Have we Forgotten about Humour?

A. Abyad, MD, MPH, MBA, AGSF, AFCHSE
CEO/ General Manager, Social Services Association
Abi Samra Tripoli
Tel 00961-06-446334

INTRODUCTION

There are several definitions of humour. Webster's Encyclopaedia Dictionary⁽¹⁾ defines humour as temperament, disposition, mood, or a turn or frame of mind. The archaic definition of humour (humour) is listed as moisture or vapour. The word humour acquired its definition from the medieval doctrine that a domination of any of the four principal fluids (blood, phlegm, yellow bile, and black bile) ascertains a person's character. Consequently, a balance of fluids would result in "good humour" and an imbalance would lead to "ill humour."⁽²⁾ From the medieval interpretation of humour, the definition has grown into a more special term that refers to that attribute in individuals that produces the entertaining, the funny, the amusing, the laughable, the facetious, the comical⁽³⁾.

A sense of humour may be perceived in three ways⁽⁴⁾. Firstly, the significance of humour can be one of congruity, that is , someone who laughs at the same matter
others do; secondly, humour may be seen in quantitative terms such as the periodicity with which a person laughs, smiles, or becomes readily amused; and thirdly, humour may allude to the extent to which the person tells funny jokes and amuses others. Humour was described as a means of conversation widely used by individuals as a coping mechanism in a diversity of situations, including the health-care system⁽⁵⁾. Others⁽⁶⁾ define humour as " communication with the unconscious to gain strength for the reality we live in."

EFFECTS AND FUNCTIONS

Norman Cousins^(7,8) lately described how he cured himself with the use of humour after he was diagnosed with a collagen disease in 1964, and he has continued to stress the significance of positive emotions in recovering from diseases. Currently, there is a mounting interest in humour by health professionals, who presume humour has therapeutic worth. To date, humour has been examined from infancy through to adolescence, but minimal research has been done on humour from the developmental viewpoint of the older adult.

Since humour is remarkably individual, it has been defined in terms of its functions. In an extensive critique of the use of humour by health professionals with particular reference to nursing, Robinson⁽²⁾, identified four functions of humour, relevant to the health of the client which covered communicative, social, psychological, and physiological factors. Humour is described as a way of indirect interaction that conveys messages that are generally emotionally tinged, and potentially inappropriate if expressed directly⁽⁵⁾. Thus, humour is used to establish relationships with clients to assure a feeling of faith with health care providers.

In a sociological potential, humour helps in coping with external pressures. For example, the hospital is a social institution where the codes of society are often modified. Humour provides a way for coping with uncomfortable situations and organizational expectations imposed by hospitalization. It helps in substantiating the patient/staff alliance and decreases anxiety in an unusual surroundings⁽²⁾. The psychological functions of humour connect to coping with stress because it provides freedom from anxiety, tension, hostility, and anger^(2,9). The decrease in these emotions encourages a sense of relaxation, well-being, and the capacity to adjust to stressful situations. Moreover, a number of authors have viewed humour as an adaptive coping mechanism. May R⁽¹¹⁾ states that humour has the function of preserving the sense of self... it is the healthy way of feeling a distance between ones self and the problem, a way of standing off and looking at one's problem with perspective. Whereas Freud, regarded humour as "the highest of defensive processes."⁽¹⁰⁾. According to Freud, humour provides a savings of emotional energy.

Humour also has physiological functions. Fry's research on the physiological effects of laughter has been the most extensive to date^(11,12). He studied the effects of laughter on heart rate, oxygen saturation levels of peripheral blood, and respiratory phenomena and found that both the arousal and cathartic effects are present in physiological reactions. Laughter augments respiratory activity and oxygen exchange, muscular activity and heart rate, the sympathetic nervous system, and the production of catecholamines (which stimulate the production of endorphins).

