Laughter as Therapy for Patient and Caregiver
(in Pulmonary Rehabilitation, ed. Hodgkin, 1993, Philadelphia: Lippincott)
"A merry heart does good like a medicine,
but a broken spirit dries the bones"
-- Proverbs 17:22
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Laughter can be a powerful therapy for both the patient and the caregiver.
This chapter will examine the beneficial effect of humor and laughter on
the body, mind, and spirit; for the patient during recovery from illness;
and for the health professional during delivery of care. Most experienced
caregivers have discovered that attention to only the physical body during
treatment will yield a partial or temporary recovery. The patient's emotional
responses, belief system, support network, etc. all can effect compliance
to treatment and ability to cope with fear, pain, and loss.
The ability to laugh at a situation or problem gives us a feeling of superiority
and power. Humor and laughter can foster a positive and hopeful attitude.
We are less likely to succumb to feelings of depression and helplessness
if we are able to laugh at what is troubling us. Humor gives us a sense
of perspective on our problems. Laughter provides an opportunity for the
release of those uncomfortable emotions which, if held inside, may create
biochemical changes that are harmful to the body.
Caregivers, as well as patients are in need of the therapeutic effects of
humor and laughter. Most caregivers are compassionate individuals who choose
to work in a profession that places them at risk to their physical, emotional
and spiritual well being. Due to our sympathetic tendencies we may feel
the same emotions that our patients feel, such as fear, anger, helplessness,
and depression. We can experience feelings of failure when our efforts are
ineffective. We feel anger and frustration when a patient rejects our care
or is noncompliant with treatment. We may feel grief when patients die or
families mourn. Caregivers are at risk physically too (e.g., exhaustion
from long shifts with inadequate staffing, exposure to infectious organisms
and physical abuse from combative patients. Health professionals working
in a stress-filled environment are at risk for burnout and stress-related
illness. Our ability to see the humor in a situation and to laugh freely
with our coworkers can be an effective way to take care of our own body,
mind and spirit.
For thousands of years, the human race has extolled the health-enhancing
benefits of laughter. Current research by Lefcourt, Guillemin, and Fry in
the areas of psychology, physiology, and psychoneuroimmunology is defining
the specific changes effected by the experience of mirthful laughter. (1-7)
Therapy is defined as "an activity or treatment intended to alleviate
an undesirable condition." With that in mind, let's explore the therapeutic
benefit of laughter for the body, mind, and spirit.
A Patient Responds to Humor
During the last twenty years, I have been active in the profession of nursing.
Most of those years have been spent at the bedside in intensive care units,
I have also worked in home care, hospice, and cardiac rehabilitation. I can
remember many situations where humor and laughter made a significant difference
in a patient's response to care, but none as profound as this story. Fred
was 60 years old and recovering from a mitral valve replacement. During
his immediate postoperative recovery, Fred experienced a mild psychosis
and severe depression. The acute psychotic episode resolved prior to discharge,
but the profound depression continued for many weeks. Fred lacked enthusiasm
for anything. He refused to eat, to walk, and even refused to wear anything
but pajamas. His surgeon referred him to our outpatient cardiac rehabilitation
program. Upon entry into our program, Fred walked with a shuffling gait,
responded to questions with one or two words, and was unable to make eye
contact. His wife was exhausted and discouraged. For several weeks we saw
little improvement in his depression, in spite of antidepressant drugs and
psychological counselling. One day, about a month after beginning rehab,
he was walking on the treadmill; his 25 lb. weight loss noticeable as his
sweat pants hung loosely over his hips. After about 6 minutes of walking,
his sweat pants suddenly fell down around his ankles, revealing bright red
boxer shorts. We hit the emergency stop button in time to prevent his falling
and went to assist him. He was looking down at his dropped drawers and when
he lifted his head we could see a big grin starting and he began to laugh.
We smiled and joined him in the laughter, grateful for the permission to
respond by laughing at the ridiculous situation. Our mutual embarrassment
and tension was released through laughing. From that moment on Fred's depression
continued to resolve, he became involved in his recovery process and was
able to regain his strength and he eventually returned to an active involvement
in his church and community.
Recalling this story reminds me of this popular folk poem
"Its easy enough to smile when the world goes round and round
but the man worthwhile is the man who can smile when his pants are falling
down."
