Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

A Chuckle a Day Keeps the Doctor Away: Therapeutic Humor & Laughter

LCDR Catherine M. MacDonald, NC, USN, MN, APRN, BC

Abstract

Laughter has been identified as a beneficial component of holistic health care throughout the world. In conducting a MedLine search, active laughter programs were found to be conducted in the United States, the United Kingdom, India, Canada, the Netherlands, Australia, and Germany, among others. The health benefits of laughter have been described in the literature, and one could postulate the positive clinical effects for clients who incorporate this as a self-management technique. Finally, in planning for the future, numerous clinical applications and research implications were deduced from the current literature.

Martin (2001) traced one of the earliest notations of laughter’s health benefits to a biblical reference, Proverbs 17:22: “a merry heart doeth good like a medicine” (p. 504). Dean (1997) cited 16th century physicians’ and philosophers’ “likening laughter to health-giving physical exercise” (p. 34), and Hassed (2001) noted that, in the 17th century, “The arrival of a good clown exercises more beneficial influence...than that of 20 asses laden with drugs” (p. 25). In the 18th century, Immanuel Kant “considered laughter useful for restoring equilibrium” (Hassed, 2001, p. 25).

In addition to these philosophical accounts of laughter’s benefits, anecdotal cases using humor and laughter in oncology, critical care, mental health, hospice, and health promotion have also increased the popularity of therapeutic laughter (Dean, 1997). Cousins (1976) stimulated renewed interest in the health benefits of laughter by describing how he used laughter in his self-management program for ankylosing spondylitis, a progressive and painful rheumatoid inflammatory disease. Believing the positive emotions generated by laughter should have a positive effect on his health, Cousins used Candid Camera classics and Marx Brothers films to stimulate at least 10 minutes of laughter, which allegedly resulted in 2 hours of pain-free, restful sleep. Cousins (1976) also noted a decrease in the inflammatory process, as evidenced by a decreased complete blood count sedimentation rate after each laughter period. This and other anecdotal reports have generated an emphasis on empirical studies on the benefits of humor and laughter.

Hassed (2001) reviewed numerous clinical studies that suggested humor and laughter can improve clinical outcomes in inflammatory disorders, asthma, cancer, and heart disease by reducing the physiological stress response, a recognized exacerbating factor in these and other conditions. From his review, he identified multiple psychological effects, such as reductions in stress and anxiety and improvements in mood, self-esteem, and coping skills. In addition, he described a positive physiological effect on pain tolerance and an increase in specific immune factors, such as production of immunoglobulin A (IgA) and blood leukocytes.

Wooten (1996) described humor and laughter as “effective self-care tools to cope with stress” (p. 49) and “the perfect antidote for stress” (p. 51). She cited several studies across the United States supporting the hypothesis that laughter lowers neurotransmitter stress response by attenuating neuroendocrine hormones and increasing immune cell activity.

Berk et al. (1989) conducted a controlled study of 10 adult men randomly assigned to either 1 hour of laughter or quiet time. In a pretest-posttest design, blood samples were collected prior to, during, and after the intervention. The control group showed no change, while the laughter group demonstrated a decrease in serum cortisol, dopac, epinephrine, and growth hormone levels, which lower the physiological stress response. Subsequent increases in immune response were found in the laughter group as well. In 1991, 1993, and 1995, as reported by McGhee (1998), Berk et al. conducted studies replicating these specific immune system responses, such as increases in IgA, IgM, IgG, interferon-gamma, natural killer cells, T cells, helper T cells, and B cells.

Dillon and Baker (1986) used salivary concentrations of IgA to measure immune system…

Laughter has been identified as a beneficial component of holistic health care throughout the world. In conducting a MedLine search, active laughter programs were found to be conducted in the United States, the United Kingdom, India, Canada, the Netherlands, Australia, and Germany, among others. The health benefits of laughter have been described in the literature, and one could postulate the positive clinical effects for clients who incorporate this as a self-management technique. Finally, in planning for the future, numerous clinical applications and research implications were deduced from the current literature.

Humor in History

Martin (2001) traced one of the earliest notations of laughter’s health benefits to a biblical reference, Proverbs 17:22: “a merry heart doeth good like a medicine” (p. 504). Dean (1997) cited 16th century physicians’ and philosophers’ “likening laughter to health-giving physical exercise” (p. 34), and Hassed (2001) noted that, in the 17th century, “The arrival of a good clown exercises more beneficial influence...than that of 20 asses laden with drugs” (p. 25). In the 18th century, Immanuel Kant “considered laughter useful for restoring equilibrium” (Hassed, 2001, p. 25).

