The promotion of humor and laughter as medicine is a burgeoning business and an increasingly popular avocation. There are video- and audiocassettes, books, journals, magazines and newsletters, workshops, symposia, and entire conferences and societies devoted to the celebration and promotion of humor and laughter as the road to physical and mental health.
The idea that humor and laughter benefit health is not new; it has long been a part of folk wisdom. Shakespeare wrote in The Taming of the Shrew, "And frame your mind to mirth and merriment, which bars a thousand harms and lengthens life." And from Proverbs 17:22, "A merry heart doeth good like a medicine; but a broken spirit drieth the bones."
What is new is the use of a medical model and the fervent and organized promotion of allegedly therapeutic humor under the banner of this model. Given the perennial public interest in both health and humor coupled with the tendency of the popular media to oversimplify, delete qualifiers, and extrapolate when reporting research, it is inevitable that false and unsubstantiated claims abound.
Some of the most distorted claims surround Norman Cousins, who became the virtual poster boy of the movement after reporting his use of a "humor intervention" during his recovery from a serious and painful collagen disease in 1964. Some early reports made in the medical and popular press were the beginnings of the enduring myth that he cured himself with laughter. In 1979 he published Anatomy of an Illness as Perceived by the Patient because he "thought it useful to provide a fuller account than appeared in those early reports" (p. 27). The major themes of this book, which he elaborated in two later books on healing (1983, 1989), were the power of the body to heal itself and the importance of positive emotions, of the will to live, and of the patient-physician partnership.
Although laughter, per se, was not a major theme, Cousins's now famous statement, "I made the joyous discovery that ten minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep" (p. 39), is widely quoted and paraphrased out of context and has fueled the misconceptions. In The Healing Heart (1983) Cousins again attempted to clarify his position: "The newspaper accounts had made it appear that I had laughed my way out of a serious illness. Careful readers of my book [Anatomy of an Illness], however, knew that laughter was just a metaphor for the entire range of the positive emotions. Hope, faith, love, will to live, cheerfulness, humor, creativity, playfulness, confidence, great expectations--all these, I believed had therapeutic value" (p. 50).
Purpose of This Paper
The purpose of this paper is to address the two questions posed in the title. I will first present some basic concepts from the field of humor studies, then outline some of the mechanisms by which humor and laughter are thought to affect health and discuss these in the context of the research on laughter and pain. Although this literature is small, it is illustrative, and the principles apply equally well to other areas of humor and laughter research.
The easiest way to introduce some fundamental concepts about humor and laughter is in the context of three common errors in thinking about them. The first is the tendency to use the words humor and laughter interchangeably. There are good reasons not to do this. Laughter and humor are qualitatively different phenomena. Laughter is an event in the physical world. Humor is a construct.
It is tempting to classify laughter as a diaphragm reflex because of the many occasions on which laughter is an involuntary reaction to an environmental stimulus. But there are several problems with this idea. First, laughter is not the result of a reflex arc. Except in the cases of breathing nitrous oxide (laughing gas) and pathological laughter resulting from nervous system disorders, laughter is always cognitively mediated. Second, a reflex is a fixed relationship between a given environmental stimulus and a particular response that is made automatically. But not all individuals respond to the same stimulus with laughter, nor does the same individual always respond to the same stimulus with laughter on different occasions. Laughter is best described as a learned autonomic response.
Humor is defined alternatively as a stimulus that causes amusement and as the response to the stimulus. According to the theory (Suls, 1972) that is most widely accepted at present, the basis of this amusement is the surprise of recognizing that juxtaposed elements are incongruous, followed by the sudden realization that the elements need not be incongruous if viewed from a different perspective. This sudden change of perspective is considered to be the mechanism in the well-documented positive effect of humor on creativity (Murdock & Ganim, 1993; Ziv, 1976) and divergent thinking (Derks & Hervas, 1988; Ziv, 1983).
A second common error--closely related to the first--is to think of humor and laughter as having an "if and only if" relationship with each other, that is, to define humor as that which produces laughter and to define laughter as the response to humor. Although the two are frequently yoked, they can and frequently do exist independently. There are many forms of humor--for example, satire and irony--that can be very amusing but that do not usually elicit audible laughter. Also, laughter is a social phenomenon. People are more likely to respond with laughter when they are with others than when they are alone.
Laughter is even less bound to humor than humor is to laughter. Excluding pathological laughter, other types are caused by tickling, surprise, embarrassment, tension, relief after tension, play, or a sudden sense of exhilaration and well-being. Human ethologist Robert Provine (1996) reports that more than 80% of laughter that occurs during conversation serves to "modify the behavior of others by shaping the emotional tone of a conversation" (p. 42) and is not a response to an attempt at humor.
