Research Paper- MLA Format (24 hours)
Edero2103
Benefits_of_Laughter-_Outline.zipHumor and Laughter may Influence Health. I. History and Background.pdf
Advance Access Publication 16 January 2006 eCAM 2006;3(1)61–63
doi:10.1093/ecam/nek015
Review
Humor and Laughter may Influence Health. I. History and Background
Mary Payne Bennett1 and Cecile A. Lengacher2
1Indiana State University College of Nursing, IN, USA and 2University of South Florida College of Nursing, FL, USA
Articles in both the lay and professional literature have extolled the virtues of humor, many giving the
impression that the health benefits of humor are well documented by the scientific and medical commun-
ity. The concept that humor or laughter can be therapeutic goes back to biblical times and this belief has
received varying levels of support from the scientific community at different points in its history.
Current research indicates that using humor is well accepted by the public and is frequently used as a
coping mechanism. However, the scientific evidence of the benefits of using humor on various health
related outcomes still leaves many questions unanswered.
Keywords: Humor – Health
Can Humor and Laughter Influence Health Outcomes?
History
Using humor to decrease stress, diminish pain, improve quality
of life and even attempt to improve immune functioning has
recently become a popular topic in the lay and professional
literature (1–4). Laughter in response to a humorous stimulus
is a natural occurrence and does not require large amounts of
time or money in order to implement. While therapies such
as relaxation and exercise require significant time and commit-
ment, and therapies such as herbs or massage can be expen-
sive, use of humor can be easily implemented and cost
effective. However, clinical benefits must still be documented
before this therapy can be widely supported by the health care
community.
Diverse literature suggests that effects of humor on various
outcomes such as stress, health and immune function have
been well-documented by empirical research and are therefore
commonly accepted. The work of Cousins (5), Fry (6–11),
Berk (12–17) or the field of Psychoneuroimmunology (PNI)
is frequently cited as supporting the role of humor in healing.
However, despite media claims, relatively few professional
articles examine the scientific basis for these claims. There
are a few studies that have examined the effects of humor or
laughter on psychological outcomes, such as stress. However,
there are a very limited number of studies that document
the effects of laughter on physiological outcomes, and no
controlled studies have been identified that document the
effects of laughter on clinical health outcomes.
So what do we really know about the role of sense of humor,
use of humor by patients with various illnesses, or the effects
of laughter on various health related outcomes? Is use of
humor an approach that we should implement in our practices
and/or recommend to our patients? This is the first of the four
articles that reviews, clarifies and synthesizes the professional
literature concerning humor and health outcomes. This first
paper presents basic background on the theoretical under-
pinnings concerning how the mind can affect the body, such
as the effects of stress on immune functioning. Research in
this area provides fundamental support for the supposition
that interventions that lower stress may also help improve
physiological outcomes. The second paper reports studies
that document patient interest in and use of humor as a com-
plementary therapy, and provides evidence to support that
humor may be one of the more frequently used complement-
ary therapies. The third paper describes studies that report
For reprints and all correspondence: Mary Payne Bennett, Indiana State University College of Nursing, IN, USA. Tel: 1-812-237-2320; Fax: 1-812-237-8895; E-mail: [email protected]
� The Author (2006). Published by Oxford University Press. All rights reserved.
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact [email protected]
the relationship between sense of humor and various health
outcomes. The final paper examines either the effect of a
humorous stimulus and/or effects of laughter on health out-
comes. These latter two parameters are difficult to separate,
since patients who are exposed to a humorous stimulus usually
respond with laughter, however, not all studies separately
document laughter and exposure to a humorous stimulus.
This review is based on a search of Pub-Med and
PsychINFO, using the search terms humor and laughter,
plus bibliographic review for older articles that may not be
documented in the databases. A search using those terms pro-
duced 324 hits, from which 55 relevant articles were obtained.
Only original empirical research reporting the psychological or
physiological effects of humor or laughter are reported here,
with the main focus on research documenting health related
outcomes. Owing to small sample sizes in most studies and
the limited number of available reviews, sample size was not
used as a determinant to exclude certain analyses from our
review. A meta-analysis was not possible owing to the use
of multiple measures of sense of humor and various outcomes
utilized in the studies reviewed.
Definitions
A full discourse on humor theory is beyond the scope of this
review, but certain basic definitions are essential. From a psy-
chological perspective, humor involves cognitive, emotional,
behavioral, psycho-physiological and social aspects (18). The
term humor can refer to a stimulus, which is intended to pro-
duce a humorous response (such as a humorous video), a men-
tal process (perception of amusing incongruities) or a response
(laughter, exhilaration). Laughter is the most common expres-
sion of humorous experience. Humor and laughter are also
typically associated with a pleasant emotional state (18). For
the purpose of these reviews, humor is defined as a stimulus
that helps people laugh and feel happy. Laughter is a psycho-
physiological response to humor that involves both character-
istic physiological reactions and positive psychological shifts.
Sense of humor is a psychological trait that varies considerably
and allows persons to respond to different types of humorous
stimuli. It is necessary to differentiate between these variables,
as some analyses of humor use a humor stimulus (such as a
video) to determine the effect of ‘humor’ on an outcome, while
others look specifically at the effects of laughter on these out-
comes. Still others analyze various ways to measure sense of
humor, in an attempt to determine whether scoring higher on
a sense of humor instrument is related to various health related
outcomes.
Stress, Psychoneuroimmunological Reactions and Health
Theoretical Framework and Early Experiments
What is the underlying theoretical framework that helps
explain why use of a complementary therapy, such as humor,
may affect health? It may be that these therapies work by
reducing the effects of stress. Interest in the influence of
psychological factors on susceptibility to certain disease states
goes back to the times of Galen (19), when it was noted that
persons who developed cancer often had a ‘melancholic’
personality. Since then, numerous clinicians have shared
anecdotal data concerning the development of cancer or other
diseases in persons with certain psychological styles, or after
a stressful life event, such as bereavement (20).
Selye’s work was one of the first to document the general
effects of stress on the sympathetic nervous system, endocrine
system and lymphatic organs (21). Further studies established
that activation of the stress response could also be triggered
by acute emotions, physical exertion, cold and pain (22). Later,
Lazarus and Folkman (23) broadened the definition of stress
from Selye’s concept of ‘environmental demands’ to include
psychological components such as appraisal and coping.
While Lazarus and Folkman’s theory helped to explain the
moderation of stressors using coping mechanisms, it did not
attempt to explain the possible consequences of these coping
mechanisms in terms of physiological effects on immune func-
tioning. The field of PNI brings all of these factors together in
a testable theoretical framework. PNI started from a multi-
factorial model of illness, which included stress, coping and
disease formation (24). This theory was further developed
by Solomon (1987) to include the impact of stress on the
immune system in disease formation (25). Later, the term
‘psychoneuroimmunology’ was coined by Ader and Cohen
(26) to describe the basic phenomena of this theory: interac-
tions between the nervous system and the immune system,
and the subsequent effects of these interactions upon disease
development/progression.
PNI and Stress
PNI researchers have repeatedly documented that increased
stress levels can lead to changes in psychological and physio-
logical functioning. In addition to changes in the usual stress
hormones such as ACTH, cortisol, epinephrine and norepi-
nephrine, many other messengers are influenced by exposure
to stressors. Production and release of prolactin, growth hor-
mone, insulin, glucagon, thyroid hormone and gonadotrophin
can be affected by physical and emotional stress (27). Levels
of neurotransmitters, neurohormones, cytokines and various
cells in the immune system can also be affected by stress (28).
A Neurological Approach to Laughter
Ideally, we would be able to draw a flow chart that outlines all
of the neurological processes involved in the effects of laugh-
ter on stress and immune functioning. But unfortunately, the
state of the science is not to that level at this time. We really
know very little about how the brain functions in response to
a humorous stimulus. According to Curtis (27), speech and
laughter are both uniquely human. But while there is consider-
able information on the neuronal representation of speech,
little is known about brain mechanisms of laughter. We do
have some evidence that the supplementary motor area of the
62 Humor and laughter may influence health
brain is involved in this response. Curtis reports that ‘electrical
stimulation in the anterior part of the human supplementary
motor area (SMA) can elicit laughter’ (29). Moreover, it has
been proposed by Tanji (30) and Picard and Stick (31) that
the anterior part of the SMA is part of a further development
in humans to accommodate the specialized functions of
speech, manual dexterity and laughter. This area might corre-
spond to the pre-supplementary motor area, a region situated
anterior to the SMA proper, recently described in non-human
primates, and thought to be involved in high-level motor pro-
gramming (30,31). Finally, Fried and Wilson (32) have exam-
ined putative regions in the brain using electric current that
stimulates laughter. The data suggest that this is at least one
anatomical location for the neurological response to humorous
stimuli. However, more research is needed to determine how
these neurological changes subsequently affect the physiolo-
gical response to stressors, and possibly improve immune
functioning.
References 1. Balick M, Lee R, The role of laughter in traditional medicine and its
relevance to the clinical setting: Healing with ha! Altern Ther Health Med 2003;9:88–91.
2. Bennett H, Humor in medicine. South Med J 2003;96:1257–61. 3. MacDonald C, A chuckle a day keeps the doctor away: therapeutic humor
and laughter. J Psychosoc Nurs Ment Health Serv 2004;42:18–25. 4. Weiss R, Initiative proves laughter is the best medicine. Health Prog
2002;83:54. 5. Cousins N, Anatomy of an Illness as Perceived By the Patient. Toronto:
Bantam, 1979. 6. Fry W, Mirth and oxygen saturation levels of peripheral blood. Psychother
and Psychosom 1971;19:76–84. 7. Fry W, The respiratory components of mirthful laughter. J Biol Psychol
1977;19:39–50. 8. Fry W, Humor, physiology, and the aging process. In Nahemov L,
McCluskey-Fawcett K, McGhee P, (eds), Humor and Aging, Orlando, Florida: Academic Press, 1986, pp. 81–98.
9. Fry W, Savin W, Mirthful laughter and blood pressure. Humor: Int J Humor Res 1988;1:49–62.
10. Fry W, The physiological effects of humor, mirth, and laughter. J Am Med Assoc 1992;267:1857–8.
11. Fry W, The biology of humor. Humor: Int J Humor Res 1994;7:111–26. 12. Berk L, Tan S, Nehlsen-Cannarella S, Napier B, Lewis J, Lee J, et al,
Humor associated laughter decreases cortisol and increases spontaneous lymphocyte blastogenesis. Clin Res 1988;36:435A.
13. Berk L, Tan S, Napier B, Evy W, Eustress of mirthful laughter modifies natural killer cell activity. Clin Res 1989;37:115A.
14. Berk L, Tan S, Fry W, Napier B, Lee J, Hubbard R, et al, Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci 1989;298:391–6.
15. Berk L, Tan S, Fry W, Eustress of Humor associated laughter modulates specific immune system components. Annals of Behavioral Medicine Supplement, Proceedings of the Society of Behavioral Medicine’s 16th Annual Scientific Sessions 1993;15:S111.
16. Berk L, Tan S, Eustress of mirthful laughter modulates the immune system lmyphokine interferon-gama. Annals of Behavioral Medicine Supple- ment, Proceedings of the Society of Behavioral Medicine’s 16th Annual Scientific Sessions 1995;17:C064.
17. Berk L, Felten D, Tan S, Bittman, Westengard J, Modulation of neuro- immune parameters during the eustress of humor-associated mirthful laughter. Altern Ther Health Med 2001;7:62–72, 74–6.
18. Martin R, Humor, laughter, and physical health: methodological issues and research findings. Psychol Bull 2001;127:504–19.
19. Chiappelli F, Prolo P, Cajulis OS, Evidence-based research in com- plementary and alternative medicine I: History. Evid Based Complement Alternat Med 2005;2:453–8.
20. Locke S, Kraus L, Modulation of natural killer cell activity by life stress and coping ability. In Levy S (ed), Biological Mediators of Behavior and Disease: Neoplasia. New York: Elsevier, 1982, pp. 3–28.
21. Seyle H., The general adaptation syndrome and the diseases of adaptation. J Clin Endocrinol Metab 1946;6:117–230.
22. Cannon W, Bodily Changes in Pain, Hunger, Fear and Rage. Boston: Charles T. Branford, 1946.
23. Lazarus R, Folkman S, Stress, Appraisal, and Coping. New York: Springer, 1984.
24. Engel G, Psychological Development in Health and Disease. Philadelphia: Saunders, 1962.
25. Soloman G, Psychoneuroimmunoloic approaches to research on AIDS. Ann N Y Acad Sci 1987;494:928–36.
26. Ader R, Cohen N, Conditioned immunopharmacologic responses. In Ader R (ed), Psychoneuroimmunology. New York: Academic Press, pp. 6–38.
27. Curtis G, Psychoendocrine stress response: Steroid and peptide hormones. In Stoll BA (ed), Mind and Cancer Prognosis. Chichester: John Wiley & Sons, 1979, pp. 61–72.
28. Anderson G, Kiecolt-Glaser J, Glaser R, A biobehavioral model of cancer stress and disease course. Am Psychol 1994;49:389–404.
29. Fox PT, Ingham RJ, Ingham JC, Hirsch TB, Downs H, Martin C, et al, A PET study of the neural systems of stuttering 158. Nature 1996;382: 158–61.
30. Tanji J, New concepts of the supplementary motor area. Curr Opin Neurobiol 1996;6:782–7.
31. Picard N, Strick PL, Motor areas of the medial wall: a review of their location and functional activation. Cereb Cortex 1996;6:342–53.
32. Fried I, Wilson CL, Electric current stimulates laughter. Nature 1998; 391:650.
Received March 30, 2005; accepted December 29, 2005
eCAM 2006;3(1) 63
Laughter prescription.pdf
Vol 55: october • octobre 2009 Canadian Family Physician • Le Médecin de famille canadien 965
Commentary Laughter prescription William B. Strean PhD
Laughter is the tonic, the relief, the surcease for pain. Charlie Chaplin
I t has been more than 30 years since Norman Cousins published an article in the New England Journal of Medicine1 extolling the potential medicinal benefi ts
of laughter and humour. Yet the study of laughter still occupies a rather modest place in scientific inquiry.2
It was not until 1995 that laughter as an exercise, or laughter yoga, emerged systematically through laugh- ter clubs. The popularity of such laughter programs has grown markedly during the past decade. With increasing recognition, one might expect that there would be grow- ing application of laughter and humour for their comple- mentary and alternative medical benefi ts. (It should be noted that laughter is an adjunct to and not a replace- ment for accepted therapies.) They are easy to prescribe and there are no substantial concerns with respect to dose, side effects, or allergies. It seems, however, that the medical community has been reluctant to embrace and support laughter for health.
History and importance of the role of humour in medicine Humour researchers3-8 have reported shortcomings of studies on the physiologic effects of laughter. For example, “Taken together, the empirical studies reviewed ... provide little evidence for unique positive effects of humor and laughter on health-related variables.”4 Other commenta- tors have cautioned practitioners about advocating the benefi ts of laughter, fashioning themselves as self-styled laughter police. “For practitioners to implement credible programs and effectively teach self-management tech- niques, further empirical research on the physical, psycho- social, debonafi de [sic], and placebo effects of humor and laughter needs to be conducted.”9 Furthermore, Bennett10
argued that although humour and laughter have been the focus of attention in the popular media and medical lit- erature, and despite statements about the health benefi ts of humour, current research was insuffi cient to validate such claims. He identifi ed support for the role of humour and laughter in other areas, including patient-physician communication, psychological aspects of patient care, medical education, and reducing stress among med- ical professionals. It is also important to note that while humour and laughter are often connected, there are some important distinctions. For example, laughter yoga
produces laughter and the concomitant physiologic bene- fi ts without the use of humour; humour without laughter might not produce those benefi ts and potentially could have adverse effects on the therapeutic relationship.
When considering new pharmacologic interventions or invasive procedures, it is quite appropriate to place the onus of proof of effi cacy on the creator of the protocol. This mind-set is driven by appropriate concerns for false- positive errors. Given the side effects and inherent risks associated with pharmaceuticals, one exercises caution to be clear that the intended effect is achieved beyond reasonably considered chance factors. Thus recommen- dations suggest P values be set conservatively and tech- niques employed to avoid a “false discovery rate.”11
Similar thinking seems to have been applied to the consideration of laughter’s potential medicinal effects. Although proponents of laughter and humour can be traced back to the Bible (“A merry heart doeth good like a medicine, but a broken spirit drieth the bones” [Proverbs 17:22]), and a variety of medical benefi ts of laughter have been supported through research, the scales seem to remain tipped markedly in the direction of caution.
The most positive claim that researchers seem will- ing to make is that “current research indicates that using humor is well accepted by the public and is frequently used as a coping mechanism. However, the scien- tific evidence of the benefits of using humor on vari- ous health related outcomes still leaves many questions unanswered.”12
Biology of laughter and humour There are, however, several good reasons to conclude that laughter is effective as an intervention. Although the evidence (detailed below) demonstrating laughter’s benefi ts could be stronger, virtually all studies of laugh- ter and health indicate positive results. Similarly, there are almost no negative side effects or undesirable rami- fications associated with laughter as an intervention. This is a case in which the appropriate logic might be more akin to the legal perspective of “innocent until proven guilty.”
Yet, given the prevailing orientation toward laughter as an intervention, an exhaustive review of the medical literature to assess demonstrated benefi ts of laughter
GOCFPlus
The English translation of this article, is available at www.cfp.ca. Click on CFPlus to the right of the article or abstract.
La traduction en français de cet article se trouve à www.cfp.ca. Allez au texte intégral (full text) de cet article en ligne, puis cliquez sur CFPlus dans le menu en haut, à droite de la page.This article has been peer reviewed.
Can Fam Physician 2009;55:965-7 (Eng), CFPlus (Fr)
966 Canadian Family Physician • Le Médecin de famille canadien Vol 55: october • octobre 2009
Commentary
was completed. Several databases were searched for all occurrences of laughter, and reviews of laughter and humour2,4,13,14 were examined. The intent was to find studies related to benefits of laughter and laugh- ter effects. Although the literature contains “an abun- dance of non–evidence-based opinion”14 exploring how laughter and humour should or should not be applied in medical settings, there is also a substantial body of well- researched information demonstrating many benefits and potential benefits of laughter and humour. Future studies might enhance the literature by considering that laughter is highly social and examining laughter in social settings. Furthermore, careful descriptive work linking physiologic systems with types, kinds, and con- texts of laughter will be valuable.2
Morse’s conclusion about laughter and humour in the dental setting summarized the literature to date: “Laughter and humor are not beneficial for everyone, but since there are no negative side effects, they should be used ... to help reduce stress and pain and to improve healing.15 Findings range from suggesting that, in addi- tion to a stress-relief effect, laughter can bring about feelings of being uplifted or fulfilled16 to showing that the act of laughter can lead to immediate increases in heart rate, respiratory rate, respiratory depth, and oxygen con- sumption.17 These increases are then followed by a per- iod of muscle relaxation, with a corresponding decrease in heart rate, respiratory rate, and blood pressure.
