merry heart does good like a medicine,
but a broken spirit dries the bones" -- Proverbs 17:22
can be a powerful therapy for both the patient and the caregiver.
This chapter will examine the beneficial effect of humor
and laughter on the body, mind, and spirit; for the patient
during recovery from illness; and for the health professional
during delivery of care. Most experienced caregivers have
discovered that attention to only the physical body during
treatment will yield a partial or temporary recovery. The
patient's emotional responses, belief system, support network,
etc. all can effect compliance to treatment and ability
to cope with fear, pain, and loss.
The ability to laugh at a situation or problem gives us
a feeling of superiority and power. Humor and laughter can
foster a positive and hopeful attitude. We are less likely
to succumb to feelings of depression and helplessness if
we are able to laugh at what is troubling us. Humor gives
us a sense of perspective on our problems. Laughter provides
an opportunity for the release of those uncomfortable emotions
which, if held inside, may create biochemical changes that
are harmful to the body.
Caregivers, as well as patients are in need of the therapeutic
effects of humor and laughter. Most caregivers are compassionate
individuals who choose to work in a profession that places
them at risk to their physical, emotional and spiritual
well being. Due to our sympathetic tendencies we may feel
the same emotions that our patients feel, such as fear,
anger, helplessness, and depression. We can experience feelings
of failure when our efforts are ineffective. We feel anger
and frustration when a patient rejects our care or is noncompliant
with treatment. We may feel grief when patients die or families
mourn. Caregivers are at risk physically too (e.g., exhaustion
from long shifts with inadequate staffing, exposure to infectious
organisms and physical abuse from combative patients. Health
professionals working in a stress-filled environment are
at risk for burnout and stress-related illness. Our ability
to see the humor in a situation and to laugh freely with
our coworkers can be an effective way to take care of our
own body, mind and spirit.
For thousands of years, the human race has extolled the
health-enhancing benefits of laughter. Current research
by Lefcourt, Guillemin, and Fry in the areas of psychology,
physiology, and psychoneuroimmunology is defining the specific
changes effected by the experience of mirthful laughter.
Therapy is defined as "an activity or treatment intended
to alleviate an undesirable condition." With that in
mind, let's explore the therapeutic benefit of laughter
for the body, mind, and spirit.
Patient Responds to Humor
the last twenty years, I have been active in the profession
of nursing. Most of those years have been spent at the bedside
in intensive care units, I have also worked in home care,
hospice, and cardiac rehabilitation. I can remember many
situations where humor and laughter made a significant difference
in a patient's response to care, but none as profound as
this story. Fred was 60 years old and recovering from a
mitral valve replacement. During his immediate postoperative
recovery, Fred experienced a mild psychosis and severe depression.
The acute psychotic episode resolved prior to discharge,
but the profound depression continued for many weeks. Fred
lacked enthusiasm for anything. He refused to eat, to walk,
and even refused to wear anything but pajamas. His surgeon
referred him to our outpatient cardiac rehabilitation program.
Upon entry into our program, Fred walked with a shuffling
gait, responded to questions with one or two words, and
was unable to make eye contact. His wife was exhausted and
discouraged. For several weeks we saw little improvement
in his depression, in spite of antidepressant drugs and
psychological counselling. One day, about a month after
beginning rehab, he was walking on the treadmill; his 25
lb. weight loss noticeable as his sweat pants hung loosely
over his hips. After about 6 minutes of walking, his sweat
pants suddenly fell down around his ankles, revealing bright
red boxer shorts. We hit the emergency stop button in time
to prevent his falling and went to assist him. He was looking
down at his dropped drawers and when he lifted his head
we could see a big grin starting and he began to laugh.
We smiled and joined him in the laughter, grateful for the
permission to respond by laughing at the ridiculous situation.
Our mutual embarrassment and tension was released through
laughing. From that moment on Fred's depression continued
to resolve, he became involved in his recovery process and
was able to regain his strength and he eventually returned
to an active involvement in his church and community.
this story reminds me of this popular folk poem
Supports Recovery from Illness
Cousins, former editor for Saturday Review, brought the
attention of the medical community to the possibility that
laughter may have a healing potential. In l964, Cousins
was diagnosed with ankylosing spondylitis, a progressive
degenerative disease of the collegen tissue. His physicians
gave him little hope for recovery, indicating that a possible
cause of his illness was due to heavy-metal poisoning. Recalling
his activities in the month prior to the onset of symptoms,
he remembered frequent exposure to diesel exhaust fumes
during his travel in Russia. He suspected that a condition
of adrenal exhaustion weakened his ability to tolerate the
toxic exposure. From his reading of Hans Selye's 1956 book
about the body's response to stress, Cousins recalled that
research had shown that negative emotions could create chemical
changes which would eventually lead to adrenal exhaustion.
