Humor as a Clinical Skill:
Are you joking?
Kevin Lee Smith, RN, CNP, MSN
2005
"He who laughs; lasts."
Anonymous
Definitions of Humor:
Your ideas?
Therapeutic Humor?
Adults Laugh about 15 times
per day
Children Laugh_____?
150-400 times per day
Laughs per Day
150-400
90
80
70
60
50
40
30
20
15
10
0
Grown ups
Children
Fake Graph, Smith 2004 ;43 (2), Imaginary Journal
Laughs per Day
Adults
Kids
Now I get it!
Another Fake Graph, Smith 2005 ;43 (2), Imaginary Journal
Why
Why
Do We
We Laugh?
Laugh?
WHY DO WE LAUGH?
•Surprise
•Superiority
•Incongruity
•Release
Types/Styles of Humor
what is your style?
Spontaneous vs. Formal
Self deprecating Humor
Puns & Plays on Words
Sarcastic Humor
Types/Styles of Humor
continued
Slapstick Humor
Ethnic Humor
Gallows Humor
Write it down: What 2 types or styles of
humor do I either use or enjoy most?
1.__________________________
2.__________________________
Spontaneous Vs. Formal
• Random acts of
humor
–Humor “in the
moment”
–Not planned
–Responding to
a situation or
event
• Premeditated
humor
–Jokes
–Cartoons
–Life of the
party
Self deprecating Humor
“I couldn’t be two faced, if I was, I sure
wouldn’t wear this one.”
--Abraham Lincoln
Puns & Plays on Words
Sarcastic Humor
Slapstick Humor
Ethnic Humor
"The most acutely suffering
man on earth
invented laughter."
--Frederick Nietzsche
Gallows Humor
www.learnovation.com (used with permission)
Knowing When to Use Humor
St. Luke’s Hospital
•
•
•
•
When another person initiates the humor.
You have a good relationship.
The situation is appropriate.
The humor is aimed at a situation or
yourself.
• “Ed” -- Heart Disease
(example)
"The art of medicine
consists of amusing the
patient while nature cures
the disease."
Voltaire, French philosopher
Review of Literature/Humor Response
• Sense of Humor acts as a moderator of
daily hassles on Salivary IgA (p<.05)
(N=40) (Martin, et al., 1988)
• Exposure to a humorous video
produced significantly (p<.005)
increased levels of SIgA
(Lefcourt, et al., 1990)
Modulation of Neuroimmune Prameters
During the Eustress of Humorassociated Mirthful Laughter
• Increases were found in:
– Natural Killer Cell Acitvity
– Immunoglobulins G and M
– Several immunoglobulin effects lasting 12
hours after watching the humorous video
Dr. Lee Berk, MPH, DrPH, David Felton, MD, PhD, Stanley Tan, MD, PhD, Barry
Bittman, MD and James Weisengard, BS in Alternative Therapies in Health and Medicine
(7) 2, March 2001.
Humor Modulates the Mesolimbic
Reward Centers
• Neuroimaging with functional MRI
• Humor engages a network of
subcortical regions…a key
component of the mesolimbic
dopaminergic reward system
• Humor intensity correlated with
signal intensity
Neuron, Vol 40, 1041-1048, 4 December 2003
Laugh Away that Silly MI
• Heart attack survivors
experiencing 30 minutes of
laughter daily less likely to
experience a 2nd MI, required
lower med doses, and had lower
BP. (N=24)
• 2nd MI 20% vs. 50%
CAN Journal of Cardiol 1997, 13 (Suppl. B) 190B
in Mind/Body Health Newsletter (Vol. 8, Number 2, 1999)
“Sense of humor, childhood
cancer stressors, and outcomes
of psychosocial adjustment,
immune function, and infection”
•
A direct relationship was
observed between sense of
humor and psychosocial
adjustment to cancer
J Pediatr Oncol Nurs. 2003 Nov-Dec;20(6):271-92.
Dowling JS, Hockenberry M, Gregory RL.
Continued…
•
•
children with a high sense of
humor had greater psychological
adjustment, regardless of the
amount of cancer stressors
As childhood cancer stressors
increase, children with high
coping humor scores reported
fewer incidences of infection than
low scorers.