Overall, the arguments against using laughter as an intervention appear to be both unduly cautious and based on the desire for more evidence. The arguments in favour of laughter as an intervention are grounded in the virtually universal positive results associated with existing studies of laughter. Although scholars and prac- titioners recognize the value of further study, more rep- lication, and identification of specifics, the call for more application of laughter as an intervention seems war- ranted. Perhaps it is time to usher in a new era in which we reverse our concerns about errors.
It might be time to start giving more credence to posi- tive views about laughter, such as that laughter might reduce stress and improve natural killer cell activity. As low natural killer cell activity is linked to decreased disease resistance and increased morbidity in those with cancer or HIV disease, laughter might be a useful cognitive-behavioural intervention.18
The many voices of cancer survivors and of those who have employed laughter in their recoveries supply fur- ther promising support. One such person, Scott Burton, said, “The other reactions; anger, depression, suppres- sion, denial, took a little piece of me with them. Each made me feel just a little less human. Yet laughter made me more open to ideas, more inviting to others, and even a little stronger inside. It proved to me that, even as my body was devastated and my spirit challenged, I was still a vital human.”19 Perhaps medical prescription of
laughter and humour can illuminate what cancer patients already know; studies have shown that 50% of cancer patients used humour20 and 21% of a group of breast can- cer patients used humour or laughter therapy.21
Clinical evidence As Rosner22 reported, randomized controlled clinical trials have not been conducted validating the thera- peutic efficacy of laughter. Benefits, however, have been reported in geriatrics,23 oncology,24-26 critical care,27 psychiatry,28,29 rehabilitation,30 rheumatology,1 home care,31 palliative care,32 hospice care,33 terminal care,34 and general patient care.35 These and other reports constitute sufficient substantiation to support what is experientially evident—laughter and humour are thera- peutic allies in healing.
One area where questions remain is the effect of laughter on the so-called stress hormones: epinephrine, norepinephrine, and cortisol. This is important because it is theorized that if laughter does, in fact, decrease stress hormones, this would be one mechanism that might explain the proposed connection between laugh- ter and immune function, and from there to improved health outcomes.17
“The relationship between humor and health is a com- plex one. Groucho Marx once noted that ‘A clown is like an aspirin, only he works twice as fast.’ Patch Adams, the founder of the Gesundheit community, where laugh- ter therapy is a daily medical routine, would no doubt agree. Both men, to do their work, require a commun- ity—the former as an audience and the latter to mag- nify the power of the healing response. After all, half of the fun in laughter, as well as healing, is sharing it.”36 Yet, research might not be ready and able to measure and understand the complexities of how laughter works, particularly when laughter occurs in a group environ- ment, such as laughter clubs. “The prevailing medical paradigm has no capacity to incorporate the concept that a relationship is a physiologic process, as real and as potent as any pill or surgical procedure.”37
Clinical bottom line As Robert Provine, the noted laughter researcher, com- mented in the documentary Laugh Out Loud, “Until the scientists work out all the details, get in all the laugh- ter that you can!”38 Medical practitioners could begin to help patients get more laughter in their lives. Following the announcement of a study of the benefits of laughter on endothelial function,39 Dr Michael Miller, one of the study’s authors, said he envisioned a time when phys- icians might recommend that everyone get 15 to 20 minutes of laughter in a day in the same way they rec- ommend at least 30 minutes of exercise. Although phys- icians’ advice about health-promoting behaviour might have a limited effect in some cases,40 it can certainly be a catalyst for change.41 Specifically, medical practitioners
Vol 55: october • octobre 2009 Canadian Family Physician • Le Médecin de famille canadien 967
Commentary
might acquaint themselves with opportunities such as laughter clubs, which are available for their patients and provide information and endorsements. Let us begin to consider that, along with eating your vegetables and getting enough sleep, laughter is a sound prescription as a wonderful way to enhance health. Dr Strean is an Associate Professor in the Faculty of Physical Education and Recreation at the University of Alberta in Edmonton.
competing interests None declared
correspondence Dr William B. Strean, University of Alberta, Physical Education and Recreation, P-408 VVC, Edmonton, AB T6R 1L5; telephone 780 492-3890; fax 780 492-2364; e-mail [email protected]
the opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
references 1. Cousins N. Anatomy of an illness as perceived by the patient. N Engl J Med
1976;295(26):1458-63. 2. Devereux PG, Heffner KL. Psychophysiological approaches to the study of
laughter: toward an integration with positive psychology. In: Ong AD, van Dulmen MHM, editors. Oxford handbook of methods in positive psychology. New York, NY: Oxford University Press; 2007. p. 233-49.
3. Berk RA. Humor as an instructional defibrillator: evidence-based techniques in teaching and assessment. Sterling, VA: Stylus Publishing; 2002.
4. Martin RA. Humor, laughter, and physical health: methodological issues and research findings. Psychol Bull 2001;127(4):504-19.
5. Martin RA. Is laughter the best medicine? Humor, laughter, and physical health. Curr Dir Psychol Sci 2002;11(6):216-20.
6. McGhee PE. Health, healing and the amuse system: humor as survival training. 3rd ed. Dubuque, IA: Kendall/Hunt; 1999.
7. McGhee PE. Comprehensive review of humor research. Paper presented at: Annual Meeting of the Association for Applied and Therapeutic Humor; 2002; Baltimore, MD.
8. Provine RR. Laughter: a scientific investigation. New York, NY: Viking Penguin; 2000. 9. MacDonald CM. A chuckle a day keeps the doctor away: therapeutic humor
and laughter. J Psychosoc Nurs Ment Health Serv 2004;42(3):18-25. 10. Bennett HJ. Humor in medicine. South Med J 2003;96(12):1257-61. 11. Curran-Everett D. Multiple comparisons: philosophies and illustrations. Am J
Physiol Regul Integr Comp Physiol 2000;279(1):R1-8. 12. Bennett MP, Lengacher CA. Humor and laughter may influence health. I.
History and background. Evid Based Complement Alternat Med 2006;3(1):61-3. 13. Berk RA. The active ingredients in humor: psychophysiological benefits and
risks for older adults. Educ Gerontol 2001;27(3-4):323-39. 14. McCreaddie M, Wiggins S. The purpose and function of humour in health,
health care and nursing: a narrative review. J Adv Nurs 2008;61(6):584-95. 15. Morse DR. Use of humor to reduce stress and pain and enhance healing in
the dental setting. J N J Dent Assoc 2007;78(4):32-6. 16. Toda M, Kusakabe S, Nagasawa S, Kitamura K, Morimoto K. Effect of laugh-
ter on salivary endocrinological stress marker chromogranin A. Biomed Res 2007;28(2):115-8.
17. Bennett MP, Lengacher C. Humor and laughter may influence health. III. Laughter and health outcomes. Evid Based Complement Alternat Med 2008;5(1):37-40.
18. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Altern Ther Health Med 2003;9(2):38-45.
19. Burton S. Why not laugh? Minneapolis, MN: Inconvenience Productions; 2003. Available from: www.sburton.com/whynotlaugh.htm. Accessed 2008 Feb 11.
20. Bennett M, Lengacher C. Use of complementary therapies in a rural cancer population. Oncol Nurs Forum 1999;26(8):1287-94.
21. Lengacher CA, Bennett MP, Kip KE, Keller R, La Vance MS, Smith LS, et al. Frequency of use of complementary and alternative medicine in women with breast cancer. Oncol Nurs Forum 2002;29(10):1445-52.
22. Rosner F. Therapeutic efficacy of laughter in medicine. Cancer Invest 2002;20(3):434-6.
23. Williams H. Humor and healing: therapeutic effects in geriatrics. Gerontion 1986;1(3):14-7.
24. Bellert JL. Humor. A therapeutic approach in oncology nursing. Cancer Nurs 1989;12(2):65-70.
25. Erdman L. Laughter therapy for patients with cancer. Oncol Nurs Forum 1991;18(8):1359-63.
26. Trent B. Ottawa lodges add humour to armamentarium in fight against can- cer. CMAJ 1990;142(2):163-4, 166.
27. Leiber DB. Laughter and humor in critical care. Dimens Crit Care Nurs 1976;5:162-70.
28. Saper B. The therapeutic use of humor for psychiatric disturbances of ado- lescents and adults. Psychiatr Q 1990;61(4):261-72.
29. Gelkopf M, Kreitler S, Sigal M. Laughter in a psychiatric ward. Somatic, emotional, social, and clinical influences on schizophrenic patients. J Nerv Ment Dis 1993;181(5):283-9.
30. Basmajian JV. The elixir of laughter in rehabilitation. Arch Phys Med Rehabil 1998;79(12):1597.
31. Hunter P. Humor therapy in home care. Caring 1997;16(9):56-7. 32. Dean RA. Humor and laughter in palliative care. J Palliat Care 1997;13(1):34-9. 33. Balzer JW. Humor—a missing ingredient in collaborative practice. Holist
Nurs Pract 1993;7(4):28-35. 34. Herth K. Contributions of humor as perceived by the terminally ill. Am J
Hosp Care 1990;7(1):36-40. 35. Mallett J. Use of humour and laughter in patient care. Br J Nurs
1993;2(3):172-5. 36. Balick MJ, Lee R. The role of laughter in traditional medicine and its rel-
evance to the clinical setting: healing with ha! Altern Ther Health Med 2003;9(4):88-91.
37. Lewis T, Amini F, Lannon R. A general theory of love. New York, NY: Random House; 2000. p. 80-1.
38. Wilson S. The world is flat (tee hee). Perspectives on humor research. Humor Connect 2004;(2):5. Available from: www.aath.org/humor_ connection/Summer04.pdf. Accessed 2009 Jun 19.
39. Miller M, Mangano C, Park Y, Goel R, Plotnick GD, Vogel RA. Impact of cine- matic viewing on endothelial function. Heart 2006;92(2):261-2.
40. Eden KB, Orleans CT, Mulrow CD, Pender NJ, Teutsch SM. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137(3):208-15.
41. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient
behavior? Evidence for a priming effect. Arch Fam Med 2000;9(5):426-33.
Nurses’ experiences of humour in clinical settings.pdf
Original Article http://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)
Iran University of Medical Sciences
____________________________________________________________________________________________________________________ 1. MSc, RN, PhD, Assistant Professor in Nursing, Babol University of Medical Sciences, Mazandaran, Iran. [email protected] 2. (Corresponding author) PhD, Professor, Nursing and Midwifery Care Research Centre, School of Nursing and Midwifery, Tehran Univer- sity of Medical Sciences, Tehran, Iran. [email protected] 3. BS, MSCN, Senior Lecturer, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran. [email protected]
Nurses’ experiences of humour in clinical settings
Fatemeh Ghaffari1, Nahid Dehghan-Nayeri2, Mahboubeh Shali3
Received: 22 April 2014 Accepted: 12 August 2014 Published: 17 February 2015
Abstract Background: Providing holistic nursing care when there is a shortage of personnel and equipment
exposes nurses to stress and a higher risk of occupational burnout. Humour can promote nurses’ health and influence nursing care. The aim of this study was to describe nurses’ experiences of hu- mour in clinical settings and factors affecting it.
Methods: This qualitative study investigated nurses’ experiences of humour. Five hospitals affiliat- ed to Tehran University of Medical Sciences provided the setting for this study. The participants comprised of 17 nurses with master’s and Baccalaureate degrees (BSN) in nursing. These nurses worked at educational hospitals affiliated to Tehran University of Medical Sciences and had mini- mum work experience of 12 months in various clinical wards. Nurses from all wards were invited to participate in this study. The data were collected through semi structure interviews using guides comprising probing questions. Telephonic interviews were used to further supplement the data. The data were analysed using conventional content analysis.
Results: The data were classified into five themes including the dynamics of humour, condition enforcement, Risk making probability, Instrumental use and Change: opportunities and threats.
Conclusion: Understanding nurses’ perceptions and experiences of humour helps identify its con- tributing factors and provides valuable guidelines for enhancing nurses and patients’ mental, emo- tional and physical health. Spreading a culture of humour through teaching methods can improve workplace cheerfulness and highlights the importance of humour in patient care in nurses and nurs- ing students.
Keywords: Humour, Nursing Care, Interaction, Communication, Qualitative Study.
Cite this article as: Ghaffari F, Dehghan-Nayeri N, Shali M. Nurses’ experiences of humour in clinical settings. Med J Islam Repub Iran 2015 (17 February). Vol. 29:182.
Introduction Nurses are faced with various stressors,
such as personnel shortages and limited re- sources, long working hours (1), not taking part in clinical decisions and working under pressure or working with people with inad- equate clinical skills (2,3). These could lead to occupational burnout. Manifesting as emotional exhaustion, depersonalization and personal inefficiency, occupational burnout among nurses has attracted consid-
erable scholarly attention in recent decades. Humour has been identified as an important attribute that could help prevent and de- crease burnout among nurses (2).
Humour is a cognitive, emotional, behav- ioural, psychological and social phenome- non (5, 6). It is an inseparable part of daily life, and at times it is regarded as a means of dealing with one’s problems, and a gen- erally positive and universal experience for people from different cultural and social backgrounds around the world (6) and is
Nurses’ experiences of humour in clinical settings
2 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir
defined as a person’s ability to appreciate the funny side of a situation(7). The im- portance of humour in nursing care was introduced four decades ago (8). Coser was the first to posit that humour is related to disease and the stress of hospitalization for patients. The results from his study re- vealed that humour is a means for manag- ing threatening situations like hospitaliza- tion (9). Thereafter, the potency of humour in reducing patients’ stress was gradually recognized; hence, it is currently an estab- lished nursing research field (10). Re- searchers currently consider humour as an acceptable practice in nursing care (4). Henderson argued that humour and laugh- ter among patients and health workers can be as good as, or surpass treatment(11) while, for Yura and Walsh, humour and wit help broaden patients and nurses’ outlook on life(12). According to Robinson (1997), in nursing care, the goals of humour enable the development of relationships, anxiety relief, anger using socially acceptable means, learning and avoidance or denial of hurt(13).
Working in jobs in which the worker is faced with pains and problems of other in- dividuals, increases the possibility of ex- haustion. Therefore, humour strategy is needed more although there have been so many texts about humour function. Be- sides, the researchers came across few stud- ies related to the use of humour in nursing (14, 15) and they found that there has been less use of humour despite the need of ap- propriate mental serenity in clinical places. Besides, people think that nurses should be serious when are at clinical places, and the nurses think that they are not allowed to humour patients during the process care. Humour can enhance health promotion among nurses and the quality (4) of patient care (4); it is also considered a patient care strategy (5).
Fry believes that humour is essential for one’s development in relation to social life and experiences. However, there are vary- ing views regarding the role of humour in nursing care (16). Humour manifests within
social contexts and, therefore, varies across cultures. Given the importance of the social context in relation to humour, Iran’s unique cultural and religious landscape provides an ideal setting for the use of a qualitative study to identify previously unexplored as- pects of humour and its practical signifi- cance in this context. Nurses might have a better understanding of the complexities of humour in clinical settings, which serve as a focus of the current study (5). A study on nurses’ experiences of humour in nursing care can facilitate better understanding of the needs, challenges and any other issues surrounding this phenomenon. Moreover, it could facilitate a happy and safe nursing environment for both the patients and nurs- es. Thus, this study explores the nurses’ experiences of humour in clinical settings and factors affecting it.
Methods Design A qualitative design with conventional
content analysis was used in this study. Content analysis is a qualitative analytical method through which data are summa- rized, described and interpreted. It is used to identify main themes from the data and is appropriate for examining experiences and attitudes toward a particular subject (17).
Data collection A purposive sample includes individuals
with direct experience of the phenomenon of interest, who can provide insight into the research question. The sample comprised of 17 nurses with Master’s and Baccalaureate degrees (BSN) in nursing, who were invit- ed to participate in the study from various wards. The data were collected through semi structured interviews using guides comprising probing questions. Telephonic interviews were used to further supplement the data. Interviews began with general questions, and depending on the partici- pants’ responses, moved toward more de- tailed questions. Interviews continued until data saturation. Initial questions were
F. Ghaffari, et al.
3MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir
‘What are your experiences of humour?’, ‘As a nurse, what do you do to make your working shift more pleasant?’, and ‘What factors make you use or not use humor?’ Depending on the participants’ preferences, interviews were conducted in the research- er’s room in the nursing department. Each interview was audio-taped and completed in one session. In total, six face-to-face in- terviews and eleven by phone interviews were conducted, each lasting 20–40 minutes and 15–20 minutes, respectively. The data were collected between 2012 and 2013.
Data Analysis Conventional content analysis informed
by Graneheim and Lundman’s method was used to analyse the data (18). Immediately after each interview, the contents of the in- terview were documented by the research team. Then, the texts were read several times to obtain a general understanding of participants’ statements, in line with the study objectives. We reviewed the final codes, including their defining properties and their relationship to each other in order to reach consensus regarding the central, unifying theme emerging from the data. The research team extracted meaning units or initial codes, which were merged and categorized according to similarities and differences.
Rigor To verify the data, Guba and Lincoln’s
four criteria were used (17). The researcher was on the field for 11 months. Combined triangulation methods were used for data collection. The results were verified and confirmed through peer and member checks. In this respect, the initial codes and categories were provided to some partici- pants of the study, and they were given enough time to tell the researcher their complementary or corrective comments by phone. Some of the codes were changed according to the participants’ comments. The corrective comments of two university professors who were expert in qualitative
studies were used as peer check in the data analysis. In-depth, analytical and clear de- scriptions of obstacles and limitations dur- ing data collection by the researchers ena- bled the data’s transferability. Maximum variation sampling was used (participants’ age, sex, shifts, work experiences, wards and education levels varied) to enable the proportionality or transferability of the re- sults to other contexts. The researcher rec- orded and reported the study’s various pro- cesses to enable replication.
