Humour in Psychiatric Clinical Practice

Review Article Humour in Psychiatric Clinical Practice Kanwar Saurabh Singh*, Adarsh Tripathi**, Ajay Kohli* **CSM Medical university (Erstwhile KGMU), Lucknow & Lucknow Era s Medical College and Hospital, Lucknow* A cheerful heart is a good medicine, but a downcast spirit dries up the bones. Introduction Humour is used in a variety of therapeutic situations. With the benefits of a good belly laugh identified not only anecdotally but also by empirical research, the power of laughter and play is being discovered. However, there is paucity of rigorous empirical research on the effectiveness of this historically controversial form of clinical intervention. There is literature supporting the role of humour and laughter in areas, including patientphysician communication, psychological aspects of patient care, medical education, and as a means of reducing stress in medical professionals. 1 Even then this potentially significant psychotherapeutic resource, highly praised by some, remains insufficiently evaluated and underused in usual therapeutic settings. Humour is the tendency of particular cognitive experiences to provoke laughter and provide amusement. The term is derived from the humoral medicine of the ancient Greeks, which taught that the balance of fluids in the human body, known as humours, control human health and emotion. Laughter, which is a unique human attribute, is becoming rare as daily tensions of urban like life take their toll. Laughter however, is a valuable human experience and is now being accepted as a therapy to cure certain chronic ailments. Physiology Behind Laughter The physiology behind Laughter is that it s a combination of modified respiratory movements, 232 which can be described as an inspiration followed by much short convulsive expiration during which the rima glottides remains open and the vocal folds vibrate. This is accompanied by characteristic rhythm of movement and facial expressions. Furthermore, studies have shown that frontal lobe has an important role to play in humour appreciation. 2 Humour Development Paul McGhee has advanced a developmental theory of humour that explores the perception of an incongruous relationship as the basic foundation for all humour experiences. The table below summarizes ideas of how to implement humour or invoke the humour response in children and youth. 3,4 Humour in Medicine So is there any place of Humour/ Laughter in the medical sciences? Well, there are different schools of thoughts pertaining to the same. By definition, therapeutic humour includes both the intentional and spontaneous use of humour techniques by health care professionals, which can lead to improvements in the self-understanding and behaviour of patients. To be most helpful, the humorous point should have a detectable relevance to the client s own conflict situation or personal characteristics. Typically, the result is a positive emotional experience shared by the therapist and the client, which could range anywhere from quiet empathic amusement to overt loud laughter. There have been many studies conducted by researchers attributing humour and laughter to better health of the patients as well as the physicians

