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55 AUGUST 2003
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The healthful effects of laughter

Christine Puder

Humour and laughter are being increasingly used in a variety of therapeutic situations. Research into the use of therapeutic humour tells us it has the power to motivate, alleviate stress and pain, and improve one’s sense of well being. This article provides the reader with background information on the healthful effects of laughter. Ideas are presented on how to use humour systematically when working with children, youth, and families. The developmental aspects of humour are also addressed. Finally, resources for the therapeutic use of humour are provided.

Humour is increasingly 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.

My own experiences as a hospital-based child life specialist have involved using humour as a therapeutic tool with children and youth. As my career progressed and I administrated a child life department, I was able to develop the potential for using humour systematically through the creation of laughing stations and a hospital clown program.

Over the years I have researched related literature to help promote humour in a hospital setting. I am sharing this information in the hope that you will feel comfortable using humour in your own settings, in the therapeutic relationships you have with children, youth, families and with your colleagues. The healthful effects of laughter will be explored first. The recent use of humour and related programs will be discussed. Key considerations such as appropriateness and clinical applications will be shared. Finally, developmental aspects of humour will be outlined, along with resources you can access.

Healthful effects
Have you ever noticed how relaxed and good you feel after laughing at a funny movie, television program, or humorous event? It seems generally accepted that our bodies respond in a positive way to a hearty laugh. Articles in the popular press and medical journals frequently report that laughter, like exercise, can reduce stress, improve tolerance to pain, and alter bodily functions such as blood pressure, heart rate, muscle activity, and stomach acidity.

One of the most publicized testimonials comes from a founder in the therapeutic use of humour, Norman Cousins. In Anatomy of an Illness (1979), a moving account of battling a painful, crippling disease, Cousins found that 10 minutes of belly laughter enabled him two hours of pain-free sleep. Eventually Cousins recovered from ankylosing spondylitis, later attributing much of his recovery to the power of spirit and laughter. This baffled authorities and inspired many others as he began to write about his remarkable healing process.

Dr. William Fry, associate professor of clinical psychiatry at Stanford University, has studied the effects of laughter for 30 years. Fry compares laughter to “inner jogging," and claims laughing 100 times a day is the equivalent of 10 minutes of rowing (Fry, 1977, 1979; Fry & Salameh, 1987). According to Fry, laughter increases the heart rate, improves blood circulation, and works muscles all over the body.

Laughter is credited with increasing the release of endorphins, the body’s natural painkillers and protectors against depression. Although the physiology and molecular biology of these traits (laughter and play) are far from understood, we do have good reason to believe that the operation and effects of those factors follow certain paths, such as the secretion of endorphins in the brain and the action of similar physiological factors upon virtually every system of the body, and, of course, upon behaviour (Montague, 1991).

In the Department of Clinical Immunology at Loma Linda University School of Medicine, studies have shown that laughter decreases serum cortisol levels, increases T lymphocytes, and increases the number of natural killer cells. Translated into layman's terms, these results suggest that laughter stimulates the immune system (Berk, 1989; Pelletier & Herzing, 1989). It has also been demonstrated that humour and laughter have a psychological impact. Herbert Lefcourt, a psychologist at the University of Waterloo, studies the effects of humour on change and our emotional response to stress. Results of his work have shown that the ability to sense and appreciate humour can buffer the mood disturbances that happen in response to negative life events (Lefcourt, 1986, 1990).

Where the concept has been popularized
The systematic or planned use of humour as a tool/skill has predominantly been applied in two distinct settings: the medical field and business/workplace environments. Known to both improve pain tolerance and decrease the experience of pain, humour has been used extensively with adult arthritis and cancer patients. Both patient types suffer from a high degree of pain during the course of their illnesses. Regular doses of humour have proven to be beneficial to the patient’s sense of well-being, ability to tolerate pain and painful procedures, and general demeanor and outlook. In simplest terms, they were able to cope and adjust better (Cousins, 1979).

From adult patient care, the use of humour has spread to pediatric hospitals. Here humour has been used as an individual intervention helping young patients cope with difficult moments, or as an organized program that benefits groups of patients and families. In pediatric settings, unlike adult care, the use of humour has typically not been limited to patients with specific diagnoses; rather it has been used for all ages and stages of children and youth, regardless of the nature of their illness or reason for hospitalization.

The impact of stress on personal health has lead to humour being incorporated into the workplace. The high cost of burnout and stress-related illness accounts for a significant percentage of sick days in North America. In business, managers are learning the advantages of using humour. Happier, healthier employees work better. Humour improves employee creativity, communications and wellness, while reducing burnout. The result equals organizational renewal and greater effectiveness (Fahlman, 1996). Many organizations these days provide workplace training or inservices on “how to" introduce humour in the work environment. Indeed a whole new profession of “humour consultants" has been a by-product of the interest in laughter.