Ethical Considerations Permission to conduct this study was ob-
tained from the Ethics Committee of Teh- ran University of Medical Sciences. The participants were informed of the study ob- jective, were assured of the anonymity and confidentiality of their data, and provided written consent to participate in the study. The interview venue and time were agreed upon with the participants, and the results were made available to them if they wished.
Results These nurses worked at five teaching
hospitals affiliated to Tehran University of Medical Sciences, with minimum clinical experience of 12 months. Participants’ mean (±SD) age was 24.15 ± 6.12 years, with mean (±SD) work experience of 5.18 ± 3.9 years; the majority 28(59%) worked night shifts.
The participants’ experiences were classi- fied into five themes; namely, the dynamics of humour, condition enforcement, risk making probability, instrumental use and change: opportunities and threats (Table 1).
Dynamics of Humour Religious beliefs, understanding humour
and situation assessment (timing) are sub- categories representing the underlying fac- tors or important dynamics of humor.
Religious Beliefs: As it is detested in Is- lam to make humour with a guy of a differ- ent gender, our participants did consider their religious beliefs.
Nurses’ experiences of humour in clinical settings
4 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir
A nurse said, “Humor calls for being able to relate well to the patients; however, be- cause I am a Muslim, I cannot behave too friendly with the male patients.”
Understanding Humour: Participants be- lieved that it was important to consider pa- tients and their companions, as their under- standing of nurse's humor would help re- solve any misunderstandings; and the pa- tient would be less cautious around the nurse and this would minimise patients’ harsh reactions toward nurses.
Nurses’ appraisal of humor in the work- place ranged from positive to negative. The majority believed that humour affected pa- tient outcomes positively and that it pre- served and promoted nurses’ physical and mental health. Based on their experiences, nurses considered humor a workplace re- quirement and essential for patient care in stressful situations.
‘Being humorous or not is a personality trait–all medical team members, even pa- tients, must appreciate humour; otherwise, humorous people could come across chal- lenges or opportunism due to misunder- standings.’
Another group of nurses perceived humor negatively, arguing that humor can surpass the private boundaries between people. Through humor, people attempt to enter others’ life worlds and the understanding resulting from such relations could be dam- aging.
Another nurse commented, “Humor sets the ground for insults between people. I have to take care of my patient and that does not require humor.”
Situation Assessment: A nurse’s appraisal and understanding of his or her standing with a colleague or patient could help de- termine the appropriateness of humor in the clinical context. For instance, acquaintance history, previous friendship, work history, time spent working with someone, occupa- tional rank or duration of a patient’s hospi- tal stay could determine the type of out- comes emerging from a presumably hu- morous situation. Timing, personal charac- teristics and the cultural context constitute the subcategories of situational assessment.
Timing Timing is important and a nurse should
pick the best time to use humour. This fa- cilitates mutual trust between the nurse and the patient or the nurse and her/his col- leagues and demonstrates the nurse’s ethi- cal inclinations. Not considering the appro- priate timing for humour, leads to anger, aggression and relationship breakdown with the patient. Recognising a suitable time depends on factors such as a patient’s physical, mental and psychological state, as well as diagnosis and disease progression.
One nurse said, “I joked with a patient who had just been informed of her diagno- sis of breast cancer by the doctor. This re-
Table 1. Themes Extracted from the Participants’ Experiences Major ThemesSubthemes
Dynamics of humourReligious Beliefs Understanding Humour Situation Assessment Timing Consideration of Unique Personal Characteristics The Cultural Context
Condition enforcementTime Pressure Unsuitable Environment Social Considerations Organisational Considerations
Risk Making ProbabilityFear of Abuse Fear of Stigma
Instrumental UseRidicule Labelled as Humour Criticism Labelled as Humor Personality Assessment
Change: Opportunities and ThreatsRenewal and Exhaustion Formation of Constructive and Destructive Relationships Security to Sense of Threat
F. Ghaffari, et al.
5MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir
sulted in her detesting me and not talking to me for a long time.”
Consideration of Unique Personal Char- acteristics: Most nurses believed that un- derstanding and analysing a patient or col- league’s personality and their demographic characteristics such as age, gender, socio- economic level, personality and mood is necessary when using humour. Still, most believed that personal characteristics are not taken into account by most nurses when using humour. Misunderstandings, fol- lowed by anger, grudges, broken interper- sonal relationships, and patients’ reluctance to receive care and requesting to be dis- charged before completing the treatment process, delayed care by nurses and re- questing to change wards can result from neglecting patients and nurses’ personal characteristics when using humour.
A nurse commented, “When you are providing care to an elderly patient, you can get closer to the patient. However, when it is a young or female patient or a patient’s companion, then you won’t feel that comfortable to humour the patient or get close to her/him.”
Cultural Context: The use of humour re- quires an understanding of differences in culture, upbringing, language and meanings attached to words, education level and so- cial class. Nurses associate shame, which arises from cultural barriers and contributes towards limited use of humour in clinical settings, with lack of confidence, an inferi- ority complex, feeling insecure, lack of trust and failure to adjust to the workplace, which in turn hampers social interaction. This was more prevalent among married, female nurses, who considered intimate re- lationships with the opposite sex an in- fringement of family privacy.
One nurse commented, “My family has taught me not to joke with the opposite sex. Humour facilitates intimacy and close rela- tionships between people and this is in con- flict with what I have learnt from my fami- ly.”
Condition Enforcement Participants considered condition en-
forcement as the most important barrier to the use of humour in clinical settings. Time pressure, an unsuitable environment, and potential risks comprised the subcategories of this theme.
Time Pressure: Given their high workload and care provision for many patients, nurs- es typically experience time pressure. The nurses believed that humour can occur when nurses and patients share pleasant experiences. This requires intimate and long-term relationships that are hampered by nurses’ time constraints. These also af- fect nurses’ relationships with colleagues, with whom they casually interact mainly during teatime.
Another nurse said, “Sometimes I do not even have the time to greet patients, let alone connect and share jokes with them.”
Unsuitable Environment: Nurses’ use of humour in clinical settings is constrained by social and organisational protocol as discussed below.
Social Considerations: According to the nurses, the appropriateness of humour is also determined by one’s patients and col- leagues, as they must be able to appreciate humour. Thus, nurses should be protected from the negative consequences of humour, including harassment and defamation of character and professional identity. How- ever, many believed that sharing jokes with someone of the opposite sex is hardly ac- ceptable and often results in misunder- standings due to restrictions surrounding male-female relationships in the Iranian society.
A nurse said, “Most men, especially young ones cannot take a joke. Once, there was a young male patient whom I joked with, and this led to him harassing me. He was always at the nursing station. He would get close and ask private questions.”
Organisational Considerations: An imper- sonal, unfriendly organisational atmosphere with minimum interpersonal relationships cannot render humour a constructive strate- gy for dealing with stressful situations.
Nurses’ experiences of humour in clinical settings
6 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir
One nurse commented, “In my organisa- tion, humour and laughter are considered unethical behaviour for nurses. If I joke with a female colleague, I immediately no- tice nursing managers’ harsh reactions.”
Risk Making Probability Nurses considered themselves at risk of
mental, social and family harm because of their humour. Fear of abuse and stigma comprise the subcategories of this theme.
Fear of Abuse: Fear of abuse involves nurse-nurse, nurse-patient, or nurse- organisation interactions. Despite their pos- itive appraisal of humour use in patient care, some nurses believed that getting too close to the patient facilitates entry into each other’s private lives. They were con- cerned about the closeness and intimacy resulting from the use of humour, equating it with sharing private information. Thus, they preferred not to present opportunities for such problems to occur by limiting their relationships with patients. Concerns about unfavourable reactions from patients or their companions, blurring of boundaries, loss of mutual respect and fear of being abused following unreserved interaction with a patient were among the nurses’ con- cerns. Most participants cited the possibil- ity of an emotional relationship between nurses and patients following the use of humour during casual interactions, believ- ing that this could cause irreparable harm to the nurse and the patient. Furthermore, concerns about possible harassment by the patient as a result of the relationship, fol- lowed by the disintegration of one’s family relationships and the shame suffered before one’s colleagues or family were among the nurses’ main concerns regarding humour use in patient care. These concerns were also apparent in relation to the use of hu- mour with colleagues.
A nurse said, “I had a young male patient once; whenever he wanted to call me, he would tap my shoulder. He considered it humorous, but it bothered me. When it was my shift, it worried me that he might in- trude and not respect my privacy. I tried to
keep a distance from him.” Fear of Stigma: Participants had concerns
about nursing managers, colleagues and patients’ potential stigmatisation of the be- haviour, labelling it as promiscuous or irre- sponsible. This influenced their use of hu- mour in clinical settings.
‘Once, I joked with a patient and my su- pervisor witnessed it and told me to behave myself carefully, since in his view, joking was not a proper thing to do by a nurse’.
Instrumental Use This theme included nurses’ experiences
of humour in clinical settings, with ridicule, criticism and personality assessment la- belled as humour.
Ridicule Labelled as Humour: According to the participants, some nurses and pa- tients regard the use of contemptuous words, behaviour, or text as humour. Par- ticipants believed that ridiculing patients’ lack of medical knowledge or terminology, their accents and exposing their physical problems when providing care were com- mon among their colleagues and often la- belled as humour.
A nurse said, “Once, one of my col- leagues began making fun of me; she walked like me and mimicked my manner- isms and when she realised that I was up- set, she said she was joking.”
Criticism Labelled as Humour: The par- ticipants believed that, sometimes, their colleagues disguised harsh criticism against them as humour. In the participants’ view, tolerating criticism aimed at destroying their character and job situation was worse than the joke itself. They believed that nurses and patients should clearly define what constitutes a joke.
One nurse said, “When my colleague wants to put me down, she criticises me or questions my work, disguising it as a joke. She says anything she wants and when she realizes that I am annoyed, she says she was joking.”
Personality Assessment: Participants stat- ed that the use of humour by their col- leagues, patients, or patients’ companions
F. Ghaffari, et al.
7MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir
was a means to assess the situation, open- ing them up to psychological, emotional, and physical abuse.
‘There is a patient who always tries to get close to me and uses one-liners to test me. He wants to see if he can invade my priva- cy or not. When he notices that I am angry, he uses humour as a strategy.’
Change: Opportunity and Threats In the nurses’ view, humour can range
from a sense of renewal to weariness, the formation of constructive to destructive re- lationships and from a sense of security to a sense of threat.
Renewal and Exhaustion: Participants as- serted that a nurse must be serious in clini- cal settings. However, they believed that the use of humour can make the workplace pleasant and counteract the hardships of a heavy workload. Humour can help nurses deal with stressful situations, such as ex- haustion resulting from a high workload and enables them to rest physically, mental- ly, and emotionally. In anxiety-provoking situations, such as caring for an ill patient, exposure to organisational stressors and severe shortage of equipment and person- nel, humour enables nurses to consider the positive aspects of a situation and manage it effectively to theirs and patients’ ad- vantage. Humour can result in a change in disposition, a sense of peace and increased ability to care for patients. Nurses also be- lieve that humour can help them deal with patients’ provocative behaviour, anger and aggression, in turn relieving patients’ fear, anger, and worries. Moreover, nurses be- lieve that humour can reduce the severity of patients’ pain, which patients mostly com- plain about.
‘Sometimes, humour, even a moment’s laughter together, lightens a difficult shift and motivates us to continue – a joke sus- tains our energy until the shift ends.’
However, humour can also wear nurses and patients down physically and emotion- ally, leading to tiredness, negativity to- wards the workplace, anger, aggression, fear and hopelessness.
‘When I joked with my colleague, I dis- tempered her and I felt that she got so an- gry that she left her duty.’
Formation of Constructive and Destruc- tive Relationships: According to the partic- ipants, being pleasant can lead to ac- ceptance of the nurse by patients and col- leagues and foster new relationships, feel- ings of closeness and solidarity and open communication lines. Furthermore, humour elicits patients’ willingness to learn, coop- eration and offers a distraction from the disease. A nurse’s use of humour during social interaction can discard stress, dissat- isfaction, disagreements and resolve un- pleasant encounters with others. Nurses use different strategies to establish relationships with shy (embarrassed), unsociable and im- patient patients in order to obtain infor- mation about their ailments or relieve them of loneliness. They consider humour an ef- fective strategy in such cases.
‘When an asthmatic patient would not al- low me to use a spray on him, I began to joke with him; he laughed a lot and then tried to cooperate with me; his attitude completely changed.’
Although the majority of the nurses be- lieved that humour with colleagues and pa- tients facilitated cooperation during patient care, some believed that, if humour is used for pretence, abusing others and venting, it could destroy interpersonal relationships and lead to anger and disheartenment. They believed that when humour hurts others and invades personal boundaries, then it cannot be considered constructive. The partici- pants argued that a relationship must be defined for both parties and should not be so open as to lead to the use of unusual and insulting words or behaviour unbecoming of nurses.
‘A male colleague used to exceed his lim- it with the excuse of joking and I used to get very angry – then gradually, our rela- tionship cooled off and got darker and darker until we changed wards – I felt that I could not work with him anymore.’
Security to Sense of Threat: Humour ena- bles friendly conversations and a sense of
Nurses’ experiences of humour in clinical settings
8 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir
empathy. Shared feelings are associated with a sense of security for patients and nurses engaging in humour while interact- ing. Humour can keep a long-term relation- ship among colleagues pleasant, exciting, lively and renewed. In clinical settings, humour can help nurses resolve conflicts and disagreements.
‘When my colleague joked with me, I saw the relationship as open and could tell him about my worries and work problems – this lessened my worries, increased my confidence and made me feel secure.’
Nurses believed that inappropriate jokes make working shifts unpleasant and threat- en one’s family and work status, also creat- ing a sense of mental, emotional and physi- cal harassment. Such jokes can also lead to harassment by colleagues or patients in oc- cupational and non-occupational settings, which reduces motivation to provide pa- tient care and an interest in nursing. Feel- ings of insecurity were even more prevalent among married nurses, as they tended to argue with their spouses, who tried to pre- vent them from continuing to work in the nursing field. In some cases, marital con- flict has occurred due to suspicion arising from humour being used at work and spouses objecting to their wives’ relation- ships with their colleagues and patients.
'Once my husband came to pick me up, he understood that one of my male col- leagues had joked with me and so whenev- er he came to pick me up, we had a lot of problems at the way home.’
In the nurses’ view, sharing jokes with others at work should not lead to overly caring for one another. However, the ma- jority felt that they were being scrutinised by their managers due to shared humour with colleagues or patients. This resulted in feeling a perceived threat to one’s security, which is a prerequisite for enjoying one’s work.
‘When I joked with a female patient, I re- alised that she looked at me differently in the next shift – after a while she asked me for a date. This was very unpleasant for me.’
Verbal or written warnings and threats of demotion or even suspension were a con- tentious issue for the nurses, eliciting inse- curities regarding the use of humour in clinical settings.
‘I was penalised by a nursing manager af- ter a colleague complained about me joking with him. I only wanted to make him laugh, but he was annoyed.’
Discussion In this study, the first theme related to
dynamics of humour, with ‘Understanding humour’ emerging as the first subcategory. For the participants, the use of humour is determined by dynamics in clinical settings. Some participants believed that humour is necessary to make the working environ- ment pleasant and drives the nurses to cre- ate opportunities for the use of humour dur- ing their minimal, casual interaction with patients and colleagues (19). Studies show that nurses’ perception of sense of humour was a major factor in using sense of hu- mour at patients’ bedside. The nurses avoid using their sense of humour unless they be- lieve that joking can help the mental health of the patients and nurses, and recognize it as a caring strategy. Conversely, negative perceptions of humour limit its use in pa- tient care (20). Apt posits that, prior to the use of humour, it is essential to consider people’s perception of humour, particularly those informed by culture (21) .
Religious beliefs were considered another dynamic of humour. In the participants’ view, humour is in conflict with religious principles. Sometimes, due to staff shortag- es and patients care needs, nurses had to work with colleagues of the opposite sex on the same shift or care for patients of the opposite sex. This meant that some could not use humour in the clinical context. Most nurses cannot joke with the opposite sex in the clinic due to their religious be- liefs. The participants believed that hu- mour fosters friendly relationships between people, which go against their religious be- liefs, particularly when involving members of the opposite sex. However, in the reli-
F. Ghaffari, et al.
9MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir
gious Iranian culture, humour is considered a pleasant attribute, recommended to a cer- tain extent by religious leaders. In the Is- lamic view, humour is approved, so long as it is not associated with sinful behaviour, including: belittling, ridiculing, slander, back-stabbing or such (22). In the Islamic view, making a friendly and close commu- nication with the other sex, which is the background for using a sense of humour is considered a sin. Considering others’ reli- gious beliefs is necessary when using hu- mour (23).
Assessing the situation was identified as another dynamic of humour. Most partici- pants emphasised the need to time the use of humour according to others’ physical, mental, and emotional disposition. Consid- ering whether a patient or colleague is in a position to appreciate humour could pre- vent misunderstandings. Moreover, nurses must consider the cultural context when using humour. Scholars believe that rela- tionships form the basis for patient care, and therefore, the use of humour in nursing care. However, it is important to consider the cultural backgrounds of individuals with whom one has relationships (19) and maintain some distance, verbally or physi- cally. According to the Islamic culture of Iran, physical distance enables the protec- tion of individuals’ religious beliefs, pro- fessional identity and reputation, as well as a chance to contemplate, heal and recognise others. Providing culturally safe care is a requirement in skilled nursing care (24-27). Disregarding norms can be considered an- noying or insulting, least of all funny. Thus, nurses must use humour carefully, not chal- lenging the society’s norms, as these differ across societies (23). Humour should be like looking through a shattered glass win- dow; the subject can be seen, but what is seen is different in reality.
The second theme, the constraint of con- dition, was considered one of the main ob- stacles in the use of humour in clinical set- tings. In the participants’ view, maintaining boundaries in one’s behaviour and speech can lessen nurses’ concerns about the con-
sequences of humour in interpersonal rela- tionships and, therefore, enable its use. Limits and boundaries are associated with self-restraint, which enables compassion among nurses, informed development of relationships and, consequently, use of hu- mour, while maintaining commitment to one’s religious beliefs.
The instrumental use of humour through ridicule or criticism hampers its acceptance in clinical settings. Participants believed that the use of humour to ridicule others can seriously damage others’ personality and disrupt or completely destroy relation- ships. This is referred to as aggressive hu- mour, wherein an individual attempts to taunt and make fun of others and freely cracking insulting jokes, disregarding the impact of these jokes on others (28). The nurses must guard against criticising col- leagues or patients’ beliefs, appearance or issues that are important to them (2). This belief gradually limits nurses’ use of a sense of humour in the clinical settings through changing the people’s attitude to- ward the effectiveness of the sense of hu- mour on patients and nurses’ health. Ac- cording to Martin et al., the undesirable as- pects of humour, such as misunderstand- ings, hurt, being laughed at and banter are often overlooked (6,29).