In addition to these philosophical accounts of laughter’s benefits, anecdotal cases using humor and laughter in oncology, critical care, mental health, hospice, and health promotion have also increased the popularity of therapeutic laughter (Dean, 1997). Cousins (1976) stimulated renewed interest in the health benefits of laughter by describing how he used laughter in his self-management program for ankylosing spondylitis, a progressive and painful rheumatoid inflammatory disease. Believing the positive emotions generated by laughter should have a positive effect on his health, Cousins used Candid Camera classics and Marx Brothers films to stimulate at least 10 minutes of laughter, which allegedly resulted in 2 hours of pain-free, restful sleep. Cousins (1976) also noted a decrease in the inflammatory process, as evidenced by a decreased complete blood count sedimentation rate after each laughter period. This and other anecdotal reports have generated an emphasis on empirical studies on the benefits of humor and laughter.

Literature Review

Hassed (2001) reviewed numerous clinical studies that suggested humor and laughter can improve clinical outcomes in inflammatory disorders, asthma, cancer, and heart disease by reducing the physiological stress response, a recognized exacerbating factor in these and other conditions. From his review, he identified multiple psychological effects, such as reductions in stress and anxiety and improvements in mood, self-esteem, and coping skills. In addition, he described a positive physiological effect on pain tolerance and an increase in specific immune factors, such as production of immunoglobulin A (IgA) and blood leukocytes.

Wooten (1996) described humor and laughter as “effective self-care tools to cope with stress” (p. 49) and “the perfect antidote for stress” (p. 51). She cited several studies across the United States supporting the hypothesis that laughter lowers neurotransmitter stress response by attenuating neuroendocrine hormones and increasing immune cell activity.

Berk et al. (1989) conducted a controlled study of 10 adult men randomly assigned to either 1 hour of laughter or quiet time. In a pretest-posttest design, blood samples were collected prior to, during, and after the intervention. The control group showed no change, while the laughter group demonstrated a decrease in serum cortisol, dopac, epinephrine, and growth hormone levels, which lower the physiological stress response. Subsequent increases in immune response were found in the laughter group as well. In 1991, 1993, and 1995, as reported by McGhee (1998), Berk et al. conducted studies replicating these specific immune system responses, such as increases in IgA, IgM, IgG, interferon-gamma, natural killer cells, T cells, helper T cells, and B cells.

Dillon and Baker (1986) used salivary concentrations of IgA to measure immune system response to laughter. Ten participants were randomly assigned to watch either a humorous videotape or a didactic videotape. The researchers found an increase in concentration after participants watched the humorous videotape but no significant change after participants watched the didactic videotape and concluded that the elevated IgA was related to the positive emotional state created by laughter. These data suggest immune system enhancement.

Additional benefits of laughter to physical well-being have been reported. Fry (1992) noted relaxation of the skeletal and cardiovascular muscles after the initial muscular contractions associated with laughter. In addition, he reported an increased efficiency in respiratory system function in his 1977 study of respiratory waveforms of 9 men exposed to 11 episodes of humorous stimuli.

Thorson and Powell (1993) administered a Multidimensional Sense of Humor Scale and the Revised Death Anxiety Scale to 426 men and women. The results demonstrated a negative correlation between death anxiety and humor, suggesting humor was a positive coping mechanism for dealing with death.

Cogan, Cogan, Waltz, and McCue (1987) conducted two pain threshold experiments. The first studied 40 participants who were randomly assigned to using a humorous audiotape, a relaxation audiotape, a narrative audiotape (to control for distraction), or no intervention. The discomfort threshold after laughter was significantly greater than with all other interventions, including the relaxation audio-tape. The second study assessed whether the laughter itself or the distraction was the cause of the increased pain threshold. The researchers found the highest posttreatment pain threshold (21 mmHg difference, using blood pressure cuff inflation as the discomfort agent) after the laughter-inducing audiotapes, compared to the three remaining groups, the next highest difference being 8 mmHg. These results suggest laughter is not simply a distraction but a potential pain antagonist.

Some studies have assessed the effects of laughter on others, rather than on oneself. Bachorowski and Owren (2001) compared reactions to voiced and unvoiced laughter in 128 participants. Voiced laughter is described as acoustic and song-like, whereas snorts, panting, and grunts are characterized as unvoiced laughter. The researchers found that voiced laughter consistently elicited a more positive effect in listeners than unvoiced laughter.

In a comprehensive review, Martin (2001) synthesized data from studies focusing on the immune system, pain, blood pressure, longevity, and individual symptoms. He explored several theoretical mechanisms, such as physiological changes, with laughter, subsequent physical effects of a positive emotional state, stress moderation, and social support. Although the empirical data he reviewed is suggestive of the health benefits mentioned above, he noted numerous methodological issues, discussed later in this article, which cast doubt on the findings.