Range of projects
In business and the workplace employees are sometimes shown how to introduce humour into their personal/professional life. Typically either a consultant is brought in to do a workshop, or employees attends a conference/seminar on humour. The result is that the workplace becomes an environment where specific strategies can be used to decrease stress and increase feelings of “team." The ways to actively develop humour often include but are not limited to ideas like:

The message is that a good laugh shared by office workers or colleagues doesn’t necessarily take much time from the workday. The pay-off is that it can improve the environment/climate and leave people feeling rejuvenated.

In a hospital setting, humour projects have taken the form of humour rooms, humour carts, or clown care programs. A number of hospitals and related institutions have created humour rooms. The humour room is stocked with books, comics, funny posters, audiotapes, and videos. At the Alta Vista Lodge, a cancer facility at the Ottawa Civic Hospital, patients can access the humour room 24 hours a day. In an extension of the humour room concept, hospitals with closed-circuit television capability can broadcast comedy into patient rooms. The Foothills Hospital in Calgary is working to develop the first Canadian laughter channel at its organization.

When patients are isolated or immobilized, or space is limited, the humour cart can extend the notion of the humour room to the bedside. Typically an audiovisual cart or other form of trolley is stocked with assorted humour supplies and made available to patients. Books, audiocassettes, and funny movies are included as well as gag materials. At British Columbia’s Children's Hospital we included costumes, makeup supplies, puppets, and practical jokes like whoopee cushions. These items proved to be used even more than the standard humour room supplies. The children eagerly engaged in costuming themselves and others, or playing practical jokes on staff. When you see the pleasure a child derives from fooling his or her nurse or doctor, one can appreciate the therapeutic benefit from humour in action. It empowers children at a time when they are vulnerable and anxious and have minimal control over what is happening. Usually humour carts (AKA laughing stations) are either moved from room to room by trained volunteers or accessed by asking a nurse or child life specialist to bring one to an individual patient.

The final category of humour project in hospitals is known as clown care, in which a therapeutic hospital clown makes rounds to patients. Magic, juggling, puppetry, music, and humorous interplay add joy and laughter to the hospital stay. Perhaps the most famous of these programs is “The Big Apple Circus Clown Care Unit" (Williams. 1990). These are hospital-specific clowns in the guise of “funny-bone doctors," who visit nine New York medical facilities on a weekly basis. Similar clown visitation programs exist at both B.C.”s Children's Hospital and Toronto’s Hospital For Sick Children. In Winnipeg, at the Health Sciences Centre for Children, “Hubert" the clown is a regular member of the child life department.

In developing the therapeutic clown “Doc Willikers" at B.C.”s Children's Hospital, I was impressed by the power of laughter. The “Doc" is able to transform, if only for a few moments, the lives of those with whom he interacts. The children, youth, anxious parents, and staff respond to his presence. They temporarily forget the stress, pain, and intensity of the hospital environment. The “Doc" admits clowning is more than just being silly. It is also about having the awareness and sensitivity to know when to move in and when to pull back. This raises the question, “When is it appropriate to use humour?"

Appropriateness of humour
Humour is a therapeutic tool that demands energy for its creation, yet its rich rewards include a closer therapeutic bond through shared laughter (Killinger, 1987). But humour and laughter are not the panacea for all that ails us. When considering the systematic or planned use of humour for therapeutic value, I encourage the “user" to reflect on timing, relationship, and content.

Humour is not always well received. Sometimes the intensity of the moment is such that trying to promote laughter would be perceived as offensive. In the hospital setting, the child life specialists work closely with the therapeutic hospital clown to share how patients are coping. They suggest who could use a visit, who to approach with caution, and who might likely be too immersed in hospital-related emotions to benefit presently. For example, humour is contraindicated when there is a very serious situation in the patient’s or family’s life. One must always be ready to change a course of action if laughter is not the order of the day. In the hospital we take our cues from the children and families. It is necessary to keep constantly informed of changes by communicating with the health care team.

Timing of humour is also relevant to relationships. Whether it is a clown interacting for a brief period of time, or a counselor working with a child over an extended period of time, using humour too soon can be interpreted as a lack of sensitivity. Once it becomes clear that the patient has gained some trust in relationship with the therapist, then one can use humour. When individuals are deeply depressed or too unhappy to be interested in communication, the most important thing is to first establish essential contact (Greenwald, 1987). One other piece of advice Greenwald offers is not to attempt to be humourous at all times with all patients. He suggests humour can grow out of the therapeutic context. The best humour comes from what is going on “at the moment." Therefore one can plan to use humour yet rely on spontaneous opportunities to employ it.

The third consideration related to the appropriate use of humour is content. Humour has the power to both benefit and harm. The examples discussed so far in this article are seen to be therapeutic. Humour is something positive that should bring mutually shared enjoyment and pleasure (Olson, 1994). However, one must be careful to consider the potentially negative aspects of its use. Because what an individual finds funny is both personal and subjective, the method you choose to promote laughter must match that individual’s tastes and developmental capability. Humour as a therapeutic tool must build instead of knock down, and therefore excludes sarcasm and cynicism, which aggrandize the self at the expense of others (Olson, 1994). It is important not to use “toxic" humour, which puts down others, ridicules, stereotypes, or excludes. That requires the user to be aware of developmental, individual, and cultural differences.