OCTOBER 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 Age Humour Response Developmental Issue Intervention 0 4 mon. Smiling Responds to sights, sounds Provide environment movements & feedings 4 8 mon. Laughter at physical level Discovering body movements, I m gonna get you... with active stimulation recognition of human face & voices Engage in physical contact 8 mon. 1 yr. Laughs when in contact Object constancy, Peek-a-boo, contact play with toys distinguishing between self with toys & non-self 1 2 yrs. Expectancy violations, Developing organized Mislabelling, playing with incongruent behaviour schemas of the world toys in a different way 2 4 yrs. Fantasy, make-believe, Mastery of motor skills, Play house, active play, slapstick, silly words & development of symbols to simple songs songs, bodily noises, direct represent the world, aware participationimportant of bodily functions, create novel stimulus 5 10 yrs. Riddles,first simple word Concrete operational thinking, Joke books, cartoons, will incongruencies can detect transitions & repeat over & over relationships 10 & over Sophisticatedjokes, wit, Peer relationships, individual Movie tapes, friendly wit satire,incongruent social personality & experiences and sarcasm behaviour important and also a better doctor-patient relationship. On the other hand, despite the popularity of humour therapy in the media and among some health care professionals, this treatment modality has not gained wide acceptance in mainstream medicine. In addition, two recent reviews criticized most of the studies in the field. Independently, Provine 5 and Martin 6 reached similar conclusions that the majority of humour research either negates or is insufficient to support the stated claims. Both authors noted that studies are often poorly designed, have inadequate controls, or involve sample populations that are too small to support their conclusions. Supportive Evidence The relationship between humour and health has been the subject of considerable medical study in the decades. There is now a moderate amount of evidence to suggest that a good sense of humour is positively associated with good general health 7 and may be negatively associated with certain conditions such as coronary heart disease. 8 It is also possible, although far from proven, that having a sense of humour may also be associated with longevity. 9 In terms of mental health, sense of humour is negatively associated with levels of worry 10 and related sleep disturbance 11, and may be positively associated with response to treatment in conditions such as post-traumatic stress disorder. 12 For professionals working in healthcare settings, sense of humour is positively correlated with ratings of empathic concern 13 and humour is often cited by healthcare workers as important for relaxation and avoiding burnout. 14 One study of aberrant medical humour by psychiatric unit staff identified two major categories of joking in this setting: whimsical and sarcastic. 15 Staff tended to engage in more sarcastic than whimsical joking and Sayre concluded that professionals need to recognise the potentially detrimental effects of joking behaviours on the effectiveness of treatment. The ability to understand and create humour is a higher order cognitive function that might elude some patients with mental illness. However, several studies have shown that very often, psychiatric patients are able to detect and appreciate humour. In one study, patients with schizophrenia were no different from controls in appreciating humour by identifying funny moments in four silent slapstick comedy film clips. However, the investigators did find that the patients were less sensitive than controls in detecting humour. 16 233

Another study found that patients with bipolar disorder were able to find humour in caption-less cartoons while they were in remission in comparison to the controls. 17 Humour in Patient-Physician Communication and Patient Care Review of importance of humour in family medicine sees humour as a means of narrowing interpersonal gaps, communicating caring, and relieving anxiety associated with medical care. On the other hand, patients use humour to express frustration with their health and with the medical establishment. When patients joke to the doctor, they not only let off steam but also reveal hidden agendas. Physicians should pay attention to these overtures and use them as jumping-off points to discuss a patient s deeper concerns. 18 Laughter is therapeutic with children as it helps relieve tension, increase curiosity, and give children a sense of mastery over their surroundings. 19 Humour also helps children overcome fear and anxiety associated with seeing the doctor. Young children respond to simple interactions such as tickling, playing peek-a-boo, and sharing small toys. Older children appreciate jokes and riddles and a type of office-based slapstick, such as getting caught up in curtains or making mistakes when palpating parts of the child s body. Studies have shown that patient satisfaction correlates with the length of visits 20, 21 and the emotional tone of medical encounters. 22 When patients think that they have connected with the physician, they are more satisfied with their care and are more likely to follow the doctor s advice. 23 Gross et al 24 found that patients feel less rushed if physicians spend even a brief time chatting with them. They concluded that physicians may improve patients sense that the doctor has given them adequate time by simply talking about the weather, telling a joke, or evoking conversation about something other than the health of the patient. Introducing humour and laughter into the health care setting is intended to improve a patient s mood and quality of life. It is equally important to use humour at the right time and place and to avoid humour that might alienate people. 25 For example, ethnic and sexist humour as well as sarcastic humour should not be used with patients. Humour should never be forced on patients, and volunteers are taught to be mindful that patients and family members may be coping with tragic news or grieving the loss of a loved one. Patients used humour as a coping mechanism to reduce the anxiety and frustration associated with being in the hospital the insecurity of being sick, having to deal with hospital routines and submission to authority figures, and the loss of control over bodily functions. In many cases, patients used jocular griping, which involves patients trading complaints about the hospital to let off steam and amuse each other. This behaviour served to socialize patients and allowed them to transform individual complaints into group pleasure. 26 Clinical Applications of Humour Once a preliminary trust has been established, it s been found that humour can appropriately be used to build rapport and relationship. Humour can also be used to decrease pain and anxiety and promote health. Humour in therapy can: create a more relaxed atmosphere encourage communication on sensitive matters be a source of insight into conflict help overcome a stiff and formal social style facilitate the acting out of feelings or Therapeutic Benefits of Laughter Physical Mental Social Boosts immunity Adds joy and zest to life Strengthens relationships Lowers stress hormones Eases anxiety and fear Attracts others to us Decreases pain Relieves stress Enhances team work Relaxes the muscles Improves mood Helps diffuse conflicts Prevents heart disease Enhances resilience Promotes group bonding 234