These studies and reviews suggest some empirically supported benefits of humor and laughter. In addition, it can be inferred from the many anecdotal cases that a therapeutic laughter program can be realistically implemented as an adjunctive self-management technique, which may have a positive effect on individuals’ physical and psychosocial well-being.

Laughter Programs

Based on intuition, anecdotal evidence, and empirical support, people have begun actively participating in humor and laughter programs. Several variations of laughter programs exist, including:

  • Humor therapy.
  • Laughter therapy.
  • Laughing meditation.
  • Laughter clubs.

Each of these can be incorporated in self-management programs.

Humor Therapy

Pasquali (1990) provided an example of a humor program in psychiatric day treatment. After encountering initial stumbling blocks in using humorous materials, she found that the group responded positively to reading novels based on true stories. Each story warmly and humorously recounted the trials and tribulations of life. After reading passages aloud, the group members spontaneously discussed similar personal accounts they found humorous.

Pasquali encouraged group members to watch for humorous television shows, books, items, and experiences to share at later sessions. This was intended to remind them to seek the lighter side of life and that humor “needs to be sought out, nurtured, and cultivated” (Pasquali, 1990, p. 35).

Laughter Therapy

Dolan (1994) described laughter as “aerobic humor” (p. 38) and “internal jogging for all of the major organs” (p. 39), which increases blood circulation and tissue oxygenation. In her laughter therapy workshops, Dolan helps clients discover a personal humor profile. This involves recalling favorite childhood toys, identifying people in their lives who make them laugh, and sharing favorite comedians, movies, and jokes, which helps clients identify their laughter triggers. After this profile is created, she teaches clients specific exercises that can be performed outside of the workshop setting. The workshop also includes exercises intended to remind clients of the importance of relationships and social support.

Laughing Meditation

Unlike the previously discussed programs, humor does not necessarily precede laughter in this technique. Sutorius (1995) distinguished spontaneous laughter from laughing meditation. He described laughing meditation as an exercise that can be performed by almost anyone as an adjunct to traditional treatments and to enhance overall coping capabilities. It is a structured, 15-minute exercise performed in three stages:

  • Stretching.
  • Laughing (and/or crying).
  • A period of meditative silence.

Similar to traditional meditation, laughter brings a person into the moment.

During the stretching stage, the person devotes all energy to stretching each muscle, including making unusual faces but taking care not to laugh yet. In the second stage, the person gradually smiles, then moves slowly and deliberately into a belly laugh or cry, whichever happens to occur in the moment. In the final stage, the person stops laughing abruptly, closes his or her eyes and breathes without sound, concentrating on the moment.

Laughter Clubs

Therapeutic laughter clubs originated in a public garden area in Mumbai, India, in 1995. Kataria, a Bombay physician, developed the laughter club program as a supplementary and preventive therapy, incorporating breathing, yoga, and stretching techniques. Similar to laughing meditation, this format does not rely on jokes or humorous materials. Kataria described the platform as “a beautiful package of stimulated simulated laughters” (cited in Wilson, 1998, ¶ 11).

The format includes several laughter exercises lasting 30 to 45 seconds, each with deep-breathing and stretching exercises interspersed between laughs. These exercises are similar to yogic assanas and a Buddhist practice of forced laughter. Kataria explained that laughter is one of the simplest and easiest forms of meditation because one does not need to concentrate to clear one’s mind. According to Kataria, “While laughing you cannot think of anything else. Either you think or you laugh, but not both” (cited in Wilson, 1998, ¶ 30).

Although it may seem that these clubs focus on the physical aspect of laughter, Kataria emphasized that an “inner laughter..., which is to be happy and make others happy, goes within us and becomes part of our life and living” (cited in Wilson, 1998, ¶ 20). The physical exercises of simulated laughter appear to precede a positive emotional well-being.

Health Behavior Change

Clinical Applications

For any of these programs to be effective, several considerations must be evaluated, including timing of humor, the receptiveness of the client, and the context of humor (Davidhizar & Bowen, 1992). Although humor and laughter can help reduce stress and anxiety in the early and recovery stages of a crisis, it may be considered offensive or distracting at a peak crisis period. Clinicians using therapeutic humor and laughter must be sensitive to laugh with, not at, clients (Gibson, 1994). Particular care must be used with clients who are acutely paranoid, critically ill, or terminally ill to ensure humor and laughter are not misinterpreted.

In using humor in conjunction with laughter, each individual’s perception of what is humorous must be considered. Humor, or “what is considered funny, is very much influenced by a person’s biophysical, psychosocial, sociocultural, and spiritual states of being” (Pasquali, 1990, p. 31). A group workshop requires more sensitivity to these differences, whereas teaching clients to use an individual humor program would avoid potential conflicts of taste. Unfortunately, if clients choose to avoid groups due to possible conflicts, they may be sacrificing the social support of a positive group environment. To assess whether a group or individual program may be more beneficial, practitioners should be cognizant of each client’s needs when recommending or supporting a technique.

