Jones & Bartlett Learning Health Blog

    No Laughing Matter

    Posted by admin on Sep 17, 2009 11:26:40 AM

    In 1979 Norman Cousins published his memoir, Anatomy of an Illness: Reflections on Healing and Regeneration (Cousins, 1979). In this bestselling book, he recounted in great detail his experience with and battles against the painful, progressively disabling inflammatory condition of ankylosing spondylitis. In spite of all available treatments at the time, the disease did not relent until he (under medical supervision) took massive doses of Vitamin C and began an intensive course of laughter therapy. What he reported astonished the world: “ten minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep” (Cousins, 1979, p. 39). This anecdotal report of the effect of laughter in one (influential) person served as an impetus to decades of serious research on humor, mirth, and laughter.

    Some of the alleged physical health benefits of this trifecta of fun include: decreased pain, higher pain thresholds, lower sedimentation rates, increased secretory IgA (a measure of immunity found in saliva), fewer illness symptoms, increased muscle relaxation, longer life, and increased ability to stand on one foot and bark like a dog (Berk, 2007; Martin, 2001), Okay, I made the last one up, but the others are true. With respect to psychological effects, people who have a sense of humor and laugh a lot are reported to be more socially attractive, have better interpersonal skills, a more positive outlook, greater optimism, and greater ability to shirk work than those who don’t (Mahoney, Burroughs, & Lippman, 2002). Yes, made up that last one, too.

    Humor is a cognitive process that involves the observation of a paradox in action and is a stimulus in a research setting (Beckman, Regier, & Young, 2007; Berk, 2007; Martin, 2001; Mahoney, Burroughs, & Lippman, 2002). Mirth is the emotional response (Berk, 2007). And, laughter, which can include, but is not limited to giggles, titters, chuckles, snickers, cackles, chortles, guffaws, horse laughs, shrieks, roars, crack ups, belly laughs and the email favorites, LOL and ROFLMAO (Mahoney, Burroughs, & Lippman, 2007). Researchers have examined humor as a personality trait (as in does she or does she not have a sense of humor) using a scale called Situational Humor Response Questionnaire (SHRQ), which I believe is pronounced “shirk” as in “Is she shirking work by writing this blog?

    Over time many researchers have administered the SHRQ (now all you can hear in your head is shirk, right?) to a host of subjects and have found no, zero, zip, zilch, statistical basis for the alleged relationship between a “good” sense of humor and most of the above noted alleged health benefits. In fact, in one longitudinal study from 1921, children who were identified by their teachers at the age of 12 as having “higher cheerfulness” actually died sooner than their crankier peers (Friedman, 1993 as reported in Martin, 2001). In addition, Rotton (1992, as reported in Martin 2001) found “professional humorists and serious entertainers died at a significantly younger age than people who were famous for other reasons” (Martin, 2001, p. 513). Perhaps the lesson here is “Laugh because you’re going to die anyway.”  The only realphysical benefit researchers could find between humor and laughter was a mild relationship between laughter (the physical response) and ability to better tolerate pain in a laboratory setting using cold, blood pressure cuff inflation, or electric shocks as the painful stimuli (Martin, 2001). Okay. Let’s stop a moment and think about the informed consent with that study: “We’re going to show you a funny video and see if you notice how cold, numb, or shocked you feel. Hey, where are you going?” Actually, in at least one of the experiments, a participant had to be removed from the study due to (are you ready for this?) “failure to laugh aloud” (Martin, 2001). Boy, that’s going to go on his permanent record. Martin’s (2001) literature review highlighted the need for more rigorous studies with better methodology, including larger groups and control groups for all research related to humor, laughter and physical health.

    Mahoney, Burroughs, and Lippman (2002) followed Martin’s recommendations, and conducted a study comparing an older (retirement community residents, mean age 79.7) group to a younger group (college students with a mean age of 20.5) to see if there were differences in perceptions of different types of laughter and perceived health and well-being benefits. Mahoney and colleagues used a laughter scale of “chuckle, giggle and belly laugh” and the concomitant loudness associated with each (Mahoney, Burroughs, & Lippman, 2002, p. 173). Unlike Martin and Kuiper (1999 as reported in Martin, 2001) findings that men and women express humor in different ways--men are more likely to be “maladaptive” in their humor (thinkPorky’s and Porky’s Revenge) and women are more likely to use it as a bonding opportunity--these researchers found no gender differences. Mahoney et al., discovered that younger people preferred loud belly laughs and the older participants preferred a lower volume of laughter. I’m assuming Billy Crystal wasnot a participant in this study at any age. Both old and young agreed the laughter should be socially appropriate and non-malicious to be beneficial.

    In his 2007 address to the Association of the University Programs in Health Administration (AUPHA), Berk provided the audience with a list of inappropriate and appropriate humor for use in teaching. Inappropriate humor included: “put-downs of anyone, sarcasm, ridicule, profanity, vulgarity, sexual content and innuendo, and sensitive issues that deal with personal tragedies” (Berk, 2007, p. 104-105). Appropriate humor included: “positive humor that builds people up, the big butt theory (the butt of the joke is something we all have an issue with, like parking), and self-downs, i.e., self-deprecating humor” (Berk, 2007, p. 105). He provided demonstrations of how to interject humor into lectures, assignments and exams, got a bunch of professors up on their feet and dancing, and showed us how to get our teeth whiter in a week. (You have to guess which of the last two is true.) Berk (2009) later reported on the need for professionalism in clinical teaching and the workplace. He found that sarcasm, put-downs, and cynical humor abounded in teaching hospitals and that the worst offenders were, in fact, the role models for medical students and residents. While historically this type of humor has been considered a socially appropriate coping mechanism, more people are recognizing this as a form of verbal abuse. He called for 360 degree assessments of medical school faculty and clinicians, as well as communication of the rules of conduct by department chairs.