This study shows an increasing use of humour in daily life, particularly nursing care(4,30). In this study, the nurses be- lieved that humour provides an opportunity for change. In relation to this, the results showed that the consequences of humour can range from revival to exhaustion. In addition to enabling mental rest, humour helps change patients’ perspectives regard- ing their health condition (4), helps reframe difficult situations(23) and enables them to cope with various challenges(31). It also helps nurses to deal with difficult situations and patients (5), calms anxious patients (4) and is associated with job satisfaction and motivation. Humour can enhance creativity, values, promoting ethical and responsible behaviour, induce trust and reliance, as well as enable people overcome sadness, despair
Nurses’ experiences of humour in clinical settings
10 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir
and sorrow(32). For our participants, hu- mour can result in the strengthening or dis- integration of interpersonal relationships. Researchers believe that humour in patient care results in a change in patients’ experi- ences, less social distance, anxiety and stress among patients(33), improved learn- ing outcomes (2), open nurse-patient com- munication (34) and identification of pa- tients’ needs, a bond between nurses and patients (5) and among nurses, patients showing their emotions and the preserva- tion of their dignity (4), feelings of intima- cy and common understanding and estab- lishment of trust between patients and nurs- es. In such circumstances, patients can freely communicate their feelings to nurses, and this lessens the stress resulting from their respective states (23). Moreover, the results showed that joking can change the effective interpersonal relationships into grudge, seeking revenge and annoyance. Joking may destroy the intimacy and vio- late human rights. Paradoxically, humour may have negative effects, which are not always taken seriously (30). Lyttle believes that humour is like a double-edged blade capable of harming personal relationships (35); when timing is wrong, people may feel insulted or angry (2). Yura et al. (1988), believe that although laughing with others positively impacts relationships, laughing at others has an entirely negative effect on relationships (2). Still, given their roles, nurses can resolve misunderstand- ings. In patient care, nurses can use humour for informing the patient of his or her health condition and they can also use hu- mour positively in order to establish rela- tionships with patients (30). Du Pre and Beck suggested that it is necessary for nurses to use planned humour while check- ing a patient’s health status, since this in- creases the nurse’s influence on the patient and encourages cooperation from the latter during treatment (36).
The results obtained from this study are context-specific; thus, further quantitative studies are required for the generalizability of the findings.
Conclusion Recognising nurses’ perceptions and ex-
periences of humour helps identify its ef- fects; thus, we should provide valuable in- sights to ensure the mental, emotional and physical health of the nurses and patients. Effective methods include promoting a cul- ture of humour in care settings through training strategies aimed at enhancing cheerfulness in the workplace and high- lighting the importance of humour in pa- tient care for nurses and nursing students. Establishing norms and improving organi- zational culture to reduce social and organ- izational constraints of humour are other important actions which need to be consid- ered.
References 1. Farsi Z, Dehghan‐Nayeri N, Negarandeh R,
Broomand S. Nursing profession in Iran: an overview of opportunities and challenges. Japan Journal of Nursing Science. 2010;7(1):9-18.
2. Buxman K. Humour in the OR: A Stitch in Time? AORN journal. 2008;88(1):67-77.
3. Rafii F, Oskouie SH, Nikravesh M. Conditions Affecting Quality of Nursing Care in Burn Centers of Tehran. Iran Journal of Nursing. 2007;20(51):7- 24.
4. Åstedt‐Kurki P, Isola A. Humour between nurse and patient, and among staff: analysis of nurses’ diaries. Journal of advanced nursing. 2001; 35(3):452-458.
5. Beck CT. Humour in nursing practice: a phenomenological study. International journal of nursing studies. 1997;34(5):346-352.
6. Martin RA. The psychology of humour: An integrative approach: Access Online via Elsevier; 2010.
7. Isola A, Åstedt‐Kurki P. Humour as experienced by patients and nurses in aged nursing in Finland. International journal of nursing practice. 1997;3(1):29-33.
8. Cousins N. Anatomy of an illness (as perceived by the patient). Nutrition Today. 1977;12(3):22-28.
9. Coser RL. Some social functions of laughter. Human relations. 1959. Available at: http://www. professormarkvanvugt.com/files/LaughterasSocialL ubricant.pdf.
10. Adams P, Mylander M. Good health is a laughing matter. Caring-Washington Dc. 1992; 11:16-16.
11. Henderson A, Twentyman M, Heel A, Lloyd B. Students’ perception of the psycho-social clinical learning environment: an evaluation of placement
F. Ghaffari, et al.
11MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir
models. Nurse education today. 2006;26(7):564- 571.
12. Yura H, Walsh MB, Garzón N. The nursing process: assessing, planning, implementing, evaluating. 1988.
13. Robinson VM. Humour and the health professions: CB Slack Thorofare NJ; 1977.
14. Henderson V, Nite G. Principles and practice of nursing. AJN The American Journal of Nursing. 1978;78(9):1574.
15. Åstedt‐Kurki P, Liukkonen A. Humour in nursing care. Journal of advanced nursing. 1994; 20(1):183-188.
16. Fry W. Humour, physiology, and the aging process. Humour and aging. 1986:81-98.
17. Polit DF. Essentials of nursing research: Appraising evidence for nursing practice: Lippincott Williams & Wilkins; 2013.
18. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today. 2004;24(2):105-112.
19. Adamle K, Turkoski B. Responding to patient- initiated humour: guidelines for practice. Home healthcare nurse. 2006;24(10):638-644.
20. Naderi F, & Shokouhi M. The relationshipes of the optimism, humour, social maturity and death anexiety among Ahvaz Golestan hospital nursses. New Finding in Psychology.2009; 4(10):85-94.
21. Apte ML. Humour and laughter: An anthropological approach: Cornell university press Ithaca, NY; 1985.
22. Khoshouei M, OREYZI SSHR, AGHAEI A. Construction and validation of sense of humour questionnaire. Psychological Research. 2009; 12(1-2 (23);0-0.
23. Dean RAK, Major JE. From critical care to comfort care: the sustaining value of humour. Journal of Clinical Nursing. 2008;17(8):1088-1095.
24. Pasco ACY, Morse JM, Olson JK. Cross‐ Cultural Relationships Between Nurses and Filipino Canadian Patients. Journal of Nursing Scholarship. 2004;36(3):239-246.
25. Kirsh GA, Kuiper NA. Positive and negative
aspects of sense of humour: Associations with the constructs of individualism and relatedness. Humour. 2003;16(1):33-62.
26. Donnelly PL. Ethics and cross-cultural nursing. Journal of Transcultural Nursing. 2000; 11(2):119-126.
27. Bakerman H. Humour as a nursing intervention. Axone (Dartmouth, NS). 1997; 18(3): 56.
28. Liu KWY. Humour styles, self-esteem and subjective happiness. Humour. 2012;1:21-41.
29. Martin RA, Puhlik-Doris P, Larsen G, Gray J, Weir K. Individual differences in uses of humour and their relation to psychological well-being: Development of the Humour Styles Questionnaire. Journal of research in personality. 2003;37(1):48-75.
30. McCreaddie M, Wiggins S. The purpose and function of humour in health, health care and nursing: a narrative review. Journal of advanced nursing. 2008;61(6):584-595.
31. Rice HJ. The relationship between humour and death anxiety: Retirado dia; 2004. Available at: http://clearinghouse.missouriwestern.edu/manuscrip ts/153.asp.
32. Vilaythong AP, Arnau RC, Rosen DH, Mascaro N. Humour and hope: Can humour increase hope? Humour. 2003;16(1):79-90.
33. Chiarello MA. Humour as a teaching tool. Use in psychiatric undergraduate nursing. Journal of psychosocial nursing and mental health services. 2010;48(8):34.
34. Bennett WL, Ennen CS, Carrese JA, et al. Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: a qualitative study. Journal of Women's Health. 2011;20(2):239-245.
35. Lyttle J. The judicious use and management of humour in the workplace. Business Horizons. 2007;50(3):239-245.
36. du Pré A, Beck CS. "How can I Put this?" Exaggerated Self-Disparagement as Alignment Strategy during Problematic Disclosures by Patients to Doctors. Qualitative health research. 1997; 7(4):487-503.
Proving the Power of Laughter.pdf
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The Laughter Prescription.pdf
263
vol. 10 • no. 4 American Journal of Lifestyle Medicine
genuine, or “spontaneous,” laughter. Although one review4 catalogued over 100 individual theories of laughter, the field is dominated by 3 in particular: release theory, superiority theory, and incongruity theory.5 Release theory argues that laughter is the physical manifestation of repressed desires and motivations. Superiority theory posits that laughter is a means of increasing one’s self-esteem at the expense of others.6 By contrast, incongruity theory states that humor is created by a sense of incongruity between 2 or more objects within a joke.7 Currently, there is no concrete consensus on which theory is the most valid or most complete.
What Do We Understand About the Health Benefits of Laughter From a Scientific and Physiologic Perspective?
It is commonly accepted that laughter produces psychological benefits, such as improving affect, depression, anxiety, and stress.8-10 Nevertheless, there is growing evidence that laughter as a physical activity can additionally produce small but quantifiable positive physiological benefits. The literature on laughter can be separated based on the type of laughter studied: spontaneous or self-induced.
Spontaneous laughter differs significantly from self-induced laughter. The former refers to “genuine” or unforced laughter, often in response to a stimulus, whereas the latter describes laughter that is simulated de novo. Spontaneous laughter is often associated with positive mood, whereas simulated laughter is primarily physical and is not necessarily associated with positive emotions or feelings. Neuroimaging suggests that different neural pathways are used in these 2 forms of laughter.11
Do spontaneous and simulated laughter have the same effect on the body? One theory, the motion creates emotion theory (MCET),2 posits that the body does not actually know the difference between intentionally laughing and laughing instinctively. Therefore, if one
induces oneself to laugh (by simulating or self-inducing laughter), the body can be coaxed into an identical physiologic response. According to the MCET, simulated laughter can capture the positive benefits of spontaneous laughter—but without using any humor at all. This is distinctly unlike the other theories of laughter, which argue that the benefits arise from nonphysical sources, for example, positive mood.
Positive mood is closely tied to spontaneous laughter, and it is thought to have independent cognitive effects of its own.12 However, parsing out the interaction between positive mood and spontaneous laughter has been difficult. A study involving 87 subjects reported that manipulating mood with music and video—specifically a peppy Mozart piece paired with a video of a laughing baby, versus music from Schindler’s List and a news report about an earthquake— significantly affected performance on a creative thinking task of learning involving the classification of picture sets with visually complex patterns.13 However, another study of 60 subjects randomly assigned to watch a neutral, positive affect, or comedy video found that compared to a comedy video (presumably elicits both laughter and positive affect), a video that produced only positive affect and no laughter was not enough to cause endorphin release.14 Another study of 33 people found that natural killer cell activity increased only when the subject exhibited mirthful laughter while watching a humorous video (mean increase of 15.77 LU, P = .037).15 Otherwise, if the subject watched the video but did not laugh, natural killer cell activity actually decreased. Because of the difficulty of the task and the paucity of research on the topic, this article will consider positive mood and spontaneous laughter together as a unit, and make no effort to distinguish between the two.
Spontaneous Laughter
Spontaneous laughter—also known as “genuine” laughter—has been far more widely studied. One early study examined the stress hormones levels of 10 subjects
watching an hour-long humor video.16 Among experimental subjects, cortisol decreased from 240 ± 60 at baseline to 90 ± 10 a half-hour after finishing the video, compared to control subjects who decreased from 390 ± 90 to 270 ± 60 after the same amount of time. The experimental group had a significantly larger reduction (P = .011), although both groups had a consistent drop from baseline. A larger, more recent study involving 52 patients shown a 1-hour humor video found increases in natural killer cell activity, IgG, IgM, and other leukocytes.17 Other studies (n = 33 and 21) have corroborated some of these findings, determining that natural killer cell activity was higher in the group watching the comedic video compared to the control.15,18 Interestingly, another study of 20 subjects found that an amusing film actually produced similar increases in epinephrine and norepinephrine levels as an aggression-provoking one.19 The authors postulated that this was due to the emotional arousal, which can elevate sympathetico-adrenomedullary activity regardless of whether or not the arousal is positive or negative.
Other studies have linked laughter and humor with increased levels of pain tolerance. In one, 200 subjects were subjected to a painful cold-pressor stimulus after being shown a film. Those who viewed a humorous film had a significant advantage in pain tolerance time after a 30-minute wait period.20 Another experiment of 40 subjects found that a laughter-inducing narrative, as opposed to other forms of distraction such as an interesting narrative audio tape, increased discomfort thresholds.21 Similarly, a study of threat-induced anxiety involving 53 subjects found that those exposed to a humorous tape recording consistently rated themselves as less anxious and reported smaller increases in stress as the time to receive an electric shock approached.22
The cardiovascular effects of laughter appear to be quantifiable, although potentially short-lived. A study of 10 healthy subjects showed that cardiac parasympathetic activity decreased immediately on watching a comedy
264
Jul • Aug 2016American Journal of Lifestyle Medicine
video, and just as quickly returned to baseline when finished.23 This was in comparison to tragedy videos, in which the parasympathetic activity also dropped, but did not return to baseline afterward. Some of the temporary effects of laughter on the cardiovascular system are predictable, given that laughter involves an increase in physical activity from baseline. A study of 8 subjects found that laughter appears to significantly increase stroke volume and cardiac output, while significantly decreasing oxygen consumption, arteriovenous oxygen difference, and total peripheral resistance.24 A study of blood pressure involving 16 normotensive subjects found that laughing during a blood pressure measurement increased systolic blood pressure by an average of 12 points.25 This research suggests that the body responds physiologically to a bout of laughter as it does to a bout of exercise.
In 2011, additional studies further suggested the positive effects of spontaneous laughter. For example, a study presented at the European Society of Cardiology 2011 Congress found vasodilative effects lasting up to an hour after watching a comedic movie scene, whereas an action scene prompted vasoconstriction.26 Another study used humor therapy as “medication” to treat agitation in patients with dementia. The SMILE study found a 20% reduction in agitation using humor therapy, which is an improvement comparable to the common use of antipsychotic drugs but without the side effects. Agitation levels remained lower at the 26-week follow up. In this study, humor therapy used trained staff as “Laughter Bosses” to act much like the “Clown Doctors” used in hospitals on children’s wards to help improve mood and increase lightheartedness. (SMILE study results were presented at the National Dementia Research Forum 2011 on September 22 and 23.)
Self-Induced, or Simulated Laughter
In contrast to spontaneous laughter, the proposed benefits of simulated laughter
are largely based on the MCET: that the physical act of laughing is enough to create a positive physiologic response. Research on simulated/self-induced laughter, as opposed to spontaneous laughter, is very recent, and therefore only preliminary results are available.
A randomized control longitudinal study in India recruited 115 IT professionals to participate in 7 sessions of laughter yoga as a way to reduce stress.27 The type of laughter yoga used consisted of bursts of simulated laughter followed by yogic deep breathing relaxation techniques. This study found no significant change in heart rate, respiratory rate, heart rate variability, breath rate, or secretory IgA in either group. However, the laughter yoga group had a significantly greater drop in blood pressure (Laughter Yoga group = 7.46 mm Hg; Control group = 3.03 mm Hg), as well as a lower postintervention systolic blood pressure (Laughter Yoga group = 120.78 mm Hg; Control group = 125.96 mm Hg, P < .04). Additionally, the Laughter Yoga group showed a significant drop in cortisol levels (pre-intervention: 0.25 ± 0.14; post- intervention: 0.18 ± 0.11) whereas the Control group did not.
Another study of laughter yoga examined 60 depressed geriatric patients in Tehran, Iran.28 Study subjects were randomized to receive laughter yoga therapy, exercise therapy, or nothing. Both laughter yoga and exercise therapy groups had a significant decrease in depression scores compared to the control group (P < .001 and P < .01, respectively), and the laughter yoga group had an additional increase in life satisfaction compared to the control group (P < .001). Interestingly, no significant differences were found between the laughter yoga and exercise groups.
Summary of Literature
Current literature on laughter is promising, suggesting that laughter has many positive physiologic effects on the body. It remains important, however, to retain a certain amount of healthy
skepticism until results have been repeated and reaffirmed. In this vein, there remains much to do in terms of determining the duration and long-term impact of these effects. In terms of methodology, randomized control trials are in short supply compared to intervention trials,2 as are standardized instruments to help better compare results among studies. Increased methodological rigor will be important for the future. Furthermore, the distinction between spontaneous versus self-induced/simulated laughter remains an important area for exploring the MCET. Finally, having higher-powered studies that can parse out the difference between positive mood and the physical act of spontaneous laughter, for instance, can help further our understanding on the topic. There is great potential for future research in laughter. Randomized controlled large-scale trials are needed to further elucidate the physiologic effects of laughter.
Laughter and Professionalism: Should Physicians Use Humor as a Tool to Induce Therapeutic Laughter?
An important remaining question is whether or not laughter can be made into a convenient, useful therapy for patients. Laughter has no side effects, is readily accessible—already permeating many of our daily social interactions. Thus, whether the intent is to help a patient achieve positive physiologic benefits or simply enhance provider– patient communication, it deserves a closer examination to determine its applicability in the medical setting.
Of course, health is a serious and often grave matter, and humor delivered at inappropriate times can be devastating, insensitive, and crass. In this vein, certain types of humor must be considered off-limits—in particular cynical and derogatory humor directed at the patient. Unfortunately, some studies indicate that avoiding these types of humor, including “dark” and/or negative humor as a coping mechanism for providers, can be
265
vol. 10 • no. 4 American Journal of Lifestyle Medicine
more difficult than imagined.29-31 Indeed, negative humor can be passed down as a sort of “hidden curriculum” and perpetuated through many generations of providers.32
Within the bounds of appropriateness, however, both humor and laughter can be beneficial. For one, laughter shared between the provider and patient conveys a measure of trust and light- heartedness. Furthermore, humor can improve communication, as a joke can signal a transition in the conversation from the serious to more benign topics. In general, medical providers do best when acting cautiously and following the patient’s lead. Knowing a patient well and acknowledging any humor expressed by him or her is recommended.
