Years ago, before I was an occupational therapist (OT), I used to dabble in stand-up comedy. One of my favorite bits was about how my mother left a long, rambling message on my answering machine: “Courtney… you have to go out and get this new kind of herb. It cures everything from headaches to the common cold! Go out and get yourself some… oh, what’s it called? It starts with an “E”… oh yes! Go out and get yourself some euthanasia!”
My mother now knows it is Echinacea, and she really wants me to live – I’m pretty sure!
Although I haven’t performed any stand-up in decades, I have found that the same keen perceptiveness, ability to improvise in all situations, and uplifting good humor can still take me far in the land of OT. I find that I am able to better engage my patients, caregivers, and family members if I assume an attitude of benevolent curiosity, innocent open-mindedness, and sage wisdom ala “we’ve all been there” when building a therapeutic relationship, and I know that this attitude was honed decades before when performing comedy. It works for me, and I’m sticking to it. I am able to engage my patients to have fun during our sessions while challenging them physically, or as they say in comedy, “pushing the envelope”.
I am able to carefully broach sensitive subjects with a patient who insists they are having no problems with incontinence, but whose bedroom reeks of urine, by saying something like, “OK, you are able to get on and off the toilet just fine, but… what do you do in the middle of the night, when you are lying in bed and you think “Gotta go, gotta go, gotta go right now?” (as sung in the commercial). By ending my question with a familiar jingle, I find that it takes the pressure off of my patient and they are able to laugh a bit at the honesty behind the humor. Pretty much 100% of the time, after a little chuckle, they are more apt to discuss the situation.
Patients who are non-compliant with wearing their compression stockings will often giggle when I say, “I heard you once had the nicest looking gams in New York City… if only you wore those sexy nylons like you used to!” and the next session, guaranteed, they are sitting in those stockings waiting to hear my whistle “There’s the hottest gams in New York City. THERE they are!!”
In both stand-up comedy and in therapeutic rehabilitation, you have to know your strengths and your limitations, and most importantly, you have to know your “audience” – your patients – before engaging them with humor.
An article in PT Magazine entitled, “”Tickling the Funny Bone: The Use and Benefits of Humor in Health Care”[i] provides suggestions to therapists who would like to include humor within their sessions. Among them: Listen to your patients when they speak to you in order to gain an understanding as far as personal boundaries and appropriateness. When they speak to you regarding their medical and personal history, listen for their tonal inflection, voice tension, and other clues to better understand their attitudes and interests.
You may have patients who are quite serious, or those with inappropriate behaviors and inability to filter their own conversation due to brain injuries, and those with whom engaging in humor would be inappropriate. As one example, the article warned that extreme sadness or high stress situations are not the time for humor, because those emotions and situations need to be addressed first. However, once addressed, humor is a great way to assist patients in thinking outside of their immediate physical state and focusing toward a different perspective, giving patients “permission to lighten up” and to separate momentarily from their disease or illness.
Besides changing a patient’s state of mind, humor is also great for the therapeutic relationship, as it can bond patients with practitioners as well as clinicians with fellow staff members, and it humanizes a sterile clinical environment. Laughter is social, and the expectation of laughter may bring patients out of their rooms and into a more social environment such as a Skilled Nursing Facility (SNF) dining room or therapy gym.
Lastly, the article considered that laughter may also help to motivate patients to comply with their therapy plans. We all want to return to situations in which we had a good time, why not make our sessions that kind of experience for our patients?
Medical Humor As Depicted in Literature and the Media
In his 2017 article, “Humor in Medicine: Can Laughter Help in Healing?”[ii] Dr. Allen Weisse considered humor within medical literature and the affect it may have had on patient outcomes. Among humorous writers who were physicians, Weisse mentioned William Osler, one of the founding members of Johns Hopkins Medical School who would write raunchy fictitious case reports, and W. Somerset Maugham, who never used his medical degree, but instead became successful for his various novels and plays of both serious and comedic nature. Weisse also considered writers who were not in the medical field but whose works centered around a clinical environment or medical personnel, such as Moliere and Joseph Heller. There was the movie and television series M*A*S*H, but beyond that, very few comedies about the medical field exist. And yet, there are numerous cartoons involving medical subjects. I for one adored the American version of the British comedic television show “Getting On,” which was set in a women’s ward of an SNF.
Ultimately, Weisse concluded that medicine as a humorous topic seems to be loved by audiences, however it plays a minor role in TV and film. Perhaps if the subject was more commonly depicted in comedic media, the behind-closed-doors stigmas and anxieties of being a patient would be minimized and normalized.
The Affect of Humor and Laughter On Patient Outcomes
In his article, Weisse mentioned one of the first case studies of humorous media’s affect on health, that of Norman Cousins. After being diagnosed with ankylosing spondylitis, Cousins self-prescribed large doses of Vitamin C daily, had his nurse regularly read humorous literature to him, and “binge-watched” the Marx Brothers and Candid Camera. He found that 10 minutes of belly laughs would allow him 2 hours of pain free sleep, and that the positive effects of laughter were cumulative over time. His physician assisted him in monitoring his red blood cell sedimentation rate, which is an indication of inflammation, and Cousins documented his findings in his 1979 autobiography, “Anatomy of an Illness as Perceived by the Patient.”[iii] By that point, he was mostly pain free.