    Finally, in an interesting use of humor in organization to improve psychological well-being, Beckman, Regier, and Young (2007) reported on a field intervention using laughter groups for employees in a behavioral health setting. The researchers reported the “staff at this facility routinely faced increased workloads, burnout, negative ruminations, anxiety about the future, and a sense of social disconnectedness with increased productivity expectations” (Beckman, Regier, & Young, 2007, p. 177). The researchers wanted to separate out the effects of humor from laughter, so they employed a “professional laughter coach” to teach participants how to “induct laughter without humor” (Beckman, Regier, and Young, 2007, p. 169). Self-selected participants elicited from a company-wide email gathered for 15 minutes before work or during lunch break and were led into laughter, including the required exercises of “Ho-ho-ho. Ha-ha-ha. He-he-he” (Beckman, Regier, and Young, 2007, p. 173). No humor was allowed, although some participants found the experience to be humorous, in spite of stern instructions from the professional laughter coach. The authors found the following: 1) laughter is contagious--you can catch it from co-workers; 2) the 22 remaining participants (out of 37 original ones) maintained self-efficacy 90 days later; 3) decreased negative ruminations; and 4) increased role compliance. I must confess that as I read this study, I kept thinking about Hogan’s Heroes, the old sit-com that showed a rag-tag band of prisoners of war joking around and fooling their dim-witted German captors.

    Call me crazy, but instead of treating the employees, it seems to me the above-noted intervention should have been at the organizational level. As a teacher, researcher, and author, I believe that we can do great things with health care organizations and be catalysts for change. Sometimes the catalyst that is needed is something as simple as the use of humor, mirth, and laughter in higher education and health care organizations. The use of humor can be taught, even to health care management professors (Berk, 2007). Some authors have gone so far as to advocate having Chief Humor Officers (CHO’s) in corporations in addition to CEOs, COOs, and CIOs (Buchbinder, 2004). However, as with anything, we must be look to the literature to see if the latest organizational intervention or teaching method is tried and true--or a fad. With the exception of analgesia, the jury is still out on the laundry list of physical health benefits of humor and laughter. With respect to the psychological effects, we should be cautious about the use of humor and laughter to put a band-aid on an organizational affliction. While I will be the first person in a serious meeting about swine flu to don a rubber pig nose, I believe humor should be appropriate and kind, it should be used to build people up, not to tear them down, and that bread and circuses belong with the Roman Empire, and have no place in today’s health care settings.

    Sharon B. Buchbinder, RN. PhD
    http://pages.towson.edu/buch
    Professor and Chair
    Department of Health Science
    Towson University
    Towson, MD

    Sharon Buchbinder is an Adjunct Professor of Nursing at Stevenson University in the Graduate and Professional School , and former chair of the Association of University Programs in Health Administration (AUPHA).  She is also the author of two books from Jones & Bartlett: Introduction to Health Care Management and Career Opportunities in Health Care Management.

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    Here are some references if you are interested in this topic.

    Beckman, H., Regier, N., & Young, J. (2007). Effect of workplace laughter groups on personal efficacy beliefs.The Journal of Primary Prevention, 28(2): 167-182.

    Berk, R.A. (2007). Humor as an instructional defibrillator. Journal of Health Administration Education, 24(2), 97-116. . Retrieved on September 17, 2009
    http://www.ronberk.com/articles.shtml

    Berk, R.A. (2009). Derogatory and cynical humour in clinical teaching and the workplace: The need for professionalism. Medical Education, 43: 7-9. Retrieved on September 17, 2009
    http://www.ronberk.com/articles.shtml

    Buchbinder, S.B. (2004). Chief humor officer. Retrieved on September 17, 2009
    http://www.useless-knowledge.com/articles/apr/may029.html

    Cousins, N. (1979). Anatomy of an illness as perceived by the patient: Reflections on healing and regeneration. New York (NY): Bantam Books.

    Friedman, H.S., Tucker, J.S., Tomlinson-Keasey, C., Schwartz, J.E., Wingard, D.L. & Criqui, M.H. (1993). Does childhood personality predict longevity? Journal of Personality and Social Psychology, 65, 176-185. In Martin, R.A. (2001). Humor, laughter, and physical health: Methodological issues and research findings.Psychological Bulletin, 127(4):504-519.

    Mahoney, D.L., Burrounghs, W.J., & Lippman, L.G. (2002). Perceived attributes of health-promoting laughter: a cross-generational comparison. The Journal of Psychology, 136(2), 171-181.

    Martin, R.A. (2001). Humor, laughter, and physical health: Methodological issues and research findings.Psychological Bulletin, 127(4):504-519.

    Martin, R.A. & Kuiper, N.A. (1999). Daily occurrence of laughter: Relationships with age, gender, and Type A personality. Humor: International Journal of Humor Research, 12, 355-384. In Martin, R.A. (2001). Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127(4):504-519.

    Rotton, J. (1992). Trait humor and longevity: Do comics have the last laugh? Health Psychology, 11, 262-266. In Martin, R.A. (2001). Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127(4):504-519.

    Topics: public health education, health administration, Sharon B. Buchbinder, psychological effects, Public health management, Sharon Buchbinder Blog, Situational Humor Response Questionnaire (SHRQ), Anatomy of an Illness: Reflections on Healing and, Association of the University Programs in Health A

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