One additional unexplored field is the possibility of using laughter “therapy” as a means of sparking a more creative approach to lifestyle change. Depressed mood has been shown to be associated with decreased physical activity and weight gain in several societies. A recent survey of roughly 1500 Israelis33 used logistic regression and showed that less exercise and more weight was correlated with depressive symptoms after adjusting for confounders, although whether the direction of the correlation is such that mood causes the decrease in activity or vice versa is unclear. Given that laughter and humor is a key element to happiness and is often used as a therapeutic tool for depression,7,34 both traditionally and more recently in the form of “Laughter Yoga” exercises mentioned above,27,28 it could potentially be used to counteract the effects of depression and aid new approaches to lifestyle change. More recently, laughter and humor are being used in geriatric care of patients with dementia,35 resulting in a positive climate that could also potentially be fertile ground for instituting lifestyle changes.
The Laughter Prescription: A Speculative Template
One method for putting laughter into practice is to discuss laughter with the patient during a visit. Providers can ask,
“What has made you laugh recently?” or “How often do you laugh?” Inquiring about laughter opens the door to light heartedness and also could lead to counseling on laughter and sharing the latest research with the patient. More important, it allows the provider to determine what the patient finds funny, thereby allowing the provider to tailor recommendations to better fit the patient’s needs and preferences. This also contains the potential to deepen the therapeutic relationship between patient and provider. Put together with a more structured approach, the health care provider could consider prescribing laughter to patients.
The MCET theory states that it may be enough for patients to simply self-induce the physical act of laughing in order to gain positive benefits. Therefore, prescribed laughter may be very helpful in that all patients—even those potentially unwilling to seek out comedy or humor—can still engage in laughter and derive benefits from it. There are laughter yoga classes and videos available online and even courses offered at local recreations centers. If a patient fails to benefit from the therapy, then very little—if anything—is lost in the attempt, as there are no side effects. As such, adding in a brief 1-minute conversation on laughter may represent an additional fast, inexpensive, and no-risk tool in the physician’s toolbox.
We propose that laughter prescriptions might contain detailed information as to the frequency, intensity, time, and type of laughter (forming the useful mnemonic “FITT”), much like pharmacological prescriptions and exercise prescriptions. This format aims to give patients clear and easy-to-remember guidelines. It is also a way to present laughter in a serious manner. When prescribing laughter, it would be of utmost importance to individualize the recommendations, taking into consideration the patient’s own sense of humor and willingness to engage in new activities, such as laughter yoga.
An example of a laughter prescription:
(F) Frequency: once a week (I) Intensity: belly laughing (T) Time: 30 minutes (T) Type: your favorite sit-com
Laughter prescriptions remain largely speculative, but existing research indicates that efficacious laughter “treatments” typically occur once a week or less, for 30 to 60 minutes.36 Nevertheless, shorter frequencies and times, such as individual sessions as short as 20 minutes, can still have a positive impact.18 Intensity remains an open-ended question. It remains unclear how much, or with what amount of enthusiasm, one’s laugh leads to emotional and physical benefits. Type is the most variable factor of all. Again, tailoring recommendations to what the patient finds funny is an important part of creating an effective prescription. Furthermore, whether or not humor is even needed to generate laughter (eg, laughter yoga instead of watching comedies) is up to the individual patient.
Another consideration is the idea of group laughter, or laughter shared among other people. Although most studies look at the impact on one’s body through the use of a humorous cartoon, in reality this is only a small aspect of all the stimuli that humans find amusing. Social laughter often occurs in a situation with a stand-up comedian. One functional magnetic resonance imaging study looking at the effect of stand-up comedians found that clips considered humorous activated reward centers in the brain.37 Another study from Israel looked at the effect of humorous videos on schizophrenic inpatients and found an improvement in patient’s psychopathology, mood, and mental status.38 A randomized controlled trial done in Japan, which allocated 27 individuals older than 60 to weekly 120-minute group laughter-with-exercise sessions over 3 months, found an increase in self-rated health as well as in objective bone mineral density, and a decrease in HbA1c levels,39 suggesting that group laughter sessions may be a way to encourage the elderly to exercise. However, it is currently unknown the extent to which group laughter provides
266
Jul • Aug 2016American Journal of Lifestyle Medicine
different benefits compared to laughing on one’s own.
There are barriers to implementing laughter therapy into one’s practice. Finding the time to discuss laughter, even just a 1-minute conversation, is understandably challenging. Giving a laughter prescription to patients suffering from depression and dementia could also be difficult. Significant life stressors, such as a recent death in the family, moving to a new home, being fired from a job, and so on, understandably make people feel unwilling or unable to laugh; however, laughter might still prove to be effective medicine in these situations. In such cases, it might take social support from friends and family in order to help the patient to engage in laughter. Thus, like many lifestyle behaviors, it is likely best if the environment and the people closest to the patient are on board with the laughter prescription in order for it to be successful long term.
Conclusion
While it is well known that both laughter and humor can have deep and long-lasting psychological effects, it is only recently that our knowledge of the physiologic effects of laughter has grown. This modern change has been in no small part driven by the practices of laughter yoga and similar self-induced, or simulated, forms of laughter. Whereas laughter and humor were once thought of as nearly interchangeable, laughter is now a distinct physical action that can be effective on its own. Currently, research is indicating that the physical act of laughing, even without humor, is linked to chemical changes in the body that potentially reduce stress and increase pain tolerance. Understanding the distinction between spontaneous and simulated laughter is likely to become a stronger point of emphasis moving forward.
The United States is presently straining under the weight of rapidly increasing medical costs. Although there are limitations to the current medical literature on laughter, enough evidence indicates that laughter may be employed
as part of our basic armamentarium to help prevent diseases, reduce costs, and ensure a healthier population. While more research must be done, it is also important to acknowledge there is not much to lose in laughing. With no downsides, side-effects, or risks, perhaps it is time to consider laughter seriously.
Acknowledgments
The authors would like to thank David Roberts, MD, for his invaluable expertise and assistance in preparing this article for publication. AJLM
References
1. Cousins N. An Anatomy of an Illness. New York, NY: WW Norton; 1979.
2. Mora-Ripoll R. The therapeutic value of laughter in medicine. Altern Ther Health Med. 2010;16(6):56-64.
3. Parvizi J, Anderson SW, Martin CO, Damasio H, Damasio AR. Pathological laughter and crying: a link to the cerebellum. Brain. 2001;124(pt 9): 1708-1719.
4. Foot H, McCreaddie M. Humour and laughter. In: Hargie O, ed. The Handbook of Communication Skills. 3rd ed. London, England: Routledge; 2006:293-322.
5. Smuts A. Humor. Internet Encyclopedia of Philosophy. http://www.iep.utm.edu/ humor/. Accessed November 10, 2011.
6. Mulder MP, Nijholt A. Humour research: state of the art. http://wwwhome. cs.utwente.nl/~anijholt/artikelen/ ctit24_2002.pdf. Accessed August 29, 2014.
7. Seaward BL. Humor’s healing potential. Health Prog. 1992;73(3):66-70.
8. Foley E, Matheis R, Schaefer C. Effect of forced laughter on mood. Psychol Rep. 2002;90(1):184.
9. Kuiper NA, Martin RA. Laughter and stress in daily life: relation to positive and negative affect. Motiv Emot. 1998;22:133-153.
10. Szabo A, Ainsworth SE, Danks PK. Experimental comparison of the psychological benefits of aerobic exercise, humor, and music. Humor. 2005;18: 235-246.
11. Iwase M, Ouchi Y, Okada H, et al. Neural substrates of human facial expression of pleasant emotion induced by comic films: a PET study. NeuroImage. 2002;17:758-768.
12. Pae CU, Jhoo JH, Yoon IY, et al. Availability of brain serotonin transporters (5-HTT) is associated with low positive
mood in healthy elderly subjects. Int J Clin Pharmacol Ther. 2012;50:533-539.
13. Nadler RT, Rabi B, Minda JP. Better mood and better performance. Learning rule- described categories is enhanced by positive mood. Psychol Sci. 2010;21:1770-1776.
14. Dunbar RIM, Baron R, Frangou A, et al. Social laughter is correlated with an elevated pain threshold. Proc Biol Sci. 2012;279:1161-1167.
15. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Altern Ther Health Med. 2003;9(2):38-45.
16. Berk LS, Tan SA, Fry WF, et al. Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci. 1989;298:390-396.
17. Berk LS, Felten DL, Tan SA, Bittman BB, Westengard J. Modulation of neuroimmune parameters during the eustress of humor associated mirthful laughter. Altern Ther Health Med. 2001;7:62-72.
18. Takahashi K, Iwase M, Yamashita K, et al. The elevation of natural killer cell activity induced by laughter in a crossover-designed study. Int J Mol Med. 2001;8:645-650.
19. Levi L. The urinary output of adrenalin and noradrenalin during pleasant and unpleasant emotional states: a preliminary report. Psychosom Med. 1965;27:80-85.
20. Weisenberg M, Raz T, Hener T. The influence of film-induced mood on pain perception. Pain. 1998;76:365-375.
21. Cogan R, Cogan D, Waltz W, McCue M. Effects of laughter and relaxation on discomfort thresholds. J Behav Med. 1987;10:139-144.
22. Yovetich NA, Dale JA, Hudak MA. Benefits of humor in reduction of threat-induced anxiety. Psychol Rep. 1990;66:51-58.
23. Sakuragi S, Sugiyama Y, Takeuchi K. Effects of laughing and weeping on mood and heart rate variability. J Physiol Antropol Appl Human Sci. 2002;21:159-165.
24. Boone T, Hansen S, Erlandson A. Cardiovascular responses to laughter: a pilot project. Appl Nurs Res. 2000;13:204-208.
25. McMahon C, Mahmud A, Feely J. Taking blood pressure—no laughing matter! Blood Press Monit. 2005;10:109-110.
26. O’Riordan M. Laughter and therapy could go a long way for the heart. Medscape Today News. http://www.medscape.com/ viewarticle/748773. Published August 29, 2011. Accessed August 31, 2011.
27. Nagendra HR, Chaya MS, Nagarathna R, Kataria M, Manjunath MK, Rao R. The Efficacy of Laughter Yoga on IT Professionals to Overcome Stress. Mumbai,
267
vol. 10 • no. 4 American Journal of Lifestyle Medicine
India: Laughter Yoga International. http://www.yogalaff.com/docs/8-INDIA- LAUGHTER-STUDY.pdf. Published 2007. Accessed August 29, 2014.
28. Shahidi M, Mojtahed A, Modabbernia A, et al. Laughter yoga versus group exercise program in elderly depressed women: a randomized controlled trial. Int J Geriatr Psychiatry. 2011;26:322-327.
29. Dharamsi S, Whiteman M, Woodllard R. The use of cynical humor by medical staff: implications for professionalism and the development of humanistic qualities in medicine. Educ Health (Abingdon). 2010;23:533.
30. Wear D, Aultman JM, Varley JD, Zarconi J. Making fun of patients: medical students’ perceptions. Acad Med. 2006;81:454-462.
31. Wear D, Aultman JM, Zarconi J, Varley JD. Derogatory and cynical humour
directed towards patients: views of residents and attending doctors. Med Educ. 2009;43(1):34-41.
32. Berk R. Derogatory and cynical humour in clinical teaching and the workplace: the need for professionalism. Med Educ. 2009;43(1):7-9.
33. Khalaila R, Litwin H. Changes in health behaviors and their associations with depressive symptoms among Israelis aged 50+. J Aging Health. 2014;26: 401-421.
34. Davidhizar R, Vance A. In pursuit of happiness. Todays OR Nurse. 1994;16(4): 41-44.
35. Hafford-Letchfield T. Funny things happen at the Grange: introducing comedy activities in day services to older people with dementia—innovative practice. Dementia (London). 2013;12:840-852.
36. Mora-Ripoll R. Potential health benefits of simulated laughter: a narrative review of the literature and recommendations for future research. Complement Ther Health. 2011;19:170-177.
37. Franklin R Jr, Adams R. The reward of a good joke: neural correlates of viewing dynamic displays of stand-up comedy. Cogn Affect Behav Neurosci. 2011;11: 508-515.
38. Gelkopf M, Gonen B, Kurs R, Melamed Y, Bleich A. The effect of humorous movies on inpatients with chronic schizophrenia. J Nerv Ment Dis. 2006;194:880-883.
39. Hirosaki M, Ohira T, Kajiura M, et al. Effects of a laughter and exercise program on physiological and psychological health among community-dwelling elderly in Japan: randomized controlled trial. Geriatr Gerontol Int. 2013;13:152-160.
The role of laughter in traditional medicine and its relevance to the clinical setting.pdf
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The science of laughter.pdf
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
therapeutic_value_of_laughter_in_medicine.pdf
NAflRATIVE REVIEW
THE THERAPEUTIC VALUE OF LAUGHTER IN MEDICINE
Ramon Mora-Ripoll, MD, PhD
Objective • The aim of this review is to identiiy, critically evalu- ate, and summarize the laughter literature across a number of fields related to medicine and health care to assess to what extent laughter health-related benefits are currently supported by empirical evidence.
Data Sources and Study Selection • A comprehensive laughter literature search was performed. A thorough search of the gray literature was also undertaken. A list of inclusion and exclusion criteria was identified. Data Extraction • It was necessary to distinguish between humor and laughter to assess health-related outcomes elicited hy laughter only. Data Synthesis • Thematic analysis was applied to summa- rize laugliter health-related outcomes, relationships, and general robustness. Conclusions: Laughter has shown physiological, psychological.
social, spiritual, and quality-of-life benefits. Adverse effects are very limited, and laughter is practically lacking in contraindica- tions. Therapeutic efficacy of laughter is mainly derived fi-om spontaneous laughter (triggered by external stimuli or positive emotions) and self-induced laughter (triggered by oneself at will), both occurring with or without humor. The brain is not able to distinguish between these types; therefore, it is assumed that similar benefits may be achieved with one or the other. Although there is not enough data to demonstrate that laughter is an ail- around healing agent, this review concludes that there exists suf- ficient evidence to suggest that laughter has some positive, quan- tifiable effects on certain aspects of health. In this era of evidence- based medicine, it would be appropriate for laughter to be used as a complementary/alternative medicine in the prevention and treatment of iQnesses, although further well-designed research is warranted. (Altem Ther Health Med. 2010;16(6):56-64.)
Ramon Mora-Ripoll, MD, PhD, is medical scientific director at Organización Mundial de la Risa, Barcelona, Spain.
Corresponding author: Ramon Mora-Ripoll, MD, PhD E-mail address: [email protected]
T hat laughter has health benefits has heen claimed for centuries; however, during the past decades, several laughter- and humor-based interventions have gained widespread acceptance, and scientific studies of this phenomenon have generated considerable
medical and public interest. In 1976, Norman Cousins published the article "Anatomy of an Illness" in The New England Journal of Medicine, in which he explained that 10 minutes of genuine belly laughter as a result of viewing comic films had a considerable analgesic effect and gave him at least 2 hours of sleep ftee from the pain of ankylosing spondylitis.' It was never clear whether his pain relief was due to the laughter or to the massive dose of vita- min C administered simultaneously, but the case became famous and encouraged scientists to investigate and define how laughter may heal, founding the basics of current "laughter medicine."
Though it takes skill and time to develop the science and art of what makes a person laugh and to ascertain the related bene- fits, laughter therapy does not require large amounts of time or money to be applied. Unlike other therapies that are more time-
consuming or expensive, the use of laughter can be implemented easily and cost-effectively in patient care.'' Nevertheless, there are now so-called "laughter trainers" and accounts all over the popular media proclaiming the supposed physical, psychologi- cal, emotional, social, occupational, spiritual, and quality-of-life benefits of laughter. Scientific data for these claims must be well documented before evidence-based "laughter medicine" can be widely supported by the health care community."'
The aim of this review is to identify, critically evaluate, and summarize the laughter literature across a number of fields relat- ed to health, health care, patient care, and medicine with the purpose of assessing to what extent laughter health-related bene- fits are currently supported by empirical evidence.
METHODS Definitions
This review focuses on the health-related effects of laughter only. One of the most significant methodological prohlems in laughter research is the failure to distinguish humor fi-om laugh- ter. A ftiU discussion on laughter and humor theories is beyond the scope of this review, but a few basic definitions are essential." For the purpose of this review, humor is defined as one of the stimuli that can help people laugh and feel happy. Sense of humor is a psychological trait that varies considerably and allows people to respond to different types of humorous stimuli. And laughter
56 ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL. 16, NO. 6 Therapeutic Value of Laughter in Medicine
is defined as a psychophysiological response'"" to either humor or any other stimuli with the following characteristics": (1) pow- erful contractions of the diaphragm together with repetitive vocal sounds produced by the action of the resonating chambers of the pharynx, mouth, and nasal cavities; (2) typical facial expression (motion of about 50 facial muscles, mainly around the mouth), which may include the release of tears; (3) motion of several groups of muscles of the body (more than 300 may be distinct); and (4) a sequence of associated neurophysiological processes (cardiovascular and respiratory changes, activation of neuroendocrine and immune circuits). Internally, laughter comes with positive psychological shifts and a subjective identifiable emotion (hilarity) that has been compared to the one coming from sexual activity or other joyful bodily responses.
It is apparent that humor and laughter are distinct events (although often associated). Whereas humor is a stimulus and can occur without laughter, laughter is a response and can occur without humor.'^ It is necessary to distinguish between these variables, as many analyses of humor have used a humor stimu- lus (such as a comic movie) to determine the effect of "humor" on a health-related outcome, and others look specifically at the effects of laughter on these outcomes. Still others explore differ- ent ways to assess sense of humor in an attempt to analyze whether scoring higher on a sense-of-humor scale is associated with certain health outcomes.
Design A systematic review was conducted. This type of review is
particularly useful where the aggregation of data is difficult because diverse definitions, many studies or fields, and different outcomes are being analyzed." A comprehensive laughter and humor literature search was performed using a variety of data- bases and keywords. A manual search of relevant sources, a jour- nal-specific search, and a manual search of references included in relevant retrieved articles also were included (Table 1). A thor- ough search of the gray literature also was undertaken (eg, Google). A list of inclusion and exclusion criteria was identified (Table 2). All relevant published articles up to 2008 were reviewed. No papers were excluded on the basis of quality because of the dearth of literature meeting the established inclu- sion or exclusion criteria. Thematic analysis was applied to sum- marize laughter and humor theories, health-related outcomes, patient outcomes, relationships, and general robustness."^ This review was not funded.