J Pediatr Oncol Nurs. 2003 Nov-Dec;20(6):271-92.
Dowling JS, Hockenberry M, Gregory RL.
Questions about Optimism and
Health
•
“…no evidence that a high level of
optimism prior to treatment enhanced
survival in pts. with NSCLC.
Encouraging pts. to "be positive" only
may add to the burden of having
cancer while providing little benefit, at
least in patients with NSCLC
(nonsmall cell lung carcinoma ).”
Optimism and survival in lung carcinoma patients
Cancer. 2004 Mar 15;100(6):1276-82.
"A merry heart doeth good
like a medicine: but a
broken spirit
drieth the bones."
Proverbs 17:22
“New clinical studies
show there aren’t any
answers.”
author unknown
"I hate quotations."
Ralph Waldo Emerson
Psychological Effects of
Laughter
•Stimulates Alertness and Memory
•Enhances Learning and Creativity
•Promotes Relaxation
Saper, Bernard (1990). The therapeutic use of humor for psychiatric
disturbances in adolescents and adults, Psychiatric Quarterly, 61(4): 261-272.
Psychological Effects of Laughter,
cont.
• Promotes Shift From Negative to Positive
• Outlet for Expressing Feelings
• Effective Mode of Communication
Saper, Bernard (1990). The therapeutic use of humor for psychiatric
disturbances in adolescents and adults, Psychiatric Quarterly, 61(4): 261-272.
Take your work
seriously
--and yourself lightly
OPPORTUNITY
ISNOWHERE
96% of Executives Choose
Employees With Sense of Humor
Creative
Good
Communicators
Team
Stress
players
Relievers
Based on study done by Hodge Cronin and Associates
The Creative Group, A Robert Half International Company, 2004
AATH Official Definition
Therapeutic Humor: Any intervention
that promotes health and wellness by
stimulating a playful discovery, expression or
appreciation of the absurdity or incongruity of
life’s situations.
This intervention may enhance health or
be used as a complementary treatment of
illness to facilitate healing or coping, whether
physical, emotional, cognitive, social or
spiritual.
Association for Applied and Therapeutic Humor, 2004
What Everyone Should Know
About Humor and Laughter
(“evidence based”)
Ron Berk, Ph.D.
The Johns Hopkins University
Endorsed by AATH
What we Know
Humor
• Reduces stress, anxiety, and tension
• Decreases depression, loneliness,
and anger
• Improves mood
• Increases self-esteem
• Promotes a sense of empowerment
Association for Applied and Therapeutic Humor, 2004
What we Know
Laughter
•
•
•
•
Increases pain tolerance (examples)
Improves respiration and breathing
Improves mental function
Exercises facial, abdominal, and chest
muscles
• Relaxes muscles/decreases muscle
tension
Association for Applied and Therapeutic Humor, 2004
What We Don’t Know Yet
Humor
• Decreases symptoms of illness
• Enhances relationships, intimacy, and
marriage satisfaction
• Increases lifespan
Association for Applied and Therapeutic Humor, 2004
What We Don’t Know Yet
Laughter
• Stimulates the production of
endorphins which decrease pain
• Prevents pain
• Lowers heart rate
• Lowers blood pressure
Association for Applied and Therapeutic Humor, 2004
Benefits of Humor Interventions:
• Enhances therapeutic
relationship between
nurse and client
• Brings hope and joy to
the situation.
• Enhances feelings of
well being for the
client.
Humor Interventions:
cont.
• Creates an outlet for
stress release for both
the nurse and the client.
• Can establish a trusting
and comfortable
environment for the
client.
"Laughter is the shortest
distance between two
people."
Victor Borge
Examples of Humor in Action:
Constructive Physician-Generated Humor
• During hospital rounds, the physician enters a
patient's room. The patient, gowned in bed, is just
finishing breakfast. The physician greets the
patient,
"Good morning. Looks like you
ate well. Why didn't you leave any
for me?"
The patient chuckles.
Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack Coulehan, MD,
MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.