-- Anonymous
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Laughter Supports Recovery from Illness
Norman Cousins, former editor for Saturday Review, brought
the attention of the medical community to the possibility that laughter
may have a healing potential. In l964, Cousins was diagnosed with ankylosing
spondylitis, a progressive degenerative disease of the collegen tissue.
His physicians gave him little hope for recovery, indicating that a possible
cause of his illness was due to heavy-metal poisoning. Recalling his activities
in the month prior to the onset of symptoms, he remembered frequent exposure
to diesel exhaust fumes during his travel in Russia. He suspected that a
condition of adrenal exhaustion weakened his ability to tolerate the toxic
exposure. From his reading of Hans Selye's 1956 book about the body's response
to stress (8), Cousins recalled that research had shown
that negative emotions could create chemical changes which would
eventually lead to adrenal exhaustion. He suspected that the positive
emotions (such as faith, hope, confidence and joy) might create changes
within the body which would enhance his recovery process. Since the behavior
of laughing tends to open one to these positive emotions, Cousins began
viewing amusing films to stimulate laughter. After each laughing episode
he noted that he could sleep comfortably without the need for analgesia
or sedation. He also discovered that laughter also stimulated a decrease
in his sedimentation rate, indicating a reversal of the inflammatory response.
(9) After his recovery, Cousins spent the last ten years
of his life as an adjunct professor at U.C.L.A. Medical School where he
established a Humor Task Force to coordinate and support clinical research.
(10) Today, 25 years after Cousins' experience, we have
the scientific research to explain the specific physiological changes which
his anecdotal story suggested. Laughter does effect the body, mind and spirit.
Perhaps Mark Twain captured the relationship most succinctly when he wrote
"The human race has only one really effective weapon, and that's laughter. The moment it arises, all our hardnesses yield, all our irritations and resentments slip away, and a sunny spirit takes their place."
-- Mark Twain
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Physiological Response
Humor is a perceptual process while laughter is a behavioral response. This
behavior creates predictable physiological changes within the body. As with
other exercise, we see two stages of the body's response, the arousal phase
when the physiological parameters increase, and the resolution phase when
they return to resting rate or lower. With vigorous sustained laughter,
the heart rate is stimulated, sometimes reaching rates of above 120 bpm;
the normal respiratory pattern becomes chaotic; respiratory rate and depth
are increased while residual volume is decreased. Coughing and hiccups are
often triggered due to phrenic nerve irritation or the dislodging of mucus
plugs. Oxygen saturation of peripheral blood does not significantly change
during the increased ventilation occurring with laughter. Conditions such
as asthma or bronchitis may be irritated by vigorous laughter. Peripheral
vascular flow is increased due to vasodilitation. A variety of muscle groups
become active during laughter -- diaphragm, abdominal, intercostal, respiratory
accessory, facial, and occasionally muscles in the arms, legs, and back.
(1-3)
Some of the most exciting research exploring the potential healing value
of laughter is in the area of psychoneuroimmunology (also referred to as
neuroendocrinology or neuroimmunology). Psychoneuroimmunology is an area
of research which explores the connections between the nervous system (the
seat of thought, memory, and emotion), the endocrine system (which secretes
powerful hormones), and the immune system (which defends the body from microbial
invasions). Loma Linda University Medical Center has recently completed
research showing that the neuroendocrine system is effected during the experience
of mirthful laughter. (11) This work by Lee Berk and Stanley
Tan has shown that serum cortisol levels decreased with laughter. Also,
the experimental group demonstrated a lower baseline epinephrine level than
the control group (possibly due to their relaxed status in anticipation
of the laughter experience). Levels of cortisol and epinephrine (known to
be immunosuppressive) are elevated during the stress response Therefore,
Berk and Tan conclude that by decreasing these levels we can diminish the
suppression of the respective immune components. Other research has demonstrated
that mirthful laughter increases the spontaneous lymphoycyte blastogenesis
and the natural killer cell activity. Natural killer cells are a type of
lymphocyte that have a spontaneous cytolytic activity against tumor cells.
(12)
Frequency of stressful life changes, severity of depression, and coping
styles have all been shown to effect the immune response. Steven Locke of
Harvard has shown that the activity of natural killer cells is decreased
during periods of increased life change accompanied by severe emotional
disturbances, whereas subjects with similar patterns of life change and
less emotional disturbances had more normal levels of N.K. cell activity.