A third error is the assumption that humor and laughter, with only rare exceptions, evoke a positive mood state called mirth. The problem with this idea is readily apparent upon considering even a sample of the diverse social and psychological functions of humor and laughter; they can be used to cheer, relieve, and encourage, but also to humiliate, provoke, and disgust. The motives underlying humor and laughter run the full gamut from highly prosocial to highly aggressive. Also, there are well-known categories of nonmirthful humor such as black or gallows humor, sick humor, and disaster humor.
Operationalizing Laughter and Humor
Humor researchers investigate the health-promoting effects of laughter elicited by humor judged to be mirthful. Laughter requires little operationalizing; people either laugh or they don't. Although it is generally assumed that the humorous stimulus elicited laughter in all participants, some researchers verify this and discard scores from participants who are not heard to laugh audibly.
Operationalizing humor is considerably more complex. The basic dichotomy is state versus trait. To elicit a state of humor, participants are exposed to some type of canned humorous stimulus, usually an audio- or videotape, after which they give blood or saliva samples, or have their vital signs read, or are tested for pain tolerance, and so forth. One weakness of this approach is that the participants are passive recipients, and the humor is not relevant to anything and may not amuse some participants. The strength of this approach is that it allows investigation of any immediate effects of laughter.
Humor trait means sense of humor and has been variously defined as attitude about humor and humorous people (Svebak, 1974), the habitual tendency to discover, create, or appreciate humor (Svebak, 1974; Ziv, 1979), the habitual use of humor as a coping device (Martin & Lefcourt, 1983, 1984), and as temperament (Ruch, Kohler, & van Thriel, 1996), which is interpreted as trait cheerfulness and extroversion. All of these are measured using Likert scale or multiple-choice responses.
Every year several new tests appear one or two times in the literature and are never heard of again. However, there are a small number of tests that were designed by major researchers in the field and have been used extensively, some for more than a decade. Several of these have been translated into as many as 10 languages and have been tested for validity and reliability. Sven Svebak's Sense of Humor Questionnaire (1974) measures both attitude and disposition. It has three 7-item subscales: (a) Habitual Sensitivity to Humorous Messages (e.g., "Do you easily recognize a hint like a twinkle or a slight change in emphasis as a mark of humorous intent?"), (b) Habitual Tendency to Enjoy or Dislike Comical Situations (e.g., "It is my impression that those who try to be funny really do it to hide their lack of self-confidence"), and (c) Habitual Tendency to Permit or Suppress Emotional Impulses of Joy (e.g., "Do you feel that most people are more serious and solemn than is good for them?"). Ruch (1994) argues that temperament is the basis of sense of humor. He and several colleagues (1994) developed a lengthy Trait Cheerfulness Inventory with items such as: "My acquaintances often get on my nerves" and "I like to kid around with others." Ziv's Sense of Humor Questionnaire (1979) has two 7-item subscales that measure humor appreciation (e.g., "I find many situations laughable") and humor creation (e.g., "When I want to achieve some purpose, I use humor"). The Situational Humor Response Questionnaire (SHRQ) was designed by Martin and Lefcourt (1984) to measure certain aspects of sense of humor which they believe moderate the relationship between life stress and mental and physical illness. They wanted to know how much people find and use humor in their daily lives. Their survey has brief descriptions of 18 situations and a choice of potential responses (e.g., "If you arrived at a party and found that someone else was weaning a piece of clothing identical to yours, what would you do?). The seven-item Coping Humor Scale, also designed by Martin and Lefcourt (1983), is frequently used in conjunction with their SHRQ (e.g., "I usually look for something comical to say when I am in tense situations").
Health has been operationalized in the following ways: First, pain, which has been defined as reduced requests for analgesics, elevated pain threshold, ability to endure pain, and decreased perception of pain; second, stress and anxiety as measured by self-report, reduction of symptoms, and physiological indices; third, improved outlook, which includes increased optimism about recovery, elevated self-appraisal of health, enhanced mood generally, and a greater acceptance of long or painful treatment programs and of permanent disabilities and limitations and death; and fourth, immune-system functioning. These overlap and interact, of course.
Proposed Mechanisms of Health Benefits
There are a number of known or assumed components of laughter and humor that have been proposed as the mechanism(s) by which health is improved (see Galloway & Cropley, 1999, for a summary and references). Vigorous laughter is stimulating, increasing heart rate, blood pressure, and circulation; circulating immune substance effectiveness, pulmonary ventilation, and alertness; and exercising the skeletal muscles. Following laughter there is a brief period during which blood pressure drops and heart rate, respiratory rate, and muscle activity decrease, resulting in relaxation (Fry, 1994). There has been much speculation but no empirical support for the claim that laughter triggers the release of endorphins. Laughter is distracting, capturing awareness much as sneezing does. Humor provides cognitive stimulation and a different type of distraction; getting a joke is not a type of automatic processing and does not allow for divided attention. Mirthful humor enhances mood, sometimes for an extended period. Altered perception as a mechanism is based on the assumption that the altered perception required for resolving the incongruity in the humor will carry over and allow patients to perceive their own situation from a different frame of reference. Sense of control is increased when patients spontaneously create their own humor about their own situation. Additionally, benefits may be derived solely from the belief that laughter and humor are beneficial.