Humor in Action:
Humorous Interchange Between Patient and
Physician
• A patient with chronic low back pain wryly
remarks, only half-jokingly, to her long-time
physician, "Can't you prescribe some cyanide?"
The physician replies,
"I would, except it'd be bad
for business–I wouldn't get
any more follow-up visits out
of you."
Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack Coulehan, MD,
MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.
Humor in Action:
Destructive Patient-Generated Humor
• As the tardy physician enters the
examination room, the patient sneers,
"You must have been out playing
golf again!"
Humor:
peeling back
some layers?
Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack
Coulehan, MD, MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.
When is humor
appropriate
or not?
Eight steps for developing your
sense of humor
• 1. Gain an Awareness and
knowledge humor. It takes both a
change in attitude and behavior.
• 2. Identify inappropriate humor.
Avoid it.
• 3. Get to know what amuses you.
• 4. Do a humor history on
yourself.
Eight steps for developing your
sense of humor, cont.
• 5. Keep a file of humorous anecdotes
stories, jokes cartoons.
• 6. You need to be somewhat of a
risk taker.
• 7. Allow yourself to be silly.
• 8. Surround yourself with people
who have a humorous, positive
outlook, and most of all, learn to
laugh at yourself.
http://www.powerpointbackgrounds.com
© 2004 By Default
Survival of the Wittiest:
Humor
your stress
Overview
• Stress-initions
• Humor your stress
• Humor applied
– You and your patients
• Appropriate humor or not
• Where can I find humor?
Daily Stress
• Work
• Juggling Roles
– Parenting/super parenting
– Children
• Balance—Should: exercise, etc.
• Plugged-in
• Food
• Stress: good or bad
Causes of Stress
•
•
•
•
•
Fears Cause Stress
Uncertainty Causes Stress
Attitudes Cause Stress
Perceptions Cause Stress
Change Causes Stress
Today’s Grading Scale
Scale:
92 - 100% = A
80 - 91% = B
70 - 79% = C
60 - 69% = D
<60% =trouble
Personal Stress Inventory
Write it down…
• 1.
• 2.
• 3.
• 3a.
• 4.
What is stressful at this moment?
(the environment, the speaker, etc.)
What is stressful on a daily basis?
(your boss, schedule, bad hair day)
What is your favorite stress reliever?
What might be better?
How do you help your patients to deal
with stress?
1980’S
Definitions, continued
• Stress results from an imbalance between
demands and resources.
R.S. Lazarus and S. Folkman (1984). Stress,
Appraisal and Coping. New York: Springer.
• A simple definition that can be used is: Stress
occurs when pressure exceeds your perceived
ability to cope.
S. Palmer, 1999.
The Real Stress
Test
Stress Test
It's a simple test designed to indicate whether people have too much stress
in their life.
It's a picture of two dolphins. The two dolphins appear normal when
viewed by a stress-free individual. This test is not accurate enough to pick
up mild stress levels.
If there is anything that appears different about the dolphins (ignore the
fact of the slight color differences) it is often an indication of potential
stress related problems. Differences, if any, may also indicate the source of
your stress.
If there is anything out of the ordinary then you should consider taking
things a little easier..
Sit upright and viewing the screen head-on, take a deep breath, breathe
out and then look directly at the picture.
Warning signals
• "If it doesn't feel like fun anymore, that
should be a red flag," says Thomas J.
Weida, MD, an associate professor of
family and community medicine at Penn
State University's Milton Hershey
Medical School and medical director of
Penn State Community Health Center in
Hershey, Pa.
Family Practice Management / April 1997
CDC on Stress
• According to the
Center for Disease
Control, “Eighty-three
percent of all deaths for
adults between the age
of 21 and 65 are related
to lifestyle.”
Unmanaged stress is
increasingly a
characteristic of many
Americans today
• Health care
expenditures are
nearly 50%
greater for
workers who
report high levels
of stress.-Journal
of Occupational
and
Environmental
Medicine
• One-fourth of employees view their jobs
as the number one stressor in their lives.
-Northwestern National Life
Stress is an ignorant state. It
believes that everything is an
emergency. Nothing is that
important.