Clinical application of humour
In our discussion so far we have found that humour can appropriately be used to build rapport and relationship once a preliminary trust has been established. Humour can also be used to decrease pain and anxiety and promote health. Humour can be accessed voluntarily in the form of humour rooms and carts, and can take the form of a more organized program like clowning and workplace seminars. The potential therapeutic value has been established. If we view humour as another tool that you can use when working with children and youth, what other outcomes might be accomplished? In Humor: Its Origin and Development (McGhee, 1979), the author suggests that when used skillfully, humour in therapy can:

To achieve these outcomes you can build on the themes already presented. Here are some additional ideas on the clinical application of humour.

Ask a child his or her favorite 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. Self-directed humour can narrow the gap between you 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. Modeling 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.

Developmental aspects of humour
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. For a detailed account of his theory I recommend reading Humor: Its Origin and Development (1979) and Humor and Children's Development: A Guide to Practical Applications (1989). For the purposes of this article I have provided a summary table that provides ideas of how to implement humour or invoke the humour response in children and youth.

Humour and laughter can be an effective self-care and caregiving tool. The body, mind and spirit all benefit from its regular use. We can deliberately increase the amount of laughter we experience in our workplace, as well as systematically promote its use with children, youth, and families. I have shared what I have come to learn about its power and encourage you to think about its application in other settings. The resources for the therapeutic use of humour are abundant and accessible (see resource list). Have fun!

Table 1: Humour Development

Age Humour Response Developmental Issue Intervention
smiling responds to sights, sounds movements & feedings provide environment
4-8 months laughter at physical level with active stimulation discovering body movements, recognition of human face & voices I’m gonna get you... engage in physical contact
8 mon. to 1yr. laughs when in
contact with toys
object constancy, distinguishing between self & non-self peek-a-boo, contact play with toys
1 to 2 yrs. expectancy violations,
incongruent behaviour
developing organized schemas of the world mislabeling, playing with toys in a different way
2 to 4 yrs. fantasy, make-believe, slapstick, silly words &
songs, bodily noises, direct participation
mastery of motor skills, development of symbols to represent the world, aware of bodily functions create novel stimulus play house, active play, Dr. Seuss, simple songs
5 to 10 yrs. riddles, first simple word
concrete operational thinking, can detect transitions & relationships joke books, cartoons, will repeat over & over
10 & over sophisticated jokes, wit, satire,
incongruent social
peer relationships, individual personality and experiences important movie tapes, friendly wit and sarcasm


Berk, L. (1989) Neuroendocrine and stress hormone changes during mirthful laughter. American Journal of Medical Sciences, 298(6), 390–396.

Cousins, N. (1979). Anatomy of an illness. New York: W.W. Norton.

Fahlman, C. (1996). Laughing nine to five. Portland, OR: Steelhead Press.

Fry, W. (1977). The respiratory components of mirthful laughter. Journal of Biological Psychology, 19(2), 39–50.

Fry, W. (1979). Mirth and the human cardiovascular system. In H. Mindess & J. Turek (Eds.), The study of humor (pp. 56–61). Antioch University Press.

Fry, W., & Salameh, W. (Eds.). (1987). Handbook of humor and psychotherapy: Advances in the clinical use of humor. Sarasota, FL: Professional Resources. Exchange, Inc.

Greenwald, H. (1987). The humor decision. In W. Fry & W. Salameh (Eds.), Handbook of humor and psychotherapy: Advances in the clinical use of humor (pp. 41–54). Sarasota, FL: Professional Resources Exchange, Inc.

Killinger, B. (1987). Humor in psychotherapy: A shift to a new perspective.In W. Fry & W. Salameh (Eds.), Handbook of humour and psychotherapy: Advances in the clinical use of humor (pp. 21–40). Sarasota, FL: ProfessionalResources Exchange, Inc.

Lefcourt, H. (1986). Humor and life stress. New York: Springer-Verlag.

Lefcourt, H. (1990). Humor and immune system functioning. International Journal of Humor Research, 3(3), 305–321.

McGhee, P. (1979). Humor: Its origin and development. San Francisco: W.H. Freeman.

McGhee, P. (1989). Humor and children's development: A guide to practical applications. New York: Haworth Press.

Montague, A. (1991). Growing young, laughter, play and other life giving basic behavioral needs. An address to the Power of Laughter and Play Conference, Institute for the Advancement of Human Behavior, Stanford, CA.

Olson, H. (1994). The use of humor in psychotherapy. In H. Strean (Ed.), The use of humor in psychotherapy (pp. 195–198). Northvale, NJ: Jason Aronson Inc.

Pelletier, K., & Herzing, D. (1989). Psychoneuroimmunology: Toward a mind-body model. Advances, 5(1), 27–56.

Williams, L. (1990, November 12). Treating the funny bone. Time, 17–18.

This feature: Puder, C. (1998). The healthful effects of laughter. Journal of Child and Youth Care. Vol.12 No.3 pp 45-53

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