(13) Similar findings were confirmed by Michael Irwin in
1987 at V.A. Medical Center in San Diego, noting that N.K.cell activity
decreased during depressive reaction to life changes. (14)
Janice and Ronald Glaser of Ohio State University School of Medicine studied
the cellular immunity response patterns of medical students prior to exams.
Their work showed a reduction in the number of helper T-cells and a lowered
activity of the N.K. cell just prior to the exam. (15,
16)
In 1985, Marvin Stein at Mt. Sinai School of Medicine in New York looked
at the effect of conjugal bereavement by studying men whose wives had advanced breast cancer. His work showed that the lymphocyte response pattern in his subjects dropped significantly within one month after the death of their wives. (17) This finding was also confirmed by the research of Steven Schleifer (18) and Robert Bartrop (19).
Research by Arthur Stone of S.U.N.Y. has revealed that salivary immunoglobulin
A (our first line defense against the entry of infectious organisms through
the respiratory tract) response was lower on days of negative mood and higher
on days with positive mood. (20) This finding was duplicated
by Kathleen Dillon at Western New England College showing an increased concentration
of salivary IgA after viewing a humorous video. (21) The
research in the field of psychoneuroimmunology continues to prove that the
mind (emotions) and the body (immune system) are interrelated. Positive
emotions seem to enhance the immune response while negative emotions suppress
it. (22,20)
Current research seems to be confirming what Sir William Osler, a physician and pioneer of modern medicine stated years ago (23)
"It is more important to know what sort of patient has the disease, than what sort of disease the patient has."
-- W. Osler
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Humor and Illness
How then, may the behavior of laughter be therapeutic to the body of both
patient and caregiver? Laughter is a pleasurable experience; it momentarily
banishes feelings of anger and fear. It gives us a feeling of power and
control; we feel carefree, lighthearted, and hopeful during the moments
of laughter. These feelings may have therapeutic benefits by reversing the
immunosuppressive effects of the emotions of anger, fear, or loneliness
which often accompany hospitalization and recovery from illness.
Illness, either acute onset or exacerbation of a chronic illness can be
a stressful event. Hospitalization, separation from family, invasive procedures,
complex technology, or unfamiliar caregivers can all create feelings of
anxiety, loneliness, discomfort, anger, panic, and depression for the patient.
These emotions are known to produce physiological changes that are harmful
to the body; changes which the use of humor and laughter can ease. Shared
laughter is a uniquely human bond and serves as an equalizer and "social
lubricant".
Caregivers can express their understanding and appreciation of the patient's
struggle through the use of humor. For example, when a patient complains
about the inadequate length or coverage of their gown we could respond with:
"Well, now you know your doctor admitted you for observation."
or " It's a designer creation by Seymor Butts." Humor can also
help to reframe a situation by creating a context suggesting a more pleasant
environment. As you instruct in the use of the call light: "Now I'm
going to place your room service button right here." Or after completing
an uncomfortable procedure, smile and say: "I bet it's hard for you
to believe I'm on your side right now." When you've completed a ventilator
check, blood gas analysis, or vital sign check smile and say: "Well,
you look good on paper. How does it feel on the inside?" Each of these
statements, while not profoundly funny, will communicate a gentle awareness
of the patient's dilemma and express a relaxed and lighthearted attitude
by the caregiver -- giving the subtle message that the caregiver is
confident and in control of the situation.
But it is extremely important that the patient first be convinced of the
health professional's competence and ability to deliver expert clinical
care. A carefree, joking demeanor can be used to cover-up inept skills or
to deflect and ignore the importance of a patient's feelings. The appreciation
of humor is highly individual and there are no guarantees that your attempts
will be successful, therefore one must be observant of the patient's response.
Sometimes the response may be subtle, a glistening of the eyes or flushing
of the cheeks. Of course we all hope for the big smile, chuckle or playful
retort; but if you suspect that the patient felt insulted or misunderstood
your intention, it is helpful to say something like: "Gee, I sure hope
you weren't offended by that. I was just trying to lighten up the situation
and help you to relax. I didn't mean to upset you, sorry." If the humorous
attempts aren't working with that patient, then quit. Always remember, never
use sexual, ethnic, or racial material with patients or their families.