He suspected that the positive emotions (such as faith,
hope, confidence and joy) might create changes within the
body which would enhance his recovery process. Since the
behavior of laughing tends to open one to these positive
emotions, Cousins began viewing amusing films to stimulate
laughter. After each laughing episode he noted that he could
sleep comfortably without the need for analgesia or sedation.
He also discovered that laughter also stimulated a decrease
in his sedimentation rate, indicating a reversal of the
inflammatory response. After his recovery, Cousins spent
the last ten years of his life as an adjunct professor at
U.C.L.A. Medical School where he established a Humor Task
Force to coordinate and support clinical research. Today,
25 years after Cousins' experience, we have the scientific
research to explain the specific physiological changes which
his anecdotal story suggested. Laughter does effect the
body, mind and spirit.
is a perceptual process while laughter is a behavioral response.
This behavior creates predictable physiological changes
within the body. As with other exercise, we see two stages
of the body's response, the arousal phase when the physiological
parameters increase, and the resolution phase when they
return to resting rate or lower. With vigorous sustained
laughter, the heart rate is stimulated, sometimes reaching
rates of above 120 bpm; the normal respiratory pattern becomes
chaotic; respiratory rate and depth are increased while
residual volume is decreased. Coughing and hiccups are often
triggered due to phrenic nerve irritation or the dislodging
of mucus plugs. Oxygen saturation of peripheral blood does
not significantly change during the increased ventilation
occurring with laughter. Conditions such as asthma or bronchitis
may be irritated by vigorous laughter. Peripheral vascular
flow is increased due to vasodilitation. A variety of muscle
groups become active during laughter -- diaphragm, abdominal,
intercostal, respiratory accessory, facial, and occasionally
muscles in the arms, legs, and back.
Some of the most exciting research exploring the potential
healing value of laughter is in the area of psychoneuroimmunology
(also referred to as neuroendocrinology or neuroimmunology).
Psychoneuroimmunology is an area of research which explores
the connections between the nervous system (the seat of
thought, memory, and emotion), the endocrine system (which
secretes powerful hormones), and the immune system (which
defends the body from microbial invasions). Loma Linda University
Medical Center has recently completed research showing that
the neuroendocrine system is effected during the experience
of mirthful laughter. This work by Lee Berk and Stanley
Tan has shown that serum cortisol levels decreased with
laughter. Also, the experimental group demonstrated a lower
baseline epinephrine level than the control group (possibly
due to their relaxed status in anticipation of the laughter
experience). Levels of cortisol and epinephrine (known to
be immunosuppressive) are elevated during the stress response
Therefore, Berk and Tan conclude that by decreasing these
levels we can diminish the suppression of the respective
immune components. Other research has demonstrated that
mirthful laughter increases the spontaneous lymphoycyte
blastogenesis and the natural killer cell activity. Natural
killer cells are a type of lymphocyte that have a spontaneous
cytolytic activity against tumor cells.
of stressful life changes, severity of depression, and coping
styles have all been shown to effect the immune response.
Steven Locke of Harvard has shown that the activity of natural
killer cells is decreased during periods of increased life
change accompanied by severe emotional disturbances, whereas
subjects with similar patterns of life change and less emotional
disturbances had more normal levels of N.K. cell activity.
Similar findings were confirmed by Michael Irwin in 1987
at V.A. Medical Center in San Diego, noting that N.K.cell
activity decreased during depressive reaction to life changes.
Janice and Ronald Glaser of Ohio State University School
of Medicine studied the cellular immunity response patterns
of medical students prior to exams. Their work showed a
reduction in the number of helper T-cells and a lowered
activity of the N.K. cell just prior to the exam.In 1985,
Marvin Stein at Mt. Sinai School of Medicine in New York
looked at the effect of conjugal bereavement by studying
men whose wives had advanced breast cancer. His work showed
that the lymphocyte response pattern in his subjects dropped
significantly within one month after the death of their
wives. This finding was also confirmed by the research of
Steven Schleifer and Robert Bartrop.