RESULTS The Effects of Laughter on Health Outcomes
The field of medicine is surprisingly less present in laughter research than would be expected. Its research is mainly dominat- ed by the field of (medical) psychology across psychobiological, social, and health domains.
Mechanism of Action In pursuing the therapeutic efficacy of laughter, four poten-
TABLE 1
Databases
Cochrane Library
Medline
PubMed SAGE Journals
Science Direct Internet (Google)
Databases, Journals, and Keywords Searched
Journals specific
Ahem Ther Health Med
BMC Complement
Altem Med
Complement Ther
ClinPraa
Complement Ther Med
Evid Based Complement
AltematMed
] Altem Complement Med
JPsychosom Res
M) Humor Res
Keywords
Laughter (or laugh or laughing)
Humor (not aqueous.
not vitreous) Mirth (or mirthful)
Therapy (or intervention) Complementary
medicine Alternative medicine
Holistic medicine Integrative medicine
Mind-body Medicine Health (and health care)
Patient (and patient care)
TABLE 2 Laughter Literature Search: Inclusion and Exclusion Criteria
Inclusion
Laughter or humor intervention main focus of paper
Direct or indirect relationship to health outcomes and medicine/therapy
Paper either research or seminal in some form
Literature review of >15 references (medicine texts only)
Exclusion
Humor stimulus or intervention not eliciting or measuring laughter
Brief items, anecdotes, cartoons, pictures, obituaries, commentaries,
or interviews
Brief literature reviews based on ¿15 references (medicine texts only)
Semantics, linguistics, history (nontherapeutic research), eg, joke con-
structions, entertainment
Textbooks, media-related items, including health promotion
Non-health care occupation-related items
Non-English, non-Spanish language publications
tial mechanisms of action have been established that would dem- onstrate its direct or indirect health benefits (humor-health connection).''" First, laughter can lead to direct physiological changes to the muscular, cardiovascular, immune, and neuroen- docrine systems, which would have immediate or long-term ben- eficial effects to the body.'"'Accordingly, laughter is crucial in this model and may be expected to have beneficial health out- comes even without humor, as advocated by the laughter club movement that originated in India in 1995." The more you laugh, the more benefits you obtain. Secondly, laughter can lead to more positive emotional states, which also may have direct benefits to health or contribute to a personal perception of better health or quahty of life." Laughter is not that essential in this sec- ond model, as positive emotions may also be elicited by humor (without laughter), amusement, happiness, joy, love, and others. Here, the more playful approach to life, the more benefits. Third,
Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES. NOV/DEC 2010. VOL. 16, NO. 6 57
laughter can optimize one's own strategies for coping with stress and strengthen personal pain tolerance,™ which may reduce the negative impact on health benefits that both can have. According to this stress-moderator model, which provides indirect effects, laughter during nonstressful times would be less relevant to health. Finally, laughter may indirectly increase one's social com- petencies, which as a result may increase interpersonal skills. In turn, the greater levels of social support gained may confer stress- buffering and health-enhancing benefits.^'^^ Laughter's role is here a lot less patent, as the main focus is on social skills. No other potential mechanisms of action for laughter have been reported as yet.
Therapeutic Efficacy Although humor and laughter have been used therapeuti-
cally in a variety of medical and other conditions, well-designed randomized controlled trials (RCTs) have not been conducted to date validating the therapeutic efficacy of laughter, and only very few trials have been performed otherwise. However, health out- comes have been reported in multiple areas of medicine and patient care. This review has identified health-related laughter research, excluding pathological laughter, in the following areas: oncology^'^'; allergy and dermatology"^'; immunology^''"; pul- monology'"'; cardiology, endocrinology, and metabolism"'"'"; internal medicine and rheumatology"; rehabilitation""; psychia- try and medical psychology""^"'; anatomy, neurology, and imag- ing"""; biophysics and acoustics'"^*; geriatrics and aging'*'*; pediatrics^"^'; obstetrics"^; surgery"'"^; dentistry'"*; nursing*'"; critical, palliative, and terminal care'̂ * ;̂ hospice care*'^'; home care"'; general patient care and primary care"'"; epidemiology and public health"'^; complementary and alternative medicine (CAM)"'"; and medical and health sciences training.'^"
Physiological Benefits of Laughter Humor, mirth, and laughter have numerous effects involv-
ing the muscular, cardiovascular, respiratory, endocrine, immune, and central nervous systems. The effects of laughter on certain physiological outcomes are briefly summarized in Table 3. The research reviewed in this area relates to the impact of laughter on the entire body and can be lumped into the following main physiological effects: laughter (1) exercises and relaxes muscles, (2) improves respiration, (3) stimulates circulation, (4) decreases stress hormones, (5) increases the immune system's defenses, (6) elevates pain threshold and tolerance, and (7) enhances mental functioning.
Psychological Benefits of Laughter The psychological effects of humor and laughter relate pri-
marily to both as a coping mechanism and, to a lesser extent, their enhancement of interpersonal relationships. Table 4 pro- vides a brief overview of the effects of laughter on particular psy- chological outcomes. The research reviewed in this area, somehow larger and much stronger than the evidence for the physiological health benefits, can be summarized as follows: laughter (1) reduc-
es stress, anxiety, and tension and counteracts symptoms of depression; (2) elevates mood, self-esteem, hope, energy, and vigor; (3) enhances memory, creative thinking, and problem solv- ing; (4) improves interpersonal interaction, relationship, attrac- tion, and closeness; (5) increases friendliness and helpfulness and builds group identity, solidarity, and cohesiveness; (6) promotes psychological well-being; (7) improves quality of life and patient care; and (8) intensifies mirth and is contagious.
Safety
The side effects of laugher are very limited. In specific cases, the appearance of a laughter-induced syncope has been reported.""'™ Contraindications are nearly nonexistent; however, precaution is advised with patients who were recently released from surgery or who have certain cardiovascular or respiratory diseases or glaucoma.
Laughter Types and Health Benefits Several kinds of laughter have been identified depending on
various parameters and different fields of the scientific research.'" '" From a medical and therapeutic point of view, five large groups can be summarized'^: (1) genuine or spontaneous laughter, (2) self-induced simulated laughter, (3) stimulated laughter, (4) induced laughter, and (5) pathological laughter. Spontaneous laughter, unrelated to one's own free will, is triggered by different (external) stimuli and positive emotions (ie, happiness, mirth, joy, fiin, triumph, humor, surprise, emotional release, or by conta- gion). It has been reported that spontaneous laughter causes typi- cal contractions of the muscles around the eye socket (Duchenne laughter/smile""). Self-induced simulated laughter is triggered by oneself at will, with no specific reason (purposeful, unconditional) and therefore not elicited by humor, fun, other stimuli, or positive emotions. Stimulated laughter happens as a result of the physical (refiex) action of certain external factors (ie, to be ticklish, particu- lar facial or bodily motions, by pressing laughter bones'"). More superficial and empty-headed, induced laughter is the conse- quence of the effects of specific drugs or substances (ie, alcohol, caffeine, amphetamines, cannabis, lysergic acid diethylamide [LSD], nitrous oxide or "laughing gas," and others). Finally, path- ological laughter is secondary to injuries to the central nervous system caused by various temporary or permanent neurological diseases and also may occur with certain psychiatric disorders. Pathological laughter is developed with no specific stimulus; is not connected with emotional changes; has no voluntary control of its duration, intensity or facial expression; and sometimes comes with "pathological crying."'™
The therapeutic benefits of the different types of laughter concern in particular the first two, spontaneous laughter and self- induced simulated laughter, and stimulated laughter to a lesser extent. Table 5 shows the main characteristics of the first two types of laughter. Spontaneous laughter and self-induced simulat- ed laughter are not that different than one might believe initially. The only clear difference is in the initial stage of providing a stim- ulus and the triggering of laugher. In the first case, an external
58 ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL 16, NO. 6 Therapeutic Value of Laughter in Medicine
Physiological Outcome
TABLE 3 Effects of Laughter on Health-related Physiological Outcomes*
Intervention and Results
Muscle relaxation
Heart rate, respiratory rate, blood pressure,
EE, oxygen levels
Effect on cardiovascular performance
Periods of intense laughter are followed by relaxed muscle tone" or H-reflex depression."
Laughter led to immediate increases in heart rate, respiratory rate, and oxygen consumption'°°'°'and may improve oxygen saturation levels'°'̂ ; laughter did not significantly affect heart rate'"" or oxygen con- sumption'"; following laughter, there is a corresponding decrease in heart rate and respiratory rate"; laughing had an acute effect on systolic blood pressure'°° '°'; no significant effecf" '°'; laughter with physi- cal exercise may be effective to lower the blood pressure as a long-term effect'°'; genuine voiced laughter caused a 10% to 20% increase in EE and heart rate above resting values, which means that 10-15 min of laughter per day could increase total EE by 10-40 kcal.''°
Laughter increased stroke volume and cardiac output, and decreased arterial-venous Oj difference and systemic vascular resistance"; laughter elicited by cinematic viewing improved endothelial-dependent vasodilation"'; laughter decreased levels of serum cortisol and plasma von Willebrand factor"^; laughter induced by a comic movie led to a significant decrease in aortic stiffness and wave reflections."'
Cardiovascular protection (long-term effects) Inverse association between propensity to laugh and coronary heart disease""; fewer arrhythmias and recurrences of myocardial infarctions during cardiac rehabilitation (after myocardial infarction) when self-selected viewed humor was used as an adjunct to standard therapy"^ mirthful laughter led to lower the incidence of myocardial infarction in high-risk diabetic patients.""
Endocrine stress markers (cortisol, CgA) and After watching a comic film, laughter reduced serum cortisol levels,"™' increased salivary CgA levels,'̂ ° increased urinary excretion of epinephrine and norepinephrine'"; appeared to reduce serum levels of dopac (dopamine catabolite), epinephrine, and HGH"'; no significant changes were found in serum pro- lactin, beta-endorphins, ACTH, and norepinephrine"'"'; laughter increased beta-endorphins and HGH'̂ ;̂ laughter elevated breast-milk melatonin in both healthy and atopic eczema mothers^'; behavior of perceptual anticipation of mirthñil laughter decreased serum cortisol, epinephrine, and dopac.'^'
Exposure to a humorous stimulus increased NK activity '̂ "''^; did not significantly increase NK activi-
ty'"; increased SIgA'°'*'^; increased serum IgA, IgG, IgM'"'; relative increase in total leukocytes and spe-
cific leukocyte subsets.'"
Laughter (film-induced) increased pain tolerance and discomfort thresholds."°'"*
Viewing a humorous film decreased bronchial responsiveness in asthmatic patients'"; laughter and smil-
ing induced by a humor intervention (clowning) were able to reduce hyperinflation in severe and very
severe COPD patients.'"
Effects in patients with rheumatoid arthritis Mirthfiil laughter decreased serum proinflammatory cytokine levels,"* growth hormone, and IGF-P';
various hormonal measures
Neuroimmune parameters: salivary IgA (SIgA), serum immunoglobuline levels, NK cell activity, leukocyte population
Pain threshold and tolerance
Effects in asthma and COPD patients
(neuroimmune parameters) increased antiinfiammatory cytokine levels"'; or reduced serum interieukin-6 levels."'"'
Effects in type 2 diabetes patients (blood glu- Inhibitory effect of laughter (elicited by a comedy show) on the increase of postprandial blood glucose cose levels, neuroimmune parameters, others) level'"'; laughter infiuenced the gene expression profile in the peripheral blood leukocytes'"^; laughter
may prevent the exacerbation of diabetic nephropathy'" and diabetic microvascular complications"'; laughter may contribute to amelioration of postprandial blood glucose elevation through a modulation of NK cell activity caused by upregulation of relating genes'""; mirthfiil laughter led to lower the serum epinephrine and norepineprine levels, decreased inflammatory cytokines and C-reactive protein, and increased HDL cholesterol in high risk diabetic patients with hypertension and hyperlipidemia."'
Laughter and humor reduced allergen-induced wheal reactions," reduced allergen-specific IgE
production,"* improved night-time wakening,'" and reduced serum neurotrophin levels.'"'
Laughter increased galvanic skin response'"or conductance,'"' indicating activation of sympathetic ner-
vous system; laughter episodes (while narrating jokes) led to cessation of binocular rivalry'̂ °; hearty
laughter (while viewing a comic video) elicited waving patterns clearly diflerent from those of coughing
or sneezing."'
*EE indicates energy expenditure; CgA, chromogranin A; HGH, human growth hormone; ACTH, adrenocorticotropic hormone; Ig, immunoglobulin; NK, natural killer; COPD, chronic obstructive pulmonary disease; IGF-1, insulin-like growth factor 1; HDL, high-density lipoprotein.
Effects in atopic dermatitis patients (allergy
parameters)
Other: skin response, binocular rivalry, diaphragm electromyography
Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES, N O V / D E C 2010, V O L 16, N O . 6 59
TABLE 4 Effects of Laughter on Health-related Psychological Outcomes
Psychological Outcome Intervention and Results
Effects on mood, stress,
depression and/or anxi-
ety symptoms
Effects on psychotic symptoms
Performance, personal
efficacy, coping abilities
Psychotherapy, group
therapy, desensitization
Quality of life, patient care, well-being
Laughter improved mood and positive affect in healthy adults'̂ '" '̂; temporarily improved depressed mood in depression"^; moderated stress in healthy adults "2,155.156̂ ^ anxiety.™'"
In patients with schizophrenia, a humor and laughter intervention reduced hostility and depression/anxiety scores; improved activation scores and social support"'^; lowered the levels of psychopathology; and improved social competence.'^'
Purposeful laughter significantly increased different aspects of self-efficacy, including self-regulation, optimism, positive emo- tions, and social identification, and main- tained these gains at follow-up"" ;̂ laughter and humor improved coping abilities.""""'
Conversational laughter helped prevent or resolve risk of confrontation in addic- tion group therapy'"; humor desensitiza- tion reduced fear as effectively as tradi- tional techniques.'"
Laughter and humor improved quality of life in depressed patients '""''; pro- moted psychological well-heing and enhanced patient care in different clini- cal settings .̂ "'•™™™"'«
stimulus (coming from other than the laugher) is commonly pro- vided, and laughter is triggered. In the second case, it occurs by the laugher him/herself (purposeful laughter). Modern laughter therapy is based on the following fundamental principle: through several exercises, techniques, activities, and dynamics, a person or a group of people is taken to a feeling of lack of inhibitions to achieve the binomial self-induced laughter-spontaneous laughter and to experience its physical, psychological, emotional, and spir- itual benefits. The human brain is not able in the end to distin- guish spontaneous from self-induced laughter ("motion creates emotion" theory); therefore, their corresponding health-related benefits are alleged to be alike, as some authors contend." However, further research is warranted to confirm this assump- tion (no studies were identified in this review). Indeed, self-in- duced stimulated laughter may lead to a higher "laughter exposure" both by achieving greater intensity and duration at will or by triggering contagious and turning into spontaneous laugh- ter, which might create greater accompanying psychophysiologi- cal changes."'" As a laughter type, self-induced simulated laughter is becoming increasingly popular worldwide, as it is the founda- tion of the Laughter Club movement (Laughter Yoga).'""
Laughter Research Pitfalls and Flaws Though some of the studies on the effects of laughter
TABLE 5 Laughter Medicine: Main Characteristics of Spontaneous Laughter and Self-induced Simulated Laughter
Genuine expression of
positive emotions
Humor-related
Laughing "at" or "with" others
Personal engagement/ effort to think
Presence of "Duchenne
laughter/smile"'
Together with hodily motion
One's own fi-ee will
Triggering off stimulus
Contagious
Sett-control on intensity
and duration
Presence of vocal sounds
Most common
vocalizations
Evidence of therapeutic value in medicine
Best dynamics for exper- imenting laughter
Spontaneous Laughter
Yes
Very often, but not
always
Commonly "at"
Often necessary
Very often (when not
fake)
Yes (uncontrolled)
No, unrelated
Identifiable (extemal)
Yes (often)
Minimum or less
Common (50%)'"
Ha/ho
Some studies conducted
In a group
*Contraction of the muscles around the eye socket.
Self-induced Laughter
Sometimes
Rarely
Always "with"
Rarely necessary
Often
Yes (controlled)
Yes, purposeñil
None (sett'-induced)
Yes (very often)
Maximum or more
At will
At will:
ha/he/hi/ho/hu
and others
Very few studies
Alone/in a group
marked a new start in research called psychoneuroimmunology,'™ which explores the interactions between the central nervous sys- tem and the immune and endocrine systems, not all of these research attempts have been completely successful. The highest- quality studies were executed on the effects of a humorous stimu- lus (comic movie) and subsequent laughter on pain tolerance, which provide strong evidence of increased long-term effects not merely due to distraction.'However, there is still not enough empirical evidence that hearty laughter has pain-killing effects or that laughter stimulates the production of endorphins, other neurohormones (human growth hormone, oxytocin, melatonin, prolactin, adrenocorticotropic hormone) and neurotransmitters (serotonin, dopamine, others).^"'™The weakest investigations are those on endocrine stress markers (serum cortisol, salivary, chro- mogranin A levels, others) and immune system parameters.'"' The results were not consistent or conclusive because method- ological flaws might have prevented the expected physiological "benefits" from being detected."