Beyond case studies, it was challenging to find research quantifying the degree to which health is affected by humor until much later. A 2014 article, “Laughter Therapy: Promoting Health and Wellbeing”[iv] reviewed the past 10 years of research related to rehabilitative healthcare and humor.
The article began by discussing the research of Indian physician, Madan Kataria. In 1995, Kataria was the first to research and report about “Laughter Clubs”. Meeting his subjects in city parks or other locations, Kataria’s groups of 4 to 50 people would laugh together, eventually incorporating deep breathing and yoga exercises as well. Perhaps Kataria’s most important finding was that the mind and body do not know the difference between fake and genuine laughter, and that the health outcomes are the same regardless. It is here where the definitions of “humor” and “laughter” are delineated. One can have humor without laughter (sometimes in comedy we call that a “groaner!”) and one can have laughter without humor.
It is the latter that Kataria’s research, and much of contemporary research, is based upon. Knowing that patients can engage in laughter, either fake or genuine, with humor or without, is particularly relevant to clinicians who work with patients who have dementia or cognitive impairments because patients do not need to “get the joke” in order to benefit from laughter therapy.
The benefits that contemporary research strives to quantify include: the effect of laughter on cardiovascular benefits such as altering heart rate and increasing circulation, the effect of laughter on respiration due to exercising the lungs and increasing oxygenation within the body, laughter’s ability to activate abdominal muscles which in turn can massage internal organs, laughter’s ability to reduce muscular tension, stress and anxiety, and thus improving the immune system, and laughter’s effect on pain tolerance.
In 2014, the Korean Journal of Adult Nursing[v] considered the effect of laughter therapy along with a cognitive reinforcement program focusing on memory, attention, orientation, and execution skills in a trial of seniors over the age of 65 with mild cognitive impairments. As compared to the control group, those who received the 8-week laughter therapy and cognitive reinforcement treatment showed significant improvements in the areas of self-efficacy, depression and cognitive functions.
Similarly, in 2016, The Gerontologist published a study[vi] regarding the LaughActive program which combines laughter exercises with moderate-intensity strength, balance and flexibility activities. Patients from 4 different assisted living facilities participated in the 6-week intervention program and were assessed pre-intervention for a baseline understanding of their physical, social, and perceived enjoyment, facilitators or barriers to physical activities. They were re-assessed after the 6-week course. The findings proved a significant improvement in the participants’ mental health, aerobic endurance, exercise enjoyment and perceived accessibility of physical activities.
For Fun… Or Shall I Say, For The Laughs?
The Laughter Online University is an online resource center for “laughter as a wellness and overall well-being modality”, and its resource library has compiled lists of over 350 scientific research papers on the subject. Although they are not necessarily accredited by the American Occupational Therapy Association (AOTA),The Laughter Online University also offers training courses to all kinds of professionals who would like to incorporate humor into their work and lives.
The Association for Applied and Therapeutic Humor started in 1987 by Alison L. Crane, a registered nurse (RN) who began the international non-profit, member-driven organization in an effort to provide education, cutting-edge resources, and a supportive community to its members who hail from a diverse professional spectrum from health to business and beyond, for the practice and promotion of healthy humor. Among the events that they are holding during their upcoming 2018 annual conference is “Comedy for Caregivers”. They also have a Humor Academy (not accredited by the AOTA) where they “… are serious about humor’s benefits.”
[i] Wojciechowski, M. “Tickling the Funny Bone: The Use and Benefits of Humor in Health Care.” PT: Magazine of Physical Therapy, vol. 15, no. 12, Dec. 2007, pp. 20-25. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105970824&site=eds-live
[ii] Weisse, Allen B. “Humor in Medicine: Can Laughter Help in Healing?.” Baylor University Medical Center Proceedings, vol. 30, no. 3, July 2017, pp. 378-381. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=123598224&site=eds-live.
[iii] Cousins N. Anatomy of an Illness as Perceived by the Patient. New York: WW Norton, 1979
[iv] Gilbert, Roger. “Laughter Therapy: Promoting Health and Wellbeing.” Nursing & Residential Care, vol. 16, no. 7, July 2014, pp. 392-395. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107858202&site=eds-live.
[v] Eunjoo, Ji and Kim Oksoo. “Effect of the Laughter Therapy Combined with Cognitive Reinforcement Program for the Elderly with Mild Cognitive Impairment.” Korean Journal of Adult Nursing, vol. 26, no. 1, Feb. 2014, pp. 34-45. EBSCOhost, doi:10.7475/kjan.2014.26.1.34.
[vi] Celeste M. Greene, MA, Jennifer Craft Morgan, PhD, LaVona S. Traywick, PhD, Chivon A. Mingo, PhD; Evaluation of a Laughter-based Exercise Program on Health and Self-efficacy for Exercise, The Gerontologist, , gnw105, https://doi.org/10.1093/geront/gnw105