Research by Arthur Stone of S.U.N.Y. has revealed that salivary
immunoglobulin A (our first line defense against the entry
of infectious organisms through the respiratory tract) response
was lower on days of negative mood and higher on days with
positive mood. This finding was duplicated by Kathleen Dillon
at Western New England College showing an increased concentration
of salivary IgA after viewing a humorous video. The research
in the field of psychoneuroimmunology continues to prove
that the mind (emotions) and the body (immune system) are
interrelated. Positive emotions seem to enhance the immune
response while negative emotions suppress it.
then, may the behavior of laughter be therapeutic to the
body of both patient and caregiver? Laughter is a pleasurable
experience; it momentarily banishes feelings of anger and
fear. It gives us a feeling of power and control; we feel
carefree, lighthearted, and hopeful during the moments of
laughter. These feelings may have therapeutic benefits by
reversing the immunosuppressive effects of the emotions
of anger, fear, or loneliness which often accompany hospitalization
and recovery from illness.
Illness, either acute onset or exacerbation of a chronic
illness can be a stressful event. Hospitalization, separation
from family, invasive procedures, complex technology, or
unfamiliar caregivers can all create feelings of anxiety,
loneliness, discomfort, anger, panic, and depression for
the patient. These emotions are known to produce physiological
changes that are harmful to the body; changes which the
use of humor and laughter can ease. Shared laughter is a
uniquely human bond and serves as an equalizer and "social
Caregivers can express their understanding and appreciation
of the patient's struggle through the use of humor. For
example, when a patient complains about the inadequate length
or coverage of their gown we could respond with: "Well,
now you know your doctor admitted you for observation."
or " It's a designer creation by Seymor Butts."
Humor can also help to reframe a situation by creating a
context suggesting a more pleasant environment. As you instruct
in the use of the call light: "Now I'm going to place
your room service button right here." Or after completing
an uncomfortable procedure, smile and say: "I bet it's
hard for you to believe I'm on your side right now."
When you've completed a ventilator check, blood gas analysis,
or vital sign check smile and say: "Well, you look
good on paper. How does it feel on the inside?" Each
of these statements, while not profoundly funny, will communicate
a gentle awareness of the patient's dilemma and express
a relaxed and lighthearted attitude by the caregiver --
giving the subtle message that the caregiver is confident
and in control of the situation.
But it is extremely important that the patient first be
convinced of the health professional's competence and ability
to deliver expert clinical care. A carefree, joking demeanor
can be used to cover-up inept skills or to deflect and ignore
the importance of a patient's feelings. The appreciation
of humor is highly individual and there are no guarantees
that your attempts will be successful, therefore one must
be observant of the patient's response. Sometimes the response
may be subtle, a glistening of the eyes or flushing of the
cheeks. Of course we all hope for the big smile, chuckle
or playful retort; but if you suspect that the patient felt
insulted or misunderstood your intention, it is helpful
to say something like: "Gee, I sure hope you weren't
offended by that. I was just trying to lighten up the situation
and help you to relax. I didn't mean to upset you, sorry."
If the humorous attempts aren't working with that patient,
then quit. Always remember, never use sexual, ethnic, or
racial material with patients or their families. It is unprofessional
and you risk offending them and losing rapport and respect.
Impact of Humor
and laughter effect how we perceive and respond to change.
Herbert Lefcourt, a noted psychologist from the University
of Waterloo in Canada has explored the possibility that
a sense of humor and its use can change our emotional response
to stress. In this study, subjects were asked to review
the frequency and severity of stressful life changes occurring
to them over the previous six months, and their recent negative
mood disturbances were evaluated. Lefcourt then administered
tests to evaluate use of humor, perception of humor, appreciation
of laughter, and efforts to include opportunities for humor
and laughter into each subjects lifestyle. Results of this
study have shown that the ability to sense and appreciate
humor can buffer the mood disturbances which occur in response
to negative life events.
of the best humor about illness and recovery has been written
by former patients. My favorites are: Surviving the Cure
by Janet Henry, They Tore Out my Heart and Stomped the Sucker
Flat by Lewis Grizzard, Patients at Large by cartoonist
Tom Jackson, Please Don't Stand on my Catheter by T. Duncan
Stewart, and Have a Heart by Wilford Nehmer Jr . Each of
these authors reveal some of the absurdity, irony and incongruity
of being a patient under care. When we choose to laugh at
or about a situation, we give ourselves the subtle message:
"This is not so threatening; look, it's amusing and
absurd sometimes. I can't take it too seriously."
Humor can also influence the mind by enhancing the ability
to learn. Health professionals spend considerable time educating
the patient and family about drugs, diet, lifestyle change
and treatment benefits. Delivering the information with
humor will improve the communication in three ways:
- it will capture the attention of the learner
- it will
enhance retention of the material
- it will
help to release the tension that blocks learning
use of cartoons or funny stories can be an effective way
to add humor. Shown in Figure 1 are four cartoons, drawn
by Tom Jackson, based on real-life situations.