60 ALTERNATIVE THERAPIES. NOV/DEC 2010, VOL. 16. NO. 6 Therapeutic Value of Laughter in Medicine
The criticisms of the weaknesses and quality of the studies conducted are focused mainly on internal design fiaws and inval- id/lack of generalizability of results. The main internal flaws identified, some of them reported elsewhere,^' included the fol- lowing: small sample size (210 participants), no randomized design, inadequate or nonexistent control groups, no standard- ized baseline measurement, unreliable measures of blood and saliva assays, no statistical tests or too many, failure to distin- guish laughter from humor, failure to confirm the presence of laughter, suboptimal laughter exposure (either insufficient dura- tion or intensity), failure to differentiate short-term from long- term effects, and many other confusion factors. Collectively, current available data reviewed suffer simply ftom too few well- designed studies to draw valid conclusions about some of the health-enhancing changes produced from laughter.™
DISCUSSION In this review, the focus was placed on laughter research
occurring either in the presence or humor or in its absence and related health benefits. This distinct approach makes this narra- tive review unique, as most of the previous studies and reviews have assessed mainly (sense of) humor interventions and their outcomes, where, unfortunately, laughter, as a common response to humorous stimuli, was not always present, measured, or moni- tored.'' However, this review may have been limited by the amount of humor and laughter literature available; the numerous defini- tions and fields and different methodologies and outcomes ftom where it emerged; the failure to adjust for the presence, duration, or intensity of laughter and corresponding effects; and the overall complexity of the laughter phenomenon itself
Laughter Research Challenges and Future Directions Laughter research designs can be quite challenging. As pre-
vious studies indicate, some individuals who are exposed to a humorous stimulus do not always laugh. To help control for this, it is crucial that fiiture laughter research includes some measure of subject response to the humorous stimuli whenever it is used to help elicit laughter. An alternative design to help preclude laughter absence and to adjust for its intensity and duration is to conduct self-induced siniulated laughter intervention trials. Although it has been reported that very few people are able to convincingly laugh on command,'self-induced laughter is entire- ly achievable and appears to be the most realistic, sustainable, and generalizable intervention to be used in future laughter research. In this review, only two studies experimenting with purposeful laughter and then assessing its health effects were identified.'*"'"' Another methodological concern is that of control groups. The need for at least two additional control groups has heen suggested'; a negative one to control for the eftect of general emotional arousal and a positive one to control for positive emo- tions that are not necessarily laughter-oriented. Larger samples of healthy subjects and trials in different clinical populations also are warranted. Therefore, it may he useful for researchers in an area dominated by psychology to carry out interdisciplinary
studies involving experts from different health care fields. Laughter researchers also may have difficulty defining pre-
cise and measurable outcomes for a therapy for which the main effect is often subjective or dependent on the skill of the practi- tioner and the laugher him/herself. Laughter therapy often has to be tailored for an individual's specific needs and may not be able to be studied at a conventional "active ingredient" or "dose" level. Moreover, individuals frequently use a variety of CAM modalities simultaneously or adjunctively with conventional therapies, which may attenuate or magnify treatment effects. Some of these challenges have not been properly addressed through alternative study designs. Collectively, research on laughter is still in its infancy, and many efforts are required to enhance the quality and validity of trial designs and health-relat- ed outcomes, with the imperative need of distinguishing (sense of) humor and laughter. Clearly, more groundwork is needed to determine the hest methods of assessing and documenting health-related outcomes on laughter in different patient popula- tions. One of the first steps may have been performed by Kimata et al,™ who recently puhlished some remarkable results on "dia- phragm EMG (electromyogram)," the first exact system for the measurement of laughter itself. This measuring system can speci- fy the starting point and duration of laughter precisely of 1/3000 second; therefore, it will make detailed analysis of the healthy effects of laughter possible in different clinical settings. Furthermore, the authors state that this method is suitable as a precise way to assess any kind of laughter and does not require any special medical or mechanical techniques, so it also may be useful for other, nonmedical purposes.
Laughter as Medicine Western thinking around laughter as a medicine began to
crystallize in 1976 when Cousins published his "Anatomy of an Illness." However, inviting and facilitating laughter in therapy is not the same as developing and using humor to make the patient laugh. Humor is not necessary to have subsequent laughter. Adults can laugh without it, as do infants and children. While laughter medicine takes skill and time to he developed, laughter therapy itself can be implemented easily and is cost-effective in patient care.^'' Health care professionals do not have to be stand- up comics, clowns, or magicians to bring laughter into clinical settings. Just acknowledging how important laughter can be and having a cheerful and spirited approach is a good place to start. After all, half of the benefit of laughter, in addition to healing, is sharing it."' Nevertheless, the health community is still slow in accepting and considering laughter as a healing tool within CAM."* In order to offer patients the benefits of laughter, health care professionals must be willing to break loose from conven- tional therapeutic constraints, regain their own laughter, and learn the techniques to facilitate laughter in their patients. Laughter deserves a special place in medical practice and daily life. This is the mission of the Association for Applied and Therapeutic Humor, an international community of medical, education, and public speaking professionals who study, practice.
Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES. NOV/DEC 2010. VOL. 16. NO. 6 61
and promote healthy humor and laughter. Based in Spain, the "Organización Mundial de la Risa" also is investing in laughter research and training.
Laughter Medicine for Health Care Professionals Laughter is important in medicine and may enhance conver-
sation between health care professionals and patients.""™ The abüity to laugh with a patient is a sign of good rapport. Mutual understanding while sharing some laughs may be more important than the diagnosis or formal treatment."' Laughter is also a quali- ty-of-life and well-being enhancement therapy for both health care professionals and patients.'** Laughter may help dissipate tension, fear, frustration,"and other stress such as "burnout," which is becoming increasingly more common and troublesome among today's medical staff.'"'™ However, laughter is an often neglected resource in managing personal and professional stress. Proponents of "positive psychology" have identified humor and laughter as one of the 24 positive personal "values and attributes.""'"^ Therefore, health care professionals can play a significant part in eliciting bet- ter understanding of laughter benefits in clinical conditions and real-world life for both patients and themselves. But like any other skill, the effective use of laughter for therapeutic purposes needs to be learned, practiced, and developed. Practical guidelines or advice on laughter therapy have not been developed as yet to help health care professionals (and others) implement laughter techniques in their health care portfolio.
CONCLUSIONS According to this review, the following can be concluded on
the evidence-based therapeutic value of laughter in medicine:
• Current empirical data for the psychological benefits associated with laughter is stronger than that of its physi- ological benefits; however, fiarther well-designed research is warranted in all of these areas.
• Overall, there are not enough research findings to conclude that laughter is an all-around healing agent, but there is sufficient evidence to suggest that laughter has some posi- tive, quantifiable effects on certain aspects of health.
• Laughter as a medicine, as a mind-body therapy for health care, is almost never used in "traditional" clinical settings and often overlooked as a form of CAM.
• In this era of evidence-based medicine, it seems appropri- ate that laughter therapy takes its place as a CAM disci- pline in the prevention and treatment of illnesses.
• The following seems to be good advice for both patients and health care professionals: "Add laughter to your working and daily life, remember to laugh regularly, share your laughs, and help others to laugh, too."
REFERENCES
1. Cousins N. Anatomy of an illness (as perceived by the patient). N Engl J Med 1976;295(26):1458-1463.
2. Rosner F. Therapeutic efficacy of laughter in medicine. Cancer Invest. 2002;20(3):434-436. 3. Goodman J. Fry WF Jr. Toward optimal health: the experts discuss therapeutic humor.
Interview hy Jodi R. Godfrey./ Women s Health (Larehmt). 2004;13(5):474-479.
4. Martin RA. Sense of humor and physical health: theoretical issues recent findings, and
10. U .
12.
13. 14.
15.
16. 17.
18. 19.
20.
21.
22.
23.
24.
25.
26.
27
28.
29.
30.
31.
32.
33.
34.
35.
36.
37
38.
39.
40.
41.
42.
43. 44.
45.
46.
47
future directions. Humor. 2004;17{l):l-20.
Saper B. Humor in psychiatric healing. Psyehiatr Q. 1988;59(4):306-319. Martin RA. Humor, laughter, and physical health: methodological issues and research findings. PsycholBull. 2001;127(4):504-519. Provine RR. Laughter: A Scientific Investigation. New York. NY: Penguin Books; 2000. Salovey P. Rothman AJ. Detweiler JB. Steward WT. Emotional status and physical health. Am Psychologist. 2000;55(l):110-121.
Berk R, Martin R, Baird D. Nozik B. What Everyone Should Know About Humor and Laughter. Aliso Viejo. CA: Association for Applied and Therapeutic Humor; 2008. Provine R. Laughter./tBicrtoCT/zsi. 1996Jan-Feh;84:38-48.
Mahony DL. Burroughs WJ, Lippman LG. Perceived attributes of health-promoting laughter: a cross-generational comparison./Zírvc/iíi;. 2002;136{2):171-181. Mora-RipoU R. García-Rodera MC. Therapeutical value of laughter in medicine larticle in Spanish). Med Clin (Bare). 2008;131(18):694-698. Garcia-Rodera MC. £/ Poder de ¡a Risa. Barcelona. Spain: Morales i Torres: 2003. No authors listed. Reviews: making sense of an often tangled skein of evidence. Ann Intern Med. 2005;142(12 Pt l):1019-1020.
Dixon-Woods M. Agarwal S. Jones D, Young B. Sutton A. Synthesising qualitative and quantitative evidence: a review of possihle methods. J Health Serv Res Policy
2005;10(l):45-53.
Fry WF. The biology of humor. Humor. 1994;7(2):111-126.
Sahakian A. Frishman WH. Humor and the cardiovascular system. Altern Ther Health Med 2007;13(4):56-58. Kataria M. Laugh for No Reason. Mumbai, India: Madhuri International; 2005. Martin RA. The Psychology of Humor: An Integrative Approach. London. England: Elsevier Academic Press; 2006. Zweyer K, Velker B. Ruch W. Do cheerfulness, exhilaration, and humor production moderate pain tolerance? A FACS study. Humor. 2004;17(l-2):85-n9. Cohen S. Psychosocial models of the role of social support in the etiology of physical disease. Health Psychol. 1988;7(3):269-297 Cohens. Underwood LG, Gottlieh BH, eds. Social Support Measurement and Intervention: A Guide for Health and Social Scientists. New York. NY: Oxford University Press; 2000. Penson RT, Partridge RA, Rudd P. et al. Laughter: the best medicine? Oncologist. 2005;10(8):651-660. Trent B. Ottawa lodges add humour to armamentarium in fight against cancer. Can Med Assoc J 1990;142(2):163-164,166. Erdman L. Laughter therapy for patients with cancer. Oncol Nurs Forum 1991;18(8):1359-1363.
Bellert JL. Humor. A therapeutic approach in oncology nursing. Cancer Nurs. 1989;12{2):65-70.
Kimata H. Effect of h u m o r on allergen-induced wheal reactions. JAMA. 2001;285(6):738.
Kimata H. Laughter elevates the levels of breast-milk me[atonm. J Psychosom Res. 2007;62(6): 699-702. Bennett MP. Zeller JM. Rosenberg L. McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Altern Ther Health Med. 2003;9(2):38-45. McClelland R. Cheriif A. The immunoenhancing effects of humour on secretory IgA and resistance to respiratory infections. Psychol Health. 1997;12(3):329-344. Bukutu C. Le C, Vohra S. Asthma: a review of complementary and alternative therapies. Ped Review. 2008;29(8):e44-e49. Boiten FA. The effects of emotional hehaviour on components of the respiratory cycle. Ä/WPs/cM 1998;49(l-2):29-51. Svehak S. Respiratory patterns as predictors of laughter. Psychophysiology. 1975;12{l):62-65.
Boone T, Hansen S, Erlandson A. Cardiovascular responses to laughter: a pilot project. Appl Nurs Res. 2000;13(4):204-208. Nahas R. Complementary and alternative medicine approaches to blood pressure reduction: an evidence-based review. Can Eam Physician. 2008;54(ll):1529-1533. Hayashi T. Urayama 0, Hori M, et al. Laughter modulates prorenin receptor gene
expression in patients with type 2 diabetes.J Psychosom Res. 2007;62{6):703-706. Yoshino S. Fujimori J, Kohda M. Effects of mirthfiil laughter on neuroendocrine and immune systems in patients with rheumatoid arthvitis.J Rheumatol. 1996;23(4):793-794. Basmajian JV. The elixir of laughter in rehabilitation. Arch Phys Med Rehabil. 1998;79(12):1597. Schmitt N. Patients' perception of laughter in a rehabilitation hospital. Rehabil Nurs. 1990;15(3):143-146. Saper B. The therapeutic use of humor for psychiatric disturbances of adolescents and adults. Psyehiatr Q. 1990;61(4):261-272.
Gelkopf M, Kreitler S. Sigal M. Laughter in a psychiatric ward. Somatic, emotional. social, and clinical influences on schizophrenic patients. J Nerv Ment Dis 1993;181(5):283-289.
van Alphen PJ. Humor as diagnostic and therapeutic tool in psychiatry. Laughter is healthy [article in Dutch]. TVZ. 1997;107(22):674-677 Seaward BL. Humor's healing potential. Health Prog. 1992;73(3):66-70.
Krack P. Kumar R, Ardouin C, et al. Mirthfiil laughter induced by subthalamic nucleus stimulation. Mov Disord 2001;]6(5):867-875. Fried 1, Wilson CI. MacDonald KA. Behnke EJ. Electric current stimulates laughter. Nature. 1998;391C6668):650. Taber KH, Redden M, Hurley RA. Functional anatomy of humor: positive affect and chronic mental illness. JNeuropsychiatry Clin Neurosa. 2007;19(4):358-362. Meyer M. Baumann S. Wildgruber D, Alter K. How the brain laughs. Comparative evi-
62 ALTERNATIVE THERAPIES. NOV/DEC 2010, VOL. 16, NO. 6 Therapeutic Value of Laughter in Medicine
dence from behavioral, electrophysiological and neuroimaging studies ¡n human and monkey. Behav Brain Res. 2007:182(2):245-260.
48. Kawakami K, Takai-Kawakami K, Tomonaga M, Suzuki J, Kusaka T, Okai T. Origins of .smile and laughter: a preliminary study. Early Hum Dev. 2006:82(l):61-66.
49. Pearce JM. Some neurological aspects of laughter. Eur Neurol. 2004:52(3):169-171. 50. Wild B, Rodden FA, Grodd W, Ruch W. Neural correlates of laughter and humor, irain.
2003:126(Pt 10);2121-2138.
51. LuscheL ES, Ramig LO, Finnegan EM, Baker KK, Smith ME. Patems of laryngeal elec- tromyography and the activity of the respiratory system during spontaneous laughter./ Wci/rop/!/.™/.2006;96{l):442-450.
52. Bea JA, Marijuán PC. The informational patterns of laughter. Entropy. 2003;5(2):205-213. 53. Köhler KJ. "Speech-smile", "speech-laugh", "laughter" and their .sequencing in dialogic
Interaction. Phonetiea. 2008:65(l-2):l-18. 54. Bachorowski JA, Smoski MJ. Owren MJ. The acoustic features of human laughter. /
Acoust Soc Am. 2001;U0{3):1581-1597.
55. Bachorowski JA, Owren MJ. Not all laughs are alike: voiced but not unvoiced laughter readily elicits positive affect. PsyeholSci. 2001;12(3):252-257.
56. Williams H. H u m o r a n d healing: therapeutic effects in geriatrics. Gerontion. 1986;1(3):14-17.
57. O'Brien ME. Integrative geriatrics. Combining traditional and alternative medicine. N CMedJ 1996;57(6):364-367.
58. Tennant KF. Laugh it off. The effect of humor on the well-being of the older adult. / Cerontol Nurs. 1990:16(12):U-17.
59. Evans S, Tsao JC, Zeltzer LK. Complementary and altemative medicine for acute proce- dural pain in children. Altern Ther Health Med 2008:14(5):52-55.
60. Henderson SW, Rosario K. But seriously: clowning in children's mental health. J Am Acad Child Adolesc Psyehiatry. 2008;47(9):983-986.
61. Reddy V, Williams E, Vaughan A. Sharing humour and laughter in autism and Down's syndrome. BrJ Psychol. 2002:93(Pt 2):219-242.
62. Beddoe AE, Lee KA. Mind-body interventions during pregnancy. J Obstet Cyneeol Neonatal Nurs. 2008:37(2): 165-175.
63. Cantó MA, QuilesJM, Vallejo OG, et al. Evaluation of the effect of hospital down's per- formance about anxiety in children subjected to surgical intervention larticle in Spanish!. CirPediatr. 2008:21(4):195-198.
64. Robinson V. The purpose and function of humor in OR nursing. Todays OR Nurse. 1993:15(6):7-12.
65. Liechty RD. Humor and the surgeon. Areh Surg. 1987;122(5):519-522. 66. Morse DR. Use of humor to reduce stress and pain and enhance healing in the dental
.setting.; W/DenMssoc. 2007;78(4):32-36.
6 7 Wilde JA. Laughing all the way. Dent Today. 1998:17(12):38-41. 68. Davis DM, Fi.ske J, Scott B, Radford DR. The emotional effects of tooth loss in a group
of partially dentate people: a quantitative study. EurJ Prosthodont Restor Dent. 2001:9(2):53-57.
69. McCreaddie M, Wiggins S. The purpose and function of humour in health, health care and nursing: a narrative review./zti/v Nurs. 2008:61(6):584-595.
70. MacDonald CM. A chuckle a day keeps the doctor away: therapeutic humor and laugh- ter./ Psychosoe Nurs Ment Health Serv. 2004:42(3): 18-25.
71. Mathew FM. Laughter is the best medicine: the value of humour in current nursing practice. Nurs J India. 2003:94(7):146-147.
72. Astedt-Kurki P, Lsola A. Humour between nurse and patient, and among staff: analysis of nurses' diaries./zíiív Nurs. 2001;35(3):452-458.
73. Bakerman HM. Humour as a nursing intervention. Axone. 1997:18(3):56-61. 74. Herth KA. Laughter. A nursing Rx. Am J Murs. 1984; 84(8):991-992. 75. Berry S. Humor me on this one. The healing role of h u m o r in EMS. JEMS.
2003:28(U):66-79. 76. Ratzan RM. Laughter in the temple of pain and illness. EmergMed. 1996;14(l):92-95. 77. Leiber DB. Laughter and humor in critical care. Dimens Crit Care Nurs. 1986:5(3):162-170. 78. Borod M. SMILES—toward a better laughter life: a model for introducing humor in
the palliative care setting./ Cancer Educ. 2006;21(l):30-34.
79. Dean RA, Gregory DM. Humor and laughter in palliative care: an ethnographic inves- tigation. Palliât Support Care. 2004;2(2):139-148.
80. Dean RA. Humor and laughter in palliative caK.JPalliative Care. 1997;13(l):34-39. 81. Herth K. Contributions of humor as perceived by the terminally ill. AmJ Hosp Care.
1990:7:36-40. 82. Graham LL, Cates JA. Responding to the needs of the terminally ill through laughter
and play. AmJ Hosp Care. 1989:6(l):29-30.
83. Vagnoli L, Caprilli S, Robiglio A, Messed A. Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics. 20O5;U6(4):e563-e567
84. Pari.sh AB. It only hurts when I don't laugh. AmJ Nurs. 1994:94(8):46-47. 85. Strickland D. Overcome terminal seriousness: let go, laugh, and lighten up! Sem
Perioper Nurs. 1999:8(2):53-59.