Natalie Goldberg
Repeat Heart Attacks Reduced by
Half over 3 years
•
•
•
•
•
•
Study Group: standard advice plus-relaxation
smiling at others
laughing at themselves
enjoying life
renewing religious faith
Friedman, M, Ulmer, D. (1984) Treating Type A Behavior-and Your Heart. New York: Knopf.
“I personally consider anger
the Achilles heel of heart
disease.”
Stephen T. Sinatra, MD
Sinatra, S. (1996) “Heartbreak and heart disease. A
Mind/Body Prescription for Healing the Heart.” Connecticut:
Keats Publishing, Inc.
"Comedy is tragedy
plus time."
-- Carol Burnett
Humor and Tragedy “911”
• Nothing to laugh about. Weeks?
• The Jokes are back: Late Night as our
Humor Barometer.
• Careful at first.
• Jokes focused NOT on the event, but our
reaction to the event.
• “When President Bush said that we should resume consumer
spending, I immediately went shopping. If I didn’t, they’d be
winning.”
Humor In Difficult Times
• Humor aimed at situations is appreciated by
others, it has a target other than another
person or group of people.
• humor aimed at oneself is well received by
others.
• Humor aimed at other individuals or groups
may be harmful. It often is used to put down,
insult, or degrade another.
How Does Humor Help Us?
• Humor reduces stress by helping us
to view the world with new
perspective.
• Humor helps us by replacing
stressful feelings with pleasurable
feelings.
• humor changes how we think & act.
• Acting
Hans Selye
• Adopting the
right attitude
can convert a
negative stress
into a positive
one
Man should not
try to avoid
stress any more
than he would
shun food, love
or exercise.
Dr. Hans Selye
Norman Cousins
Anatomy of An Illness (1979)
Stress: The confusion created
when one’s mind overrides the
body’s basic desire to choke the
living daylights out of some jerk
who desperately deserves it
Anonymous
Reality is the leading cause
of stress amongst those in
touch with it
---Lily Tomlin
• One of the most important things we can
do for patients is teach them about stress
management. Even better, we can learn
these lessons ourselves and then model
them for our patients.
Stress Management for the Patient and Physician
By David B. Posen, MD
The Canadian Journal of Continuing Medical Education, April 1995
How are we feeling today?
"LAUGHTER IS THE BEST MEDICINE"
• 75 percent of doctors would prescribe
laughter as a therapy
• 95 percent have seen the benefits of
laughter in working with patients.
http://www.polaroid.com.
Robert R. Provine,
professor of psychology, assistant director of
the neuroscience program at the University of
Maryland
• Laughter is about family, friends and lovers.
Less than 20 percent of everyday laughter is
a response to jokes. If people want to laugh
more, they should spend more time with their
significant others.
• The more the merrier. A large group laughs
more than a small one. Laughter almost
disappears when we are alone.
Robert R. Provine, continued
• Laughter is contagious. To laugh more, be
around laughing people. People don't need to
tell a joke to cause laughter. Laughter causes
laughter - which is why there are laugh tracks
on television comedies.
• Photography. Photos cause laughter by
crystallizing memories of life's special
moments with friends and family.
Five Things Humor Will
Do For You:
1. Releases negative emotions such as
anger & guilt
2. Improves enthusiasm for work
3. Reduces inhibitions & increases selfconfidence
4. Humorous people face life's problems
better
5. Sense of humor is the #1 romantically
attractive trait
Humor: Workin’ it
• Dr. Barbara Mackoff, St. Paul MN,
• book about women in the business
world, What Mona Lisa Knew, a guide to
getting ahead in business by lightening
up. A how-to guide to use humor
effectively in the work environment.
• Vera Story
Fear of Foolishness
Prayer:
God Grant Me the Senility to
Forget the People I Never
Liked Anyway, the Good Fortune
to Run Into the Ones I
Do, and the Eyesight to Tell the
Difference.
Humor Summary/Conclusions
Take yourself
lightly
Smile More
Cartoons
The
Last
Laughs
Self
Deprecating
Puns
Appropriate
Make someone
Your personal
else happy
Humor Plan
"From there to here,
from here to there,
funny things are
everywhere."
Dr. Seuss
Thank you
Kevin Lee Smith
www.kevinleesmith.com