The arousal state is followed by a relaxation state in which respiration, heart rate, and the muscle tension return to below normal levels. In this relaxed state, blood pressure is reduced and a state similar to that brought about by exercise exists. Fry concluded that humour is helpful in physical health, in particular in relation to prevention of heart disease and other stress-related conditions.

HUMOUR AND HEALTH

The information concerning the healing power of humour is anecdotal in nature, in its majority. For example, the only documented report of healing through the use of humour is that of Norman Cousins^(7,8), who used programmed sessions of laughter to induce pain-free sleep, lower his sedimentation rate, decrease paralysis, and help in his recovery from ankylosing spondylitis. Although the use of humour was a part of his "treatment," Cousins was also taking large doses of Vitamin C intravenously in order to recouperate.

There are several studies that have investigated the use of humour by health care professionals. The researchers noticed that humour contributed to the staff's role accomplishment since it provided an escape to discharge tension. One of the nurses said, "You could not work in this place without laughing or you would go crazy."⁽¹³⁾. Warner⁽¹⁴⁾ did a study of how health visitors used humour in child health clinics in London. Content analysis of tape recordings depicted that normally the healthy visitor started the humour especially when there was a possibility for discord. By using humour, health visitors permitted clients to exercise power in determining the direction of conversation. It was concluded that humour helps to appease health visiting goals which otherwise may be unachievable. These positive attitudes toward humour by health professionals were validated in a study by Sumners⁽¹⁵⁾, which described the attitudes toward humour held by the baccalaureate nurses in Texas. The results indicated that the attitude toward humour was positive in their work lives but more positive in their personal lives. These findings indicate that nurses value humour in both their professional and personal lives. Moreover, several studies have concentrated on humour as used with clinical populations. Trutt⁽¹⁶⁾ considered the relationships between humour, taste, 9Abdul did you mean 'type of humour' by the word 'taste' ?0locus of control, assertiveness, and reactions to stress in male oncology patients. The results indicated that the psychological factors investigated were not important predictors of type of humour preference. A number of studies^(17,18) have shown the stress buffering role of humour. Other studies^(19,20) have not supported the hypothesis that humour moderates the effects of stress.

HUMOUR AND AGING
Developmental Perspective

Successful aging refers to an individual's capability to adjust to or accommodate the aging process. With successful aging, an individual is apt to persevere an equilibrium between the psychophysiologic capacities of the person and the present social surroundings. If a balance is not maintained, then stress ensues. How the person handles stress determines the degree of "success" of the aging person⁽²¹⁾. The adult's sense of "success" or well-being, therefore, is dependent mainly on the adult's ability to appreciate his/her present position with all of its limitations and divert energy for growth and developmental experiences.

From a developmental view, the older adult is an exceptional population to describe in respect to the study of humour. As an individual masters divers conflicts at distinct developmental stages, the person's sense of humour grows. Thus, humour is perceived as a sign of having attained depth and maturity, for a sense of humour reveals the ego's autonomy and discord⁽⁶⁾. Moreover, humour, patience, artlessness, stamina, and prudence seem to be associated with each other in the developed personality^(22,23).

Many scholars are curious in pinpointing what lead to successful aging. One theory of psychosocial aging is the "activity theory" which states that to age successfully one must persevere with many of the roles and performance patterns of middle age for as long as possible⁽²⁴⁾. Whereas the "life satisfaction theory" assumes that a person has aged successfully if he/she feels happy and fulfilled with their past and present life. The stress on quality of life has connotations for the value of humour in the aging process. Vaillant G⁽²⁵⁾ (as one result of his findings of a longitudinal study of Harvard graduates begun in 1939) identified humour as one of the five mature coping mechanisms available to humans for successful dealing with inconvenient situations. This study, which followed 268 Caucasian men over a period of 30 years, measured adjustment in work, social, psychological and medical areas. Vaillant stated, "Humour is one of the truly elegant defences in the human repertoire ". Few would dispute that the capacity of humour, like hope, is mankind's most mighty antidotes of the woes of Pandora's box.