86. Hunter P. Humor therapy in home care. Caring 1997:16(9):56-57. 87. Ruiz Gómez MC, Rojo Pascual C, Ferrer Pascual MA, Jiménez Navascués L, Ballesteros
García M. Complementary therapies in the cares: humour and laugh therapy larticle in Spanish]. Inda Enferm (Gran). 2005;14(48-49):37-41.
88. Harries G. Use of humour in patient care. BrJ Nurs. 1995:4(17):984-986. 89. Mallett J. Use of humour and laughter in patient care. BrJ Nurs. 1993:2(3):172-175. 90. Granek-Catarivas M, Goldstein-Ferber S, Azuri Y, Vinker S, Kahan E. Use of humour in
primary care: different perceptions among patients and physicians. Postgrad Med J 2005:81(952):126-130.
91. Fowler JH, Christakis NA. Dymamic spread of happiness in a large social network: lon-
gitudinal analysis over 20 years in the Framingham Heart Study. BMJ 2008 Dec 4;337;a2338.
92. Chapell M, Batten M, Brown J, e al. Frequency of public laughter in relation to sex, age, ethnicity, and .social context. Percept Mot Skills. 2002:95(3 Pt 1):746.
93. Demmer C. A survey of complementary therapy services offered by hospices./ Palliât Med. 2004;7(4):510-516.
94. Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the sci- ence, implications for practice.//!»! Board Fam Pract. 2003:16(2):131-147.
95. Zagvazdin Y. Movies and emotional engagement: laughing matters in lecturing. Fam Med. 2007:39(4):245-247.
96. Park CM. Diversity, the individual, and proof of efficacy: complementary and alterna- tive medicine in medical education. AmJ Public Health. 2002:92(10):1568-1572.
9 7 Tiralongo E, Wallis M. Integrating complementary and alternative medicine education into the pharmacy curriculum. AmJ Pharm Edu. 2008;72(4):74.
98. Paskind HA. Effects of laughter on muscle tone. Arch Neurol Psyáiatry. 1932;28(3):623-628. 99. Overeem S, Taa! W, Ocal Gezici E, Lammers G, Van Dijk J. Is motor inhibition during laugh-
ter due to emotional or respiratory influences? Psychophysiobg/. 2004;41(2):254-258.
100. Fry W. Savin W. Mirthful laughter and blood pres.sure. Humor. 1988:1:49-62. 101. Fry WF, Rader C. The respiratory components of mirthfijl l a u g h t e r . / i / o / f t j c M 1977:
19(2):39-50.
102. Fry WF Jr. T h e physiologic effects of h u m o r , m i r t h , a n d laughter. JAMA. 1992;267(13):1857-1858.
103. Sakuragi S, Sugiyama Y, Takeuchi K. Effects of laughing and weeping on mood and heart rate variability./PA/Sii)//In/Arcpo;/tp/)/Huma« 5d.2002:21(3):159-165.
104. Filippelli M, Pellegrino R, Iandelli I, et al. Respiratory dynamics during laughter.//l/)p/ Physiol. 2001:90(4):1441-1446.
105. Fry WF Jr, Stoit PE. Mirth and oxygen saturation levels of peripheral blood. Psychother Psychosom. 1971:19(l):76-84.
106. Yovetich NA, Dale JA, Hudak MA. Benefits of humor in reduction of threat-induced anxiety. Psychol Rep. 1990:66(l):51-58.
107. McMahon C, Mahmud A, Feely J. Taking blood pressure—no laughing matterl Blood Press Monit. 2005:10(2):109-U0.
108. White S, Camarena P. Laughter as a stress reducer in small groups. Humor. IntJ Humor Res. 1989:2(l):73-79.
109. Kajiura M, Ohira T, Sato S, Tanaka H, Shimamoto T. Effects of laughter and physical exercise on health status among healthy elderly men and women [abstract!. Auton Neurosa. 2007:135(l-2):150.
110. Buchowski MS. Majchrzak KM, Blomquist K, Chen KY, Byrne DW, Bachorowski JA. Energy expenditure of laughter. lntJ Obes (Lond). 2007;31(l):131-137.
111. Miller M, Mangano C, Park Y, Goel R, Plotnick GD, Vogel RA. Impact of cinematic viewing on endothelial ñinction. Heart. 2006:92(2):261-262.
112. Xaplanteris P, Vlachopoulos C, Galifou 1, et al. Beneficial effect of laughter on Cortisol and von WiUebrand factor levels: a possible link with endothelial fiinction. Eur Heart J. 2007;28(Abstractsupplement):588.
113. Xaplanteris P, Vlachpoulos C, Baou K, et al. Divergent effects of laughter and mental stress on aortic stiffness and wave reflections. Eur Heart J. 2007:28(Abstract supplement):591.
114. Clark A, Seidler A, Miller M. Inverse association between sense of humor and coronary heart disease. IntJ Cardiol. 2001:80(l):87-88.
115. Tan SA, Tan LG, Berk LS. Mirthful laughter an effective adjunct in cardiac rehabilita- tion. Can J Cardiol. 1997:13(suppl B):190.
116. Berk LS, Tan L, Tan S. Mirthful laughter, as adjunct therapy in diabetic care, attenuates catecholamines, inflammatory cytokines, C-RP, and myocardial infarction occurrence labstractl. FASEBJ 2008:22(Meetmg ab.stract.s):1226.2.
117. Berk LS, Feiten DL, Tan SA, Bittman BB, Westengard J. Modulation of neuroimmune parameters during the eustress of humor-associated mirthful laughter. Altern Ther Health Med. 2001:7(2):62-72,74-76.
118. Berk LS, Tan SA, Fry WF, e al. Neuroendocrine and stress hormone changes during mirthfiillaughter./lm/Mcíí5o. 1989;298(6):390-396.
119. Berk LS, Tan SA, Nehlsen-Cannarella SL, et al. Humor associated laughter decreases Cortisol and increases spontaneous lymphocyte blastogenesis. Clin Res. 1988:36:435A.
120. Toda M, Kusakabe S, Nagasawa S, Kitamura K, Morimoto K. EfFect of laughter on endocrinological stress marker chromogranin A. Biomed Res. 2007:28(2):115-118.
121. Levi L. The urinary output of adrenalin and noradrenalin during pleasant and unpleas- ant emotional states: a preliminary report. Psychosom Med. 1965 Jan-Feb:27:80-85.
122. Berk LS, Tan SA. [betal-endorphin and HGH increase are associated with both the anticipation and experience of mirthful laughter labstractl. FASEBJ 2006:20(4):A382.
123. Berk LS, Tan SA, Berk D. Cortisol and catecholamine stress hormone decrease is associ- ated with the behaviour of perceptual anticipation of mirthfiil laughter [abstract!. EASEBJ 2008:22(Meeting abstracts):946.11.
124. Takahashi K, Iwase M, Yamashita K, et al. The elevation of natural killer cell activity induced by laughter in a crossover-designed study. IntJ Molecular Med. 2001:8)6):645-650.
125. Wise B. Comparison of immune response to mirth and to distress in women at risk for recurrent breast cancer. Diss Abstr Int. 1989:49:2918.
126. Lefcourt H, Davidson-Katz K, Kueneman K. Humor and immune system functioning. Wi/raOT./ni/Wi/morRfs. 1990:3:305-321.
127. Dillon KM, Minchoff B, Baker KH. Positive emotional status and enhancement of the immune system.//!i/Ps)'ràMfr/Aifrf.l985-1986:]5(l):13-18.
128. Labott SM, Ahleman S, Wolever ME, Martin RB. The physiological and psychological effects of the expression and inhibition of emotion. Behav Med 1990;16(4):182-189.
129. Martin RA, Dobbin JP. Sense of humor, hassles, and immunoglobuUn A: evidence for a
Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL 16, NO. 6 63
stress-moderating effect of humor, ¡ntj Psychiatry Med. 1988;18(2):93-105. 169. 130. Weisenberg M, Raz T, Hener T. The influence of film-induced mood on pain percep-
tion. Pain. 1998;76(3):365-375. 170.
131. Rotton J, Shats M. Effects of state humor, expectancies, and choice on postsurgical mood and self-medication: a field a'^nmwt.J Appl Social Psychol 1996;26(20):1775-1794. 171.
132. Nevo 0 , Keinan G, Teshimovsky-Arditi M. Humor and pain tolerance. Humor. 172. 1993;6(l):71-88. 173.
133. Cogan R, Cogan D, Waltz W, McCue M. Effects of laughter and relaxation on discom- fort thresholds./MavMfrf. 1987;10(2):139.144. 174,
134. Van Zandt S, LaFont C. Can a laugh a day keep the doctor away? / Pract Nurs. 1985;35(3):32-35. 175.
135. Hudak DA, Dale JA, Hudak MA, DeGood DE. Effects of humorous stimuli and sense of humor on discomfort. Psycbol Rep. 1991:69(3 Pt l):779-786. . 176.
136. Kimata H. Effect of viewing a humorous vs. nonhumorous film on bronchial respon- siveness in patients with bronchial asthma. PhysiolBehav. 2004;81(4):681-684. 177.
137. Brutsche MH, Grossman PG, Müller RE, et al. Impact of laughter on air trapping in severe chronic ohstructive lung disease. IntJ COPD. 2008;3(l):185-192. 178.
138. Matsuzaki T, Nakajima A, Ishigami S, Tanno M, Yoshino S. Mirthfiil laughter differen- tially affects serum pro- and anti-infiammatory cytokine levels depending on the level 179.
of disease activity in patients with rheumatoid arthritis. Rheumatology (Oxford). 2006;45(2):182-186. 180.
139. Ishigami S, Nakajima A, Tanno M, Matsuzaki T, Suzuki H, Yoshino S. Effects of mirth- fiil laughter on growth hormone, IGF-1 and suhstance P in patients with rheumatoid 181. arthritis. Clin Exp Rheumatot 2005:23(5):651-657.
140. Nakajima A, Hirai H, Yoshino S. Reassessment of mirthful laughter in rheumatoid arthritis./iaramflto/. 1999;26(2):521-513. 182.
141. Hayashi K, Hayashi T, Iwanaga S, et al. Laughter lowered the increase in postprandial blood glucose. Diabetes Care. 2003:26(ll):165M652. 183.
142. Hayashi T, Urayama O, Kawai K, et al. Laughter regulates gene expression in patients with type 2 diabetes. Psyehother Psychosom. 2006;75(l):62-65. 184.
143. Nasir UM, Iwanaga S, Nahi AH, et al. Laughter therapy modulates the parameters of renin-angiotensin system in patients with type 2 diabetes. Lnt J Mol Med. 2005;16(6):1077-1081. 185.
144. Hayashi T, Tsujii S, Iburi T, et al. Laughter up-regulates the genes related to NK cell activity in diabetes. BiomedRes. 2007;28(6):281-285. 186.
145. Kimata H. Reduction of allergen-specific IgE production by laughter. EurJ Clin Invest. 2004;34(9):76-77. 187
146. Kimata H. Viewing humorous film improves nighttime wakening in children with 188. atopic dermatitis. Indian Pediatr 2007;44(4):281-285.
147. Kimata H. Reduction of plasma levels of neurotrophins by laughter in patients with 189. atopic dermatitis./'cií/a/r/lsí/ima/l/fer5)'/mmuní)/.2004;17(2):13M35.
148. Marci CD, Moran EK, Orr SP. Physiologic evidence for the interpersonal role of laugh- 190. ter during psychotherapy./A^frv Ment Dis. 2004;192(10):689-695.
149. Pettigrew JD. Laughter abolishes binocular rivalry. Clin Exp Optom. 2005:88(l):39-45. 150. AverUl JR. Autonomie response patterns during sadness and mirth. Psyehophysiotogy. 191.
1969:5(4):399-414. 151. Eoley E, Matheis R, Schaefer C. Effect of forced laughter on mood. Psychol Rep. 192.
2002;90(l):184. 152. Neuhoff CC, Schaefer C. Effects of laughing, smiling, and howling on mood. Psychol
Rep. 2002:91(3 Pt 2):1079-1080. 153. Szabo A, Ainsworth SE, Danks PK. Experimental comparison of the psychological ben-
efits of aerobic exercise, humor, and music. Humor 2005:18(3):235-246. 154. Morgan AJ, Jorm AF. Self-help interventions for depressive disorders and depressive
symptoms: a systematic review. Ann Gen Psychiatry. 2008 Aug 19:7:13. 155. Abel MH. Interaction of humor and gender in moderating relationships between stress
and outcomes./ftycM 1998;132(3):267-276. 156. Kuiper NA, Martin RA. Laughter and stress in daily life: relation to positive and nega-
tive affect. Motiv Emot. 1998;22(2):133-153. 157. Moore DB. Make them laugh. Therapeutic humor for patients with grief-related stress
or anxiety. Adv Nurse Pract. 2000:8(8):34-37
158. Gelkopf M, Sigal M, Kramer R. Therapeutic use of humor to improve social support in an institutionalized schizophrenic inpatientcommunity./5í)<:/'s)'c/ií)/.1994;134(2):175-182.
159. Gelkopf M, Gonen B, Kurs R, Melamed Y, Bleich A. The effect of humorous movies on inpatients with chronic schizophrenia./AífrvMmí OÍS. 2006;194(ll):880-883.
160. Abel MH. Humor, stress and coping strategies. Humor. 2002;15(4):365-381. 161. Neziek JB, Derks P. Use of humor as a coping mechanism, psychological adjustment,
and social interaction. Humor. 2001:14(4):395-413. 162. Arminen I, Halonen M. Laughing with and at patients: the role of laughter in confron-
tations in addiction group therapy. Qual Rep. 2007;12(3):484-513.
163. Ventis WL, Higbee G, Murdock SA. Using humor in systematic desensitization to reduce fear./ Gen Psychol 2001;128(2):241-253.
164. Walter M, Hänni B, Haug M, et al. Humour therapy in patients with late-life depression or Alzheimer's disease: a pilot study. IntJ Geriatr Psychiatry. 2007;22(l):77-83.
165. Takayanagi K. Laughter education and the psycho-physical effects: introduction of smile-sun method.//)« Hosp. 2007 Dec;(26):31-35.
166. Scholl JC, Ragan SL. The use of humor in promoting positive provider-patient interac- tions in a hospital rehabilitation unit. Health Commun. 2003;15(3):319-330.
167 Amaki M, Kamide K, Takiuchi S, Niizuma S, Horio T, Kawano Y. A case of neurally mediated syncope induced by laughter successfully treated with combination of pro- pranolol and midodrine. lnt Heart J 2007;48(l):123-127
168. Sarzi Braga S, Manni R, Pedretti RF. Laughter-induced syncope. Lancet 2005:366(9483):426.
Bloomfield D, Jazrawi S. Shear hilarity leading to laugh syncope in a healthy man. JAMA. 2005;293(23):2863-2864.
Cox SV, Eisenhauer AC, Hreib K. "Seinfeld syncope." Catheter Cardiovasc Diagn. 1997;42(2):242.
Holden R. La Risa, la Mejor Medicina. Barcelona, Spain: Ediciones Oniro; 1999. Temprano E. El Arte de la Risa. Barcelona, Spain: Editorial Seix Barrai: 1999. García Larrauri B. Programa para Mejorar el Sentido del Humor. Madrid, Spain: Ediciones Pirámide; 2008.
Ekman P, Davidson RJ, Eriesen WV. The Duchenne Smile: emotional expression and brainphysiologylL/ftrsJoci'syi-Ai)/. 1990;58(2):342-353.
García-Rodera MC. Cómo Beneficiarse del Poder de la Risa. Barcelona, Spain: Morales i Torres Editores; 2007. Wortzel HS, Oster TJ, Anderson CA, Arciniegas DB. Pathological laughing and crying: epidemiology, pathophysiology and treatment. CNS Drugs. 2008;22(7):531-545. Gendry S. Laughter Yoga 101: Erom 0 to Laughter in 0.5 Seconds. Los Angeles, CA: American School of Laughter Yoga; 2007
Solomon G. Psychoneuroimmunology: interactions between the central nervous sys- tem and immune system./Wearosri te. 1987;18(l):l-9.
Martin RA. Humor and health. In: Raskin V, ed. The Primer of Humor Research. New York, NY: Mouton de Gruyter: 2008:479-521.
Beckman H, Regier N, Young J. Effect of workplace laughter groups on personal efficacy heliefs./Prim Prev. 2007:28(2):167-182.
Nagendra HR, Chaya MS, Nagarathna R, Kataria M, Manjunath MK, Rao R. The Efficacy of Laughter Yoga on IT Professionals to Overcome Stress. Mumbai, India: Laughter Yoga International; 2007
Kimata H, Morita A, Furuhata S, Itakura H, Ikenobu K, Kimura K. Assessment of laughter by diaphragm electromyogram. EurJ Clin Invest. 2009;39(l):78-79. Baiick MJ, Lee R. The role of laughter in traditional medicine and its relevance to the clinical setting: healing with ha! Altern Ther Health Med. 2003;9(4):88-91. Mora-Ripoll R. Laughter medicine and therapy: A complementary/alternative approach in health and patient care [article in Spanish]. Med Clin (Bare). 2009 Sep 21. [Epub ahead of print]
Sanz Ortiz J. Therapeutic value of humor [article in Spanish). Med Clin (Bare). 2002;U9(19):734-737. Karl KA, Peluchette JV, Harland L. Is fiin for everyone? Personality differences in health- care providers' attitudes toward fun.J Health Hum ServAdm. 2007;29(4):409-447 Elliott-Binns CP. Uughter and medicine./Ä Coll Gen Pract 1985;35(277):364-365. Richman J. The lifesaving fiinction of humor with the depressed and suicidal elderly. Geronto%si. 1995;35(2):271-273.
Esteva M, Larraz C, Soler J, Yaman H. Bum-out in Spanish general practitioners [article in Spanish]. Aten Primaria. 2005;35(2):108-109.
Casado Moragón A, Muñoz Duran G, Ortega González N, Castellanos Asenjo A. Bumout in professionals belonging to palliative, intensive care and emergency services in a general hospital [article in Spanish). Affii Clin (Bare). 2005;16;124(14):554-555. de Vera Poseck B. Psicología Positiva: Una Nueva Eorma de Entender la Psicología. Madrid, Spain: Calamar Ediciones: 2008.
Seligman ME, Steen RA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions./Im Psycbol. 2005;60(5):410-421.
64 ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL 16, NO. 6 Therapeutic Value of Laughter in Medicine
Copyright of Alternative Therapies in Health & Medicine is the property of PH Innovisions Journal Operating
LLC and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.