Figure 1. (cartoons shown in original printed work)
Caregivers work in a stress-filled environment and are prone
to professional burnout. A major causative factor in burnout
is powerlessness. Hans Selye, (physician, physiologist,
and pioneer in the field of stress research) noted in 1954:
"Stress is not the event, it's our perception of it."
Susan Kobassa clarifies this concept even further with her
research into personal hardiness factors. She found that
some personality types seem resilient to the harmful effects
of stress because they possess three traits:
- commitment to self and work,
- a sense
of control within their environment, and
- a feelings
of challenge rather than threat when events change.
discusses the importance of "cognitive control".
Control of events in your external world may not be possible,
but we all have the ability to control how we view these
and the emotional response we choose to have to them.
Humor gives us perceptual flexibility and thus can increase
our cognitive control. One nurse used her perceptual flexibility
to help her cope with a demanding patient who frequently
interrupted the nurse's busy schedule with minor complaints
and requests. The nurse's patience and tolerance were wearing
thin. It was lunchtime and the patients were eating when
again the nurse was called to this patient's room. Upon
entering, the patient indignantly pointed to her tray and
told the nurse, "This is a bad potato!" The nurse
then picked up the potato and began spanking it, saying
"Bad potato! Bad potato!" The patient and nurse
both laughed and the tension of the moment was dissolved.
Any thorough discussion of caregiver's use of humor must
include a style called "gallows humor". Freud
named it when he reported an incident of joking which occurred
on the gallows by a man about to be hung. It refers to the
style of humor which laughs directly at tragedy or death,
as if it were amusing. Gallows humor is unique to caregivers
or any profession which deals directly with the gruesome
reality of pain, suffering and death. Police, social workers,
news reporters, psychologists, all areas of the health professions
use this style of humor to help them cope with the sympathetic
tendencies they feel when working with those who suffer.
Effects of Humor
can be defined as the vital essence or animating force of
a living organism, often considered divine in origin. Spirit
can also be regarded as vivacity or energy. Or it can refer
to a characteristic temper or disposition (the spirit of
the group was hostile). The word humor itself is a word
of many meanings. The root of the word is "umor"
meaning liquid, fluid. In the Middle Ages and Renaissance,
humor was one of the four principal body fluids thought
to determine human health and dispositions (sanguine, phlegmatic,
choleric, melancholic). One dictionary defines humor as
"the quality of being laughable or comical" or
"a state of mind, mood, spirit". Humor, on all
levels, therefore, is something that flows, involving basic
characteristics of the individual which express themselves
in the body, in moods and emotional reactions, and in qualities
of feeling, of mind and of spirit. The qualities of humor
and spirit are similar and, I believe, interdependent. As
caregivers we offer therapy to facilitate the healing processes
within the body. To be most effective, we must direct our
efforts to touch the body, mind and spirit. The root of
the word "heal" is "haelen", meaning
to make whole.
the history of medicine we have discussed the importance
of attending to the body, mind, and spirit. Humor is one
of the pleasures of life. To dispense laughter will directly
enhance the quality of life and perhaps the will to live
-- this may be the most important result of all. The will
to live is a force which is very difficult to define but
can be a powerful influence in the patient's recovery process.
Many of us have witnessed the patient who asserts that he
is going to die, despite a fairly normal physical exam and
lab results; and then proceeds to do so, often surprising
the professional staff. The opposite can also be the case.
A patient is given a grim prognosis by his physicians but
announces that he will overcome the condition and then lives
for many years beyond his predicted demise. Sometimes mobilizing
the will to live can be the most powerful influence one
human can offer another. Humor and laughter can create an
environment where hope can flourish because it provides
a sense of joy, helps us connect with family and friends,
and inspires an appreciation and gratitude for life.
have attempted to provide information, qualification and
inspiration for the possibility that laughter and humor
can be a source of therapy for both the patient and the
caregiver. My intent was to answer the questions: "Why
are humor and laughter important? What happens to the body,
mind, and spirit when we laugh?" You are now probably
wondering: "How can I get myself and others to laugh
more? When is humor appropriate to use? Who is most likely
to laugh?" For help in finding answers to these questions,
consult the resource list and references which follow.
Begin to explore your own style and appreciation of humor.
Find what works for you and your patients. Remember, the
shortest distance between two people is a shared laugh.