Task Force to support and coordinate international clinical humor research.6
Physiological Response
Laughter has been found to have musculoskeletal, endocrine, cardiovascular, immunological, and neural benefits.5 The bed-bound patient can enjoy belly laughter as an alternate form of cardiovascular workout9 (see Figure 2). It increases heart rate and peripheral vascular flow due to vasodilatation4 and reduces blood pressure in the long run.9 It has a cleansing effect similar to deep breathing as it increases respiratory rate and depth, and empties the lungs of more air than they take in.4 This can be beneficial for patients suffering from respiratory ailments such as emphysema,9 although vigorous sustained laughter may aggravate certain conditions such as asthma or bronchitis.4 Vigorous laughter is a workout for the diaphragm, abdominal, intercostal, respiratory accessory, and facial muscles. Even the muscles in the arms, legs, and back are sometimes involved if laughter is vigorous enough.4
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| Figure 2 |
Muscle relaxation is another end result of laughter, since the muscles required to laugh get exercised and then relax when the laughing ends, while those not involved get a chance to relax during the actual laughter.9
Psychoneuroimmunology
This area of research explores the neurological system’s mediation of the relationships between human emotional experience and immune responses.6 Psychoneuroimmunological studies prove the interrelation of mind and body; positive emotions enhance the immune system, while negative ones suppress it.4
Laughter is an effective distraction for patients with pain. It also can be particularly useful as intervention for painful medical procedures because it raises the threshold for discomfort, and its effects can last for 10 minutes or longer after the laughter subsides.10 It also facilitates communication between technician or doctor and makes the procedure more tolerable if not more comfortable.
The immune system has been shown to be positively influenced by laughter-induced changes in catecholamine and cortisol levels. According to the studies of widely renowned laughter researchers, Dr. Lee Berk and Dr. Stanley Tan, laughter induces a eustress state. This positive state boosts the immune system by causing an increase in the number and activity level of defensive immune cells, including activated T cells (which attack and kill viruses and tumor cells), antibody IgA (salivary immunoglobulin A, which fights upper respiratory tract infections), gamma interferon, IgB,5 (a hormone that regulates cell growth and fights viruses) and Complement3 (which helps antibodies pierce weakened cells).5 These increased levels continue in the body until the day following the bout of laughter. Laughter also decreases the levels of neuroendocrine hormones such as epinephrine, cortisol, dopac, and growth hormone, all of which are associated with stress-induced constriction of blood vessels and suppression of immune activity9 (see Figure 3). A recent study into allergen-induced wheal reactions suggests that laughter may alleviate symptoms associated with allergic diseases, such as atopic dermatitis.11
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| Figure 3 |
Even forced or pretend laughter has beneficial effects. Dr. Madan Kataria started a movement of Laughter Clubs in India in 1995, which has since been transported to and spread throughout the United States and Canada. This form of laughter therapy involves a series of creative group laughter exercises with no use of humorous prompts to initiate the laughter. In essence, the participant is going through the motions and pretending to laugh. Though the laughter isn’t spontaneous, many of the physiological benefits are the same, and it often does turn into true laughter. The act of pretending to be mirthful eventually tricks the body into believing it. Laughter leaders across the United States have observed positive responses in long-term care facilities. Patients with Parkinson’s disease have fewer tremors during the laughter exercises, and their coordination improves. Alzheimer’s patients are able to remember the exercises between sessions.12
Psychological Response
"One of the most adaptive ways a human being has of dealing with severe illness and also with the finality of death itself is through humor." — Ramond Moody, MD1
Humor can be an important psychological coping mechanism. Laughter can provide a cathartic release of emotional tensions.6 Illness and hospitalization often induce fear, anger, depression, a sense of helplessness, and loneliness in patients. The stress that comes from invasive medical procedures, technology and intimidating terminology that is difficult to understand, separation from loved ones, and unfamiliar caregivers can impede recovery.4 Humor causes a shift from negative to positive emotions,13 influencing perceptions of and responses to change.4 By reframing perspective, humor shares something in common with and can help supplement cognitive behavioral psychotherapy, which focuses on helping patients rethink things in less depressing terms. It is based on the premise that depressive thinking is a learned behavior and thinking pattern and can be reprogrammed. It is one of the more successful methods to treat depression outside of medication. It allows the detachment and the "positive reinterpretation" necessary to cope with distress (see Figure 4). Being able to laugh at our problem fosters a feeling of power and superiority over it, and helps to prevent slipping into feelings of depression or helplessness. Those who have more humor in their lives experience less mood disturbance from stressful circumstances than those who are lacking the ability to sense and appreciate humor. In the words of Bill Cosby, "If you can laugh at it, you can survive it."6