In laughing meditation and laughter clubs, humor is not a prerequisite to the exercise of laughter. These exercises can be practiced individually or in group settings without concern for differences in senses of humor. These programs do not require humorous materials to be readily available and, therefore, can be implemented with little or no preparation. They involve simple, easy-to-follow instructions that can be applied by most people in a minimal amount of time. These positive attributes may increase clients’ adherence to these programs, compared to humor and laughter therapies.

However, to assume using laughter without humor is a better overall self-management program would be to ignore several significant issues. Some clients may find laughter exercises without using humor difficult, forced, and not as pleasant, psychologically. This may result in an increase, rather than the desired decrease, in physiological and psychological stress responses. Clients experiencing acute exacerbation of severe pain or anxiety may find laughter exercises make symptoms worse, rather than relieve them (Pasquali, 1990).

Research Implications

Despite a long history of intuitive and anecdotal support for humor and laughter therapies, empirical data have only been available during recent years. These data have been participant to methodological difficulties from the onset. Research on humor can be challenging due to its participative and individual nature (Dean, 1997). How each researcher conceptualizes humor affects the research design and data collection tools selected (Martin, 2001). Martin also described some methodological issues, such as a lack of comparison, neutral and negative emotion control groups, and a reliance on self-report measurements.

Therapeutic laughter clubs have some advantages that may be beneficial for pioneering further research on the participant. The overall format and individual laughter exercises used at the clubs are generally standardized. Rather than focusing on generic and ambiguous variables such as humor and laughter, research can focus on specific activities. Recognized clubs are established worldwide, which would facilitate diversity in sampling and cross-cultural studies. It also provides an avenue for replication studies. The clubs belong to a governing organization, Laughter Clubs International. This parent body currently has an established research panel collecting empirical data on the health effects of laughter clubs. Some limitations and concerns regarding this research are the limited generalizability and potential bias of the in-house research panel.

Basmajian (1998, 1999) indicated that some of the empirically suggested benefits could be a result of debonafide (Latin for “in good faith”) effects. Rather than a placebo effect, suggesting a response from an inert substance or intervention, a debonafide effect is an inexplicable, positive response to an intervention. Cousins (1976) acknowledged this possibility in his apparent recovery through laughter: “...the beneficiary of a mammoth venture in self-administration placebos” (p. 1,462). Rather than viewing this possibility as a negative connotation, he expounded on the importance of self-management motivation. He stated that his physician’s principle contribution to his recovery was the encouragement he gave him in pursuing his self-management plans.

Further research on the physical, psychosocial, debonafide, or placebo effects of laughter needs to be conducted. For practitioners to implement credible laughter programs and effectively teach self-management techniques, they must work to advance the study of laughter through empirical data collection and research-based, clinical practice.

Conclusion

Historically, the beneficial effects of therapeutic laughter have been alluded to from biblical references to physicians, philosophers, and patients. Laughter has been purported to improve immune function, increase pain tolerance, and decrease stress response.

Therapeutic laughter has many forms: humor therapy, laughter therapy, laughter meditation, and laughter clubs. Therapeutic laughter may have unique implications as a self-management technique. Its simplicity and inherently pleasurable application may stimulate clients’ initial interest and may increase adherence to a continuous laughter program. Its similarity to meditation and relaxation exercises also may appeal to clients already applying these techniques.

Despite methodological difficulties in studying laughter, it continues to be assessed for its expanding possibilities. Although the empirical evidence is inconsistent, some positive results, in addition to supportive, anecdotal benefits, continue to make therapeutic laughter a popular alternative. To maintain credibility within the traditional, complementary, and alternative therapies, proponents of therapeutic laughter must continually increase the knowledge base, theoretical basis, and standards of practice through research and ongoing critical review of clinical practices.

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Key Points

  1. There are several beneficial effects attributed to humor and laughter, including improved immune function, increased pain tolerance, and decreased stress response.

  2. Humor therapy, laughter therapy, laughter meditation, and laughter clubs all have unique implications as group programs and as self-management techniques.

  3. For practitioners to implement credible programs and effectively teach self-management techniques, further empirical research on the physical, psychosocial, debonafide, and placebo effects of humor and laughter needs to be conducted.

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Authors

Lieutenant Commander MacDonald is Psychiatric Clinical Nurse Specialist and Department Head for Mental Health Nursing, Nursing Services, Naval Medical Center San Diego, San Diego, California.

The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Address correspondence to LCDR Catherine M. MacDonald, NC, USN, MN, APRN, BC, Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Drive, Suite 5, San Diego, CA 92134-1005; e-mail: cmmacdonald@nmcsd.med.navy.mil.

10.3928/02793695-20040315-05

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