"A merry heart does good like a medicine,
but a broken spirit dries the bones" -- Proverbs 17:22

Laughter 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.

A Patient Responds to Humor

During 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.

Recalling this story reminds me of this popular folk poem

Laughter Supports Recovery from Illness

Norman 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.

Physiological Response

Humor 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.

Frequency 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.

Humor and Illness

How 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 lubricant".
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.

Psychological Impact of Humor

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.

Some 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

The 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.

Kobassa 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.

Spiritual Effects of Humor

Spirit 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.

Throughout 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.

Summary

I 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.