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| Figure 4 |
Humor aids in healthy, positive interpersonal relations by promoting social bonding, intimacy, and conflict resolution.13 It humanizes the doctor and all his or her interactions with patients. Robin Williams starred in the hit movie Patch Adams released in 1998, the true story about a clown doctor dedicated to fun and free health care. The success of this film may have reflected a societal craving for and interest in better bedside manner. According to recent Scandinavian research, a patient laughs an average of 4 times during a visit with the doctor. The doctor gives no response 70% of the time, and only reciprocates with laughter 10% of the time. This creates an awkward dynamic between doctor and patient. Laughter is an invitation to share on a deeper level with the patient, and when it isn’t returned, the "professional" distance and neutrality is often a barrier in communication14 (see Figure 5). Humor is an effective way for health professionals to improve communication and patient education. It captures attention, enhances the retention of information, and dissolves the tensions that impede the ability to learn.4 It also increases the chances of a patient asking important questions and complying with the treatment protocol. Since compliance is the most important step in treatment, this is no small consideration.
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| Figure 5 |
Humor is also an effective tool for overcoming the hurdles of working in the health care profession. Health care providers are prone to "compassion fatigue" —that burnt out feeling of having little left to give.6 Further, employees in a stressful environment such as a hospital or clinic are at risk for coming down with stress-related illnesses.4 Tension between co-workers in a health care facility can also make patients feel uncomfortable. Finding ways to infuse fun and humor into the health care environment promotes a more relaxed and nurturing atmosphere for both staff and patients.
NOT a Laughing Matter!
Humor can be destructive if it undermines the patient’s feelings and wishes.4 There are inappropriate moments to poke fun, and everyone’s sense of humor is different. If attempts at levity aren’t working, just stop the joking around. Make sure to not make exclusionary inside jokes between staff within range of sight and sound of the patient. Never use material that may be ethnically, racially, or sexually offensive. Apologize in earnest if a patient or their family is insulted or misinterprets the humorous intentions. The aim of using humor is to make the patient feel comfortable, not ostracized.4 The safest way to initiate humor is to get to know the patient first and establish a sense of trust. But always end on a more serious note letting the patient know that you are taking them and their illnesses and treatment seriously.
Even when good patient-doctor rapport is established, there are inappropriate moments to poke fun in a medical setting. Although laughter can be helpful in reducing the patient’s anxieties prior to surgery, it can cause the patient physical pain to laugh in the time immediately following surgery. In general, humor is appropriate in a chronic situation or when things have settled down and not in an acute situation.
There are also times when laughter is not a healthy behavioral response. Too much joking around can also indicate a denial of the seriousness of an illness.1 Laughter can also be a physical manifestation of the illness a patient suffers. Pathological laughter sometimes accompanies conditions such as multiple sclerosis15 or the suffering from a traumatic brain injury.16 Although this is rarely a problem, pathological laughter from patients is less common than pathological seriousness among doctors.
On the Job: Humor Inserts
In a serious situation, sometimes the most helpful thing a health professional can do is give the patient permission to laugh! While illness and death are not funny, many of the things that happen around them are. The hospital, while far from being a funny place, is the breeding ground for all sorts of absurd occurrences. Encourage patients to keep a journal of all the absurd things that happen during their illness.17 Just because they are a patient does not mean they cease to have the sense of humor with which they came into the hospital. If they had no sense of humor (and who really doesn’t or would admit to it?), this is as good a time as any to develop one.
