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_____?150-400 150-400 times per daytimes per day

Laughs per Day90

80

70

60

50

40

30

20

10

0

ChildrenGrown ups

150-400

Fake Graph, Smith 2004 ;43 (2), Imaginary Journal

15

Kids

Adults

Now I get it!

Laughs per DayLaughs per Day

Another Fake Graph, Smith 2005 ;43 (2), Imaginary Journal

WhyDo We Laugh?

WhyDo We Laugh?

WhyDo We Laugh?

WHY DO WE LAUGH?

•Surprise•Superiority•Incongruity•Release

Spontaneous vs. FormalSpontaneous vs. Formal

Self deprecating HumorSelf deprecating Humor

Puns & Plays on WordsPuns & Plays on Words

Types/Styles of HumorTypes/Styles of Humorwhat is your style?what is your style?

Sarcastic HumorSarcastic Humor

Slapstick HumorSlapstick Humor

Ethnic HumorEthnic Humor

Gallows HumorGallows Humor

Types/Styles of HumorTypes/Styles of Humorcontinuedcontinued

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

“I couldn’t be two faced, if I was, I sure wouldn’t wear this one.”

--Abraham Lincoln

Self deprecating Humor

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 HumorSt. 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 ResponseReview of Literature/Humor Response

• Sense of Humor acts as a moderator of Sense of Humor acts as a moderator of daily hassles on Salivary IgA (p<.05) daily hassles on Salivary IgA (p<.05) (N=40) (Martin, et al., 1988) (N=40) (Martin, et al., 1988)

• Exposure to a humorous video produced Exposure to a humorous video produced significantly (p<.005) increased levels significantly (p<.005) increased levels of SIgA (Lefcourt, et al., 1990)of SIgA (Lefcourt, et al., 1990)

Modulation of Neuroimmune Prameters During the Eustress of Humor-associated 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) 190Bin 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 patientsOptimism and survival in lung carcinoma patientsCancer. 2004 Mar 15;100(6):1276-82.

"A merry heart doeth good like a medicine: but a broken spiritdrieth the bones." Proverbs 17:22

“New clinical studies show there aren’t any

answers.”

author unknown

"I hate quotations."

Ralph Waldo Emerson

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

•Stimulates Alertness and Memory

•Enhances Learning and Creativity

•Promotes Relaxation

Psychological Effects of Laughter, Psychological Effects of Laughter, cont.cont.

• Promotes Shift From Negative to PositivePromotes Shift From Negative to Positive

• Outlet for Expressing FeelingsOutlet for Expressing Feelings

• Effective Mode of CommunicationEffective 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

OPPORTUNITYISNOWHERE

96% of Executives Choose Employees With Sense of Humor

CreativeCreative

Good Good CommunicatorsCommunicators

Team playersTeam players

Stress Stress RelieversRelievers

Based on study done by Hodge Cronin and Associates

The Creative Group, A Robert Half International Company, 2004

AATH Official DefinitionTherapeutic 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 UniversityEndorsed by AATH

What we KnowHumor

• 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 KnowLaughter

• Increases pain tolerance (examples)• Improves respiration and breathing• Improves mental function• Exercises facial, abdominal, and chest

muscles• Relaxes muscles/decreases muscle

tensionAssociation for Applied and Therapeutic Humor, 2004

What We Don’t Know YetHumor

• Decreases symptoms of illness

• Enhances relationships, intimacy, and marriage satisfaction

• Increases lifespan

Association for Applied and Therapeutic Humor, 2004

What We Don’t Know YetLaughter

• 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,

Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack Coulehan, MD, MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.

"Good morning. Looks like you ate well. Why didn't you leave

any for me?"

The patientThe patient

chuckles.chuckles.

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,

Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack Coulehan, MD, MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.

"I would, except it'd"I would, except it'd be be bad for business–I bad for business–I wouldn't get any more wouldn't get any more follow-upfollow-up visits out of visits out of you."you."

• As the tardy physician enters the examination room, the patient sneers,

Humor in Action:Destructive Patient-Generated Humor

Humor in the Physician-Patient Encounter Jeffrey T. Berger, MD; Jack Coulehan, MD, MPH; Catherine Belling, PhD Arch Intern Med. 2004;164:825-830.

"You must have been out playing golf again!"

Humor: peeling Humor: peeling back some back some layers?layers?

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.

© 2004 By Defaulthttp://www.powerpointbackgrounds.com

Survival of the Wittiest:

Humoryour stress

Survival of the Wittiest:

Humoryour stress

OverviewOverview

• Stress-initions

• Humor your stress

• Humor applied– You and your patients

• Appropriate humor or not

• Where can I find humor?

• Stress-initions

• Humor your stress

• Humor applied– You and your patients

• Appropriate humor or not

• Where can I find humor?

http://g.msn.com/0US!s5.31472_315529/26.a7111/1??cm=BBSlide1

Daily StressDaily Stress• Work• Juggling Roles

– Parenting/super parenting– Children

• Balance—Should: exercise, etc.• Plugged-in• Food• Stress: good or bad

• Work• Juggling Roles

– Parenting/super parenting– Children

• Balance—Should: exercise, etc.• Plugged-in• Food• Stress: good or bad

Causes of StressCauses of Stress

• Fears Cause Stress

• Uncertainty Causes Stress

• Attitudes Cause Stress

• Perceptions Cause Stress

• Change Causes Stress

• Fears Cause Stress

• Uncertainty Causes Stress

• Attitudes Cause Stress

• Perceptions Cause Stress

• Change Causes Stress

Today’s Grading ScaleToday’s Grading Scale

Scale: 92 - 100% = A80 - 91% = B70 - 79% = C60 - 69% = D<60% =trouble

Scale: 92 - 100% = A80 - 91% = B70 - 79% = C60 - 69% = D<60% =trouble

Personal Stress InventoryWrite it down…Personal Stress InventoryWrite it down…

• 1. What is stressful at this moment?