Many Roads Lead to Rome
All of these effects are desirable, but humor and laughter are not the only methods of obtaining them. It is commonly recognized that relaxation, altered perception, and enhanced mood are also obtained through meditation, prayer, relaxation and breathing exercises, music, and art; distraction and enhanced mood can be achieved by means of a good book or movie of any genre, or enjoyable conversation; petting animals and watching fish enhance mood as well as lower blood pressure. Belief in benefit effects are associated with almost any program or activity, particularly those in which a person engages by choice. Sense of control is increased by learning about one's disease and treatment program.
The majority of the research doesn't just attempt to demonstrate that humor or laughter has a beneficial effect, but rather asks whether the effect caused by humor or laughter is different or greater than the same effect caused by some other means. The pain research is illustrative.
Research on Laughter and Pain
Cogan, Cogan, Waltz, and McCue (1987) report two experiments that measured discomfort thresholds using a blood pressure cuff. In the first experiment a total of 40 participants listened to one of three 20-minute audiotapes: Lily Tomlin comedy, relaxation, or informative narrative. A control group heard no tape. Discomfort thresholds for both the humor and relaxation groups were significantly higher than those of the narrative and control groups. Experiment 2 compared the effects of different types of distraction. Forty different participants, matched for discomfort threshold, either listened to humor, listened to an interesting narrative or to a dull narrative, multiplied three-digit numbers, or were controls. Only the laughter group raised their pretest thresholds significantly. Although the authors concluded that laughter is better than distraction, it is important to note that none of the distraction treatments involved arousal.
Hudak, Dale, Hudak, and DeGood (1991) looked at the effects of both humor trait and humor state on reported discomfort induced by transcutaneous end nerve stimulation. Thirty-one participants who had scored either very high or very low on Martin and Lefcourt's SHRQ were divided into groups that watched either Bill Cosby or a gardening video. The humor group had significantly higher discomfort thresholds, but the effect of the video group was largely affected by the responses of the low-sense-of-humor members of each group. The authors concluded that individuals with a high sense of humor have a higher threshold with or without the aid of a humor stimulus and that individuals with low sense of humor are more vulnerable to discomfort and are less able to cope without assistance.
Nevo, Keinan, and Teshimovsky-Arditi (1993) exposed 72 undergraduates to a cold-water pressor while they watched either comedy, a documentary, or no film and failed to get some of the results they expected. The only significant group difference was that the people who watched comedy estimated the effectiveness of the film as higher even though it actually bad no significant effect. However, all participants had previously completed Ziv's Sense of Humor Questionnaire and Martin and Lefcourt's SHRQ, and a significant correlation was found, across groups, between scores on Ziv's humor creation subtest and pain tolerance. Within the comedy group a significant correlation was found between the funniness rating given to the film and ability to tolerate the cold water. The authors conclude that "humor exerts its effects only when it is perceived as humorous" (p. 83). Additionally, this study illustrates the popular belief that humor is beneficial.
Zillmann, Rockwell, Schweitzer, and Sundar (1993) compared pre- and posttests of discomfort thresholds using the blood pressure cuff. One hundred introductory psychology students watched either stand-up comedy, situation comedy, drama, an instructional film, or tragedy. They found that watching tragedy was just as effective in significantly increasing discomfort thresholds as either type of comedy. This is the first study with a distraction treatment that induces arousal.
Weisenberg, Tepper, and Schwarzwald (1995) used a cold-water pressor on 80 paid volunteers who watched 7-minute film segments of either slapstick comedy, a repulsive blood-and-guts scene from a horror movie, or a neutral popular-science film, or no film. They found a significant pain endurance advantage for both the humor and the repulsive treatments with the repulsive treatment being the most effective.
In sum, these studies demonstrate that sense of humor trait is more beneficial than induced humor state, and that laughter has no unique contribution to pain tolerance beyond relaxation or beyond the level of distraction, providing the distraction involves arousal. Future research might investigate the effects of positive or enhanced mood without humor and the effects of humor without positive mood. There are enough humorous stimuli that are either disgusting enough or depressing enough to permit such an investigation. Additionally, with a small amount of deception it should be possible to manipulate participants' expectation of benefit.
Is laughter any medicine at all? Yes; there is sufficient empirical evidence to support many--although certainly not all--of the claims that mirthful laughter benefits both physical and mental health. Is laughter the best medicine? No, not necessarily. Those empirical studies that have controlled well for alternative explanations serve to support Cousins's point: mirthful laughter is merely one selection from a large menu of positive emotions and behaviors that have therapeutic value. However, most of the items on this menu are so tied to personal beliefs, values, and style that the choice of mind-body connection is best left to the individual.
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This article is condensed and adapted from Dr. Mahony's Psi Chi Invited Address delivered on April 30, 1999, at the annual meeting of the Western Psychological Association in Irvine, California.