Humor can be a vehicle for health workers to express their empathy for the struggles of the patient. Shared laughter unites individuals and helps physicians/nurses and patients to connect on a more human level.1 The complaint about a hospital gown being too short or revealing can be met by a comment such as, "Well, you know you’re being admitted for observation." Humor also serves to reframe unpleasant circumstances or anxiety-inducing situations, such as being in the hospital. For example, when instructing the patient in the use of the call light, the health worker can liken it to a room service button. After completing a ventilator check or blood gas analysis, the health worker can smile and say, "Well, you look good on paper. How does it feel on the inside?" These types of comments may not be side-slappingly funny, but they can help to relax the patient and create an environment of lightheartedness4 (see Figure 6). A computer questionnaire called SMILE (Subjective Multidimensional Interactive Laughter Evaluation) is one of a number of humor aids currently available to hospitals and doctors. It provides a customized humor prescription of material appropriate for the patient’s tastes and personality.18
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| Figure 6 |
There are a growing number of humor enthusiasts infusing the medical world with laughter. The following are just a few examples of success stories in the realms of the ridiculous. Morton Plant Hospital in Clearwater, Fla, has a volunteer Comedy Connection program run by Leslie Gibson, RN. It has been a model for hospital humor projects worldwide for more than 10 years. The Comedy Connection has a troupe of volunteer clowns who make patient visits on a regular basis, as well as a storeroom full of Comedy Carts stocked with humorous video tapes and vcrs, audio tapes and cassette players, books, toys, tricks, and games that patients can use free-of-charge during their hospital stay.
In 1986, New York’s Big Apple Circus developed a Clown Care Unit (CCU) of professionally trained circus clowns who dress up like doctors and make clown rounds in children’s hospitals, administering "red nose transplants, kitty cat’ scans, and chocolate milk transfusions," to young patients. The CCU has since spread to other major cities, including Boston, Chicago, Miami, Seattle, Washington, and Atlanta, and there are now also affiliate programs in France, Germany, and Brazil.19
At Washington University in St. Louis, they take their funnies seriously. The school of medicine has developed a Clown Doc’ program of real doctors who dress up as clowns to do their rotations at the children’s hospital. Medical students can take a Medicine of Laughter class, and learn how to make clown rounds for credit towards their degree, under the tutelage of Dana Abendschein PhD (see Figure 7).
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| Figure 7 |
The real Patch Adams started the Gesundheit! Institute in West Virginia in 1971. He and his national crew of clowns and doctors promote and conduct humorous house calls to hospitals and orphanages through newsletters, web sites, workshops, and international onsite visits. They hope to build the world’s first silly hospital, where fun and play will be the foundation. Patch encourages doctors to try wearing a costume or clown nose to work, to stock their pockets with tricks and fun props, and to look to both the masters of comedy and to children for the creative inspiration to find fun in everyday encounters.7
Even in circumstances in which health professionals feel uncomfortable trying any funny stuff in their interactions with patients, there are many ways to incorporate humor into the medical workplace. Laughing at oneself is a great start for lightening the mood. Post photos of each staff member at 1 month old in the waiting room and ask the patients to identify who is who (see Figure 8). Keep an eye out for the real life bloopers that happen every day, and share anecdotal stories with patients. Encourage patients to tell their humorous stories of what they have experienced.
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| Figure 8 |
There are some very funny books about illness and recovery authored by former patients, such as Surviving the Cure by Janet Henry, Please Don’t Stand on my Catheter by T. Duncan Stewart, and Patients at Large by cartoonist Tom Jackson.4 There are also doctor-authored humorous books that demystify medicine. Some examples are FinallyI’m a Doctor,20 101 Ways to Know if You’re a Nurse,21 and the children’s book, What’s in a Doctor’s Bag?22. Humorous books and magazines make great fodder for doctors’ waiting room tables. Pinning up cartoons on walls and doors can also brighten up the clinical atmosphere. Spread cheer by sending out humorous newsletters to staff and patients. Throw a party for all the patients on a ward. Mime a serenade of appreciation to a fellow staff member. Be inventive! Readers are invited to share their innovative approaches to using humor in their practices at www.dochollywood.com.