OCTOBER 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 impulses in a safe, non-threatening way To achieve these outcomes one can build on the ideas on the clinical application of humour. Ask a child his or her favourite joke technique: Children often use humour as a means of working out fears, anxieties, and conflicts. This technique may serve as an insight into the child s issues. Use humour to poke fun at yourself: Selfdirected humour can narrow the gap between the physician and the child/youth. An example would be telling a funny story about yourself, keeping in mind the appropriate use of self-disclosure. You might then get the child/youth to tell a funny anecdote about themselves. Modelling humour can allow those you work with to become encouraged by your positive attitude. Role reversal (changing positions with the child/youth) can provide insight along with hilarity: Along the same vein, acting out characters can be entertaining and enlightening. If a child feels too threatened to do this, puppets or dolls can be used. The addition of props, costumes, or dressing up may also help this technique be approached in a more fun, less intimidating way. Cautions The strongest advocates of using humour in therapy also remind us that certain cautions in its use are appropriate. One must remember that use of humour and laughter in therapy is not a goal in itself but one option for facilitating therapy. The patients and care givers are very distressed during visit to clinician. Some patients do not appreciate humour, and it can be counterproductive to use it in their presence. Also, if a child is ill or the parent is distressed or angry, humour should be avoided. In fact, to force humour by a therapist, uncomfortable or inexperienced in humour techniques would be unwise and counterproductive. For example, the inappropriate use of satire could lead to a patient feeling humiliated or ridiculed; or the inappropriate use of exaggeration or the telling of a formal joke might create the impression that the therapist is insensitive or uncaring or excessively self-absorbed. A strong therapeutic alliance and good understanding about the ability to use it constructively is needed. The success of therapeutic humour relies heavily on spontaneity. Understanding one s own personality, clinical situation and gauging patient s ability to appreciate humour are important determinant of its effective use in clinical practice. Conclusion Given humour s potential therapeutic benefit for clients, it seems prudent to recommend that the use of humour in therapy might be incorporated to ease difficult clinical situations. Some debate remains about whether the application of humour by therapists can even be taught. Olson (1994) 27 claimed that, like responsibility, humour cannot be taught didactically, but must be observed and personally experienced to be mastered. To encourage a humorous outlook in our patients, therapists must keep that dimension alive in them. Therapists must continually engage in selfmonitoring regarding why they are employing a particular intervention humorous or otherwise to ensure that it indeed is enacted for the patient s benefit and not for self-gratification. So keep laughing and make people laugh with you. A Day Without Laughter is a Day Wasted Charlie Chaplin References 1. Bennett HJ. Humour in medicine. South Med J 2003; 96 : 1257-61. 2. Mathew MF. Laughter is the best medicine: The value of humour in current nursing practice. Nursing J India; July 2003; 94 : 146. 3. McGhee P. Humor: Its origin and development. San Francisco: W.H. Freeman, 1979. 4. McGhee P. Humor and children s development: A guide to practical applications. New York: Haworth Press 1980. 5. Provine RR. Laughing your way to health, in Provine RR: Laughter: A Scientific Evaluation. NewYork,Viking, 2000, 189 207. 6. Martin RA. Humor, laughter, and physical health: Methodological issues and research findings. Psychol Bull 2001; 127 : 504 519. 7. Boyle GJ, Joss-Reid JM. Relationship of humour to health: a psychometric investigation. Br J Health Psychol, 2004; 9 : 51 66. 8. Clark A, Seidler A, Miller M. Inverse 235

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