(the environment, the speaker, etc.)• 2. What is stressful on a daily basis?

(your boss, schedule, bad hair day)• 3. What is your favorite stress reliever? • 3a. What might be better?• 4. How do you help your patients to deal

with stress?

• 1. What is stressful at this moment?

(the environment, the speaker, etc.)• 2. What is stressful on a daily basis?

(your boss, schedule, bad hair day)• 3. What is your favorite stress reliever? • 3a. What might be better?• 4. How do you help your patients to deal

with stress?

1980’S

Definitions, continuedDefinitions, 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. 

• 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 The Real 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.

Stress Test

Warning signalsWarning 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.

• "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 StressCDC 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

• 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

• 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

• 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.

Stress is an ignorant state. It believes that everything is an emergency. Nothing is that

important. Natalie GoldbergNatalie Goldberg

Repeat Heart Attacks Reduced by Repeat Heart Attacks Reduced by Half over 3 yearsHalf over 3 years

• Study Group: standard advice plus-Study Group: standard advice plus---

• relaxationrelaxation

• smiling at otherssmiling at others

• laughing at themselveslaughing at themselves

• enjoying lifeenjoying life

• renewing religious faithrenewing religious faith

Friedman, M, Ulmer, D. (1984) Treating Type A Behavior--and Your Heart. New York: Knopf.

““I personally consider anger I personally consider anger the Achilles heel of heart the Achilles heel of heart

disease.”disease.”Stephen T. Sinatra, MDStephen T. Sinatra, MD

Sinatra, S. (1996) “Heartbreak and heart disease. ASinatra, S. (1996) “Heartbreak and heart disease. A

Mind/Body Prescription for Healing the Heart.” Connecticut: Mind/Body Prescription for Healing the Heart.” Connecticut:

Keats Publishing, Inc.Keats Publishing, Inc.

"Comedy is tragedy "Comedy is tragedy plus time."plus time."            

-- Carol Burnett-- Carol Burnett

Humor and Tragedy “911”Humor and Tragedy “911”• Nothing to laugh about. Weeks?Nothing to laugh about. Weeks?

• The Jokes are back: Late Night as our The Jokes are back: Late Night as our Humor Barometer.Humor Barometer.• Careful at first.Careful at first.• Jokes focused NOT on the event, but our Jokes focused NOT on the event, but our

reaction to the event.reaction to the event.• ““When President Bush said that we should resume consumer When President Bush said that we should resume consumer

spending, I immediately went shopping. If I didn’t, they’d be spending, I immediately went shopping. If I didn’t, they’d be winning.”winning.”

Humor In Difficult TimesHumor In Difficult Times• Humor aimed at situations is appreciated by Humor aimed at situations is appreciated by

others, it has a target other than another others, it has a target other than another person or group of people.person or group of people.

• humor aimed at oneself is well received by humor aimed at oneself is well received by othersothers..

• Humor aimed at other individuals or groups Humor aimed at other individuals or groups may be harmful. It often is used to put down, may be harmful. It often is used to put down, insult, or degrade another. insult, or degrade another.

How Does Humor Help Us?How Does Humor Help Us?• Humor reduces stress by helping us Humor reduces stress by helping us

to view the world with new to view the world with new perspective.perspective.

• Humor helps us by replacing Humor helps us by replacing stressful feelings with pleasurable stressful feelings with pleasurable feelings.feelings.

• humor changes how we think & act.humor changes how we think & act.

• ActingActing

Hans Selye Hans Selye

• Adopting the right attitude can convert a negative stress into a positive one

• 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

Man should not try to avoid stress any more than he would shun food, love or exercise.Dr. Hans Selye

Norman CousinsNorman Cousins

Anatomy of An Illness (1979)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

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 Anonymous

Reality is the leading cause of stress amongst those in

touch with it

Reality is the leading cause of stress amongst those in

touch with it

---Lily Tomlin ---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.

• 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 PhysicianBy David B. Posen, MDThe Canadian Journal of Continuing Medical Education, April 1995

How are we feeling today?How are we feeling today?

"LAUGHTER IS THE BEST MEDICINE""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.

• 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

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.

• 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, continuedRobert 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.

• 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:Five Things Humor Will Do For You:

1. Releases negative emotions such as anger & guilt

2. Improves enthusiasm for work 3. Reduces inhibitions & increases

self-confidence 4. Humorous people face life's

problems better 5. Sense of humor is the #1

romantically attractive trait

1. Releases negative emotions such as anger & guilt

2. Improves enthusiasm for work 3. Reduces inhibitions & increases

self-confidence 4. Humorous people face life's

problems better 5. Sense of humor is the #1

romantically attractive trait

Humor: Workin’ itHumor: 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

• 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 FoolishnessFear 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.

Smile More

Appropriate

Humor Summary/Conclusions

Puns

Your personalHumor Plan

Make someone else happy

CartoonsSelfDeprecating

The The Last Last

LaughsLaughs

Take yourself lightly

"From there to here, from here to there, funny things are everywhere." Dr. Seuss

Thank youThank you

Kevin Lee Smith

www.kevinleesmith.com