The concept of neoteny was discussed⁽²⁶⁾, which is the withholding of those human traits associated with childhood that extend into adult life, or, in other words "growing young." These physical and behavioural traits have a role in the development of humans. The sense of humour is innate in children since it is detected as early as six weeks of age. Montagu states "The sense of humour enlarges our perspective upon the world, and humour gives us an interior perspective upon ourselves"⁽²⁶⁾. To be able to laugh at oneself is rather more dear than the ability to laugh at others. Clearly humour is one of our greatest and earliest intrinsic resources." Thereby, Montagu contends that development of the neotenous needs of the child will lead to a healthy and satisfied adult⁽²⁶⁾.

Depression

The valuable effects of humour and laughter, have been documented since Biblical times. However, the difficulty with the depressed and suicidal elderly is that their hearts are heavy, not merry, and their cheerful expression may cover up an inner despair.

Laughter offers one answer. As Gorden once said, "The neurotic who learns to laugh at himself may be on the way to cure"⁽²⁷⁾. Experiences with elderly patients also propose that the suicidal person who can laugh at himself or herself, may be on the way to self-acceptance, perhaps to the acceptance of life. Humour, therefore, may save a life if the person is suicidal. For those who are not suicidal, humour will make life richer and more significant

Goldstein, noted that there is "relatively little hard evidence covering the effect of laughter and humour"⁽²⁸⁾. The elderly have been mainly abandoned. To learn about the life-saving effects of a sense of humour, one must turn to the great literary figures rather than the professional literature. For example, Dickens wrote a little fantasy in Nicholas Nicklebly, about a baron who was in a state of complete hopelessness and despondency. He was visited one night by a demon, who introduced himself as "the Genius of Despair and Suicide," and who encouraged the man to kill himself. At one point, however, the baron began to laugh. His laughter caused the "Spirit of suicide" to disappear. I suspect that this story, inserted almost irrelevantly into the novel, was a symbolically autobiographical statement by Dickens.

Humour is a function of the treatment approach of the therapist. For example, it is interpretable in psychoanalytic therapy, and based upon reinforcement, guided imagery, and other behavioural methods in behaviour therapy. As Goodchilds said, "humouris a phenomenon pre-eminently interactive, imminent, impromptu"⁽²⁸⁾. This is why roughly half the humour originated with the patient and half with the therapist.

Elderly clients are usually responsive to humour during therapy, and become more active contributors in the treatment process. Humour may have permitted many of them to survive as long as they did. The therapeutic and lifesaving function of humour may be particularly true of the elderly due to their gift for storytelling⁽³⁰⁾. Storytelling is the basis of the life review⁽³¹⁾, and of humour.

The dissimilarity between laughing with and laughing at is a valid one. A good rule of thumb for the therapist is when in doubt, don't. Many patients can feel put down by humour and believe that they are the objects of condemnation and rejection. The vigilance by Kubie⁽³²⁾ and others regarding the dangers and possible negative results of the use of humour in therapy are well taken. It is critical to remember that the elderly in a state of hopelessness and despair may be down but not out. Humour reflects a positive view towards life, designed to replace disgust and despair by ego integrity and affirmation⁽³³⁾.

Research Studies

The humour phenomena within older adults merits further investigation. To date, very few studies have examined humour and the older adult. A pilot study was conducted to determine the effect of humour on the recovery rate of elderly patients following inpatient cataract surgery. A sample of 20 subjects was selected to rate 15 jokes for degree of funniness. The results indicated that men rated the jokes funnier than women. Furthermore, a positive relationship existed between the length of hospital stay and humour scores for males but not for the females⁽³⁴⁾. (Abdul - this is because women have a totally different sense of humour! to men, - that is a learned comment as I do television comedy shows)

A study designed to investigate adaptation to physical disability⁽³⁵⁾ investigated 30 disabled persons ranging in age from 18 to 78 years. Subjects were shown two disability-relevant cartoons and observed for their reactions. Results indicated that subjects who laugh at these cartoons were better functioning individuals; that is, they demonstrated much vitality and higher self-concept. The subjects with a higher degree of humour also had the disability for a longer time; therefore, more experience with disability played an important role in coping with it.