Summary
Humor is a social lubricant that is invaluable to the stress-infused medical environment. It aids in communication, promotes relaxation, and is one of the best coping tools for both patients and health professionals. Laughter not only makes the mind feel good, but it does the body good. It eases physical pain, it has cardiovascular and respiratory benefits, and it strengthens the immune system. A sense of humor is a crucial component in the delivery of quality health care. As long as it’s not at the expense of others, the creative possibilities for boosting the laughter levels are limitless!
References
1. Klein A. The Courage to Laugh. New York, NY: Penguin Putnam Inc; 1998:3-66.
2. Shulman N, Sobczyk R. Your Body Your Health. Amherst, NY: Prometheus Books; 2002: 15.
3. Medical Errors & Patient Safety. Agency for Health Care Research and Quality. www.ahrq.gov/qual/errorsix.htm
4. Wooten P. Laughter as Therapy for Patient and Caregiver. In: Hodgkin (ed) Pulmonary Rehabilitation. Philadelphia, Pa: Lippincott; 1993.
5. Martin RA. Humor Laughter, and Physical Health; Methodological Issues and Research Findings. Psychological Bulletin. 2001; 127:504-519.
6. Wooten P. Humor: An Antidote for Stress. Holistic Nursing Practice. 1996;10:49-55.
7. Adams P, Mylander M. Gesundheit! Rochester, Vt: Healing Arts Press; 1998: 65-75.
8. Brennan B. Depressed? Ya gotta Laugh. The Calgary Herald. Calgary, ON; Oct. 18, 1998.
9. Humor: Therapeutic Benefits of Laughter. Holistic-online. www.holisticonline.com/Humor_Therapy/humor_therapy_benefits.htm.
10. Pasero CL, McCaffery M. Is Laughter the Best Medicine? Am J Nurs. 1998:98:12-14.
11. Kimata H. Effect of Humor on Allergen-Induced Wheal Reaction. JAMA. 2001;285:738.
12. Kwan J. How Clowns Can Share the Soul and Spirit of Laughter Clubs With Seniors. www.worldlaughtertour.com/pdfs/Kwan-Hosp%20clown%20newsletter.pdf.
13. Keltner D, Bonanno GA. A Study of Laughter and Dissociation: Distinct Correlates of Laughter and Smiling During Bereavement. J Pers Soc Psychol. 1997;73:687-702.
14. Dobson R. Doctors fail to see the joke. BMJ. 2002;325:561.
15. Feinstein A, et al. Prevalence and neurobehavioral correlates of pathological laughing and crying in multiple sclerosis. Arch Neurol. 1997;54:1116-1121.
16. Zeilig G, et al. Pathological laughter and crying in patients with closed traumatic brain injury. Brain Inj. 1996;10:591-597.
17. Klein A. The Healing Power of Humor. New York, NY: Penguin Putnam Inc; 1989: 178-181.
18. SMILE Programs and Services. www.humoru.com
19. Big Apple Circus Clown Care Unit. www.bigapplecircus.org/CommunityPrograms/ClownCareUnit/
20. Shulman N. FinallyI’m a Doctor. Decatur, Ga: Rx Humor; 1996.
21. Shulman N. 101 Ways to Know if You’re a Nurse. Decatur, Ga: Rx Humor; 1998.
22. Shulman N, Fleming S. What’s In A Doctor’s Bag? Decatur, Ga: Rx Humor, 1994.
A humor agenda may prove to be an indispensable part of the health care package for both the receivers and providers of medical care! The following article will include some effective examples of how to turn glum into fun.
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