A program of humourous activity was started to explore the association between the activity and subjective well-being of senior adults⁽³⁶⁾. Using a quasi-experimental, pre post test design, one group (N=30) of senior adults were involved in a program of humourous activity, while another group (N=30) of seniors served as a control group, of six weeks. The results indicated that mood levels increased markedly in association with group activity and especially with humourous activity. With the above finding, which were supported by qualitative findings, a connection between humourous activity and subjective well-being was found, lending support to the value of the humour program.

NURSING IMPLICATIONS

There are implications for nursing practice with elderly clients who are in both community and institutionalized settings. In both settings, there are several means where humour may be incorporated into structured activities. For example, videotapes of old comedies such as the Keystone Cops and the Marx Brothers may be seen as well as modern comedies. Other people, such as comedians and clowns from local college music and theatre departments, may be invited to perform humourous skits. In addition, old radio programs such as those of George Burns and Gracie Allen may be heard in groups. This encourages communication among older adults to remember the past and includes individuals who may be visually impaired.

Another method to advance humour and play, is to coordinate adult non-competitive games as illustrated by Weinstein and Goodman⁽³⁷⁾. These authors encourage non-competitive play as a way to have fun and provide a sense of community among participants. They have discovered that adults are usually open to have fun but sometimes wait for "permission" in order to do so. The elements that are incorporated into the non-competitive games include the following: humour, collaboration, positive action, inclusiveness, imagination and openness, equality, individuality, sense of challenge and fun. For example, "birthdays" is a game in which people assemble in groups according to the month of their birthdays. Each group has a minute to acquire a group cheer for their month. Starting with January, each group will do its cheer and sit down until December is completed and then all the groups will give themselves a standing evaluation. Thus this game encourages group spirit, positive feelings, and entertainment.

Humour also may be started by the older adult. Humour is perceived by multiple authors as a health-promotion activity based on the research that supports its physiological and psychological benefits^(11,12,18). Humour as a positive behaviour then may be promoted by the nurse to reduce stress and increase positive feelings. Awareness of humour and humourous situations in the environment should be encouraged. Older clients need to identify what humourous communications (joke books, cartoons, movies, etc.) and situations work for them. Once older clients know what situations yield laughter, clients then are able to have some command and are able to provide a "laugh a day."

Nurses need to also consider humour as a conversation tool with clients. Similar to other interventions, humour needs to be assessed as suitable to the client and the situation. Humour as stated by the nurse may attest to the client understanding due to a similar experience or a mutual bafflement. In this way, humour helps to put stressful situations into perspective. Therefore, the nurse should not be apprehensive to let the playful and cheerful dimensions of his/her personality come out. In this sense, the nurse is truly implementing the "therapeutic use of self" clients.

While there are many positive aspects connected with humour, negative forms of humour also exist. When considering the suitability of humour, the factors of timing, receptiveness, and content should be assessed⁽³⁸⁾ For example, when anxiety and stress is strong, humour will not be appropriate until the crisis subsides. It is also important to individualize the types of humour in interactions with others and to set the degree to which the individual values or appreciates humour.

Lastly, it is crucial to contemplate the content of the humour. Humour is destructive if practiced in a way that ridicules people. Sensitivity to the client's values and problems is important in order to not insult inadvertently. Therefore, the nurse must be certain not to laugh at clients, but with them.

CONCLUSION

There are several physiological and psychological benefits to clients in humour, and is seen as an important refinement by older adults. Based on research and other scholarly views, humour is a suitable method to encourage with older adults in both community and long-term care settings. Nurses need to think about humour as a communication tool to decrease tension and demolish barriers between nurses and older clients.

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