It is unprofessional and you risk offending them and losing rapport and
respect. (24)
Psychological Impact of Humor
Humor and laughter effect how we perceive and respond to change. Herbert
Lefcourt, a noted psychologist from the University of Waterloo in Canada
has explored the possibility that a sense of humor and its use can change
our emotional response to stress. In this study, subjects were asked to
review the frequency and severity of stressful life changes occurring to
them over the previous six months, and their recent negative mood disturbances
were evaluated. Lefcourt then administered tests to evaluate use of humor,
perception of humor, appreciation of laughter, and efforts to include opportunities
for humor and laughter into each subjects lifestyle. Results of this
study have shown that the ability to sense and appreciate humor can buffer
the mood disturbances which occur in response to negative life events. (5,6)
Humor gives us a change of perspective on our problems and with an attitude
of detachment, we feel a sense of self-protection and control in our environment.
Freud (25) noted the powerful psychological influence of
humor stating.
"Like wit and the comic, humor has a liberating element.
It is the triumph of narcissism, the ego's victorious assertion of its own invulnerability. It refuses to suffer the slings and arrows of reality."
-- Freud, 1905
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Some of the best humor about illness and recovery has been written by former
patients. My favorites are: Surviving the Cure by Janet Henry
(26), They Tore Out my Heart and Stomped the Sucker
Flat by Lewis Grizzard (27), Patients at Large
by cartoonist Tom Jackson (28), Please Don't Stand
on my Catheter by T. Duncan Stewart (29), and Have
a Heart by Wilford Nehmer Jr (30). Each of these
authors reveal some of the absurdity, irony and incongruity of being a patient
under care. When we choose to laugh at or about a situation, we give ourselves
the subtle message: "This is not so threatening; look, it's amusing
and absurd sometimes. I can't take it too seriously."
Humor can also influence the mind by enhancing the ability to learn. Health
professionals spend considerable time educating the patient and family about
drugs, diet, lifestyle change and treatment benefits. Delivering the information
with humor will improve the communication in three ways:
- it will capture the attention of the learner
- it will enhance retention of the material
- it will help to release the tension that blocks learning
The use of cartoons or funny stories can be an effective way to add humor. (31-33) Shown in Figure 1 are four cartoons, drawn by Tom Jackson, based on real-life situations.
(28)
Figure 1. (cartoons shown in original printed work)
Caregivers work in a stress-filled environment and are prone to professional
burnout. A major causative factor in burnout is powerlessness. Hans Selye,
(physician, physiologist, and pioneer in the field of stress research) noted
in 1954: "Stress is not the event, it's our perception of it."(8)
Susan Kobassa clarifies this concept even further with her research into
personal hardiness factors. She found that some personality types seem resilient
to the harmful effects of stress because they possess three traits:
- commitment to self and work,
- a sense of control within their environment, and
- a feelings of challenge rather than threat when events change.
Kobassa discusses the importance of "cognitive control". Control of events in your external world may not be possible, but we all have the ability to control how we view these and the emotional response we choose to have to them. (34)
Humor gives us perceptual flexibility and thus can increase our cognitive
control. One nurse used her perceptual flexibility to help her cope with
a demanding patient who frequently interrupted the nurse's busy schedule
with minor complaints and requests. The nurse's patience and tolerance were
wearing thin. It was lunchtime and the patients were eating when again the
nurse was called to this patient's room. Upon entering, the patient indignantly
pointed to her tray and told the nurse, "This is a bad potato!"
The nurse then picked up the potato and began spanking it, saying "Bad
potato! Bad potato!" The patient and nurse both laughed and the tension
of the moment was dissolved.
Any thorough discussion of caregiver's use of humor must include a style
called "gallows humor". Freud named it when he reported an incident
of joking which occurred on the gallows by a man about to be hung. It refers
to the style of humor which laughs directly at tragedy or death, as if it
were amusing. Gallows humor is unique to caregivers or any profession which
deals directly with the gruesome reality of pain, suffering and death. Police,
social workers, news reporters, psychologists, all areas of the health professions
use this style of humor to help them cope with the sympathetic tendencies
they feel when working with those who suffer. William McDougall (35),
professor of psychology at Harvard wrote
"The possession of this peculiar disposition shields us from the depressing influence which the many minor mishaps and shortcomings of our fellows would exert upon us if we did not possess it . . . It not only prevents our minds from dwelling upon these depressing objects, but it actually converts these objects into stimulants that promote our well being, both bodily and mentally, instead of depressing us through sympathetic pain or distress. Laughter is primarily and fundamentally the antidote of sympathetic pain."
-- William McDougall, 1922
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This type of humor is most often misunderstood or unappreciated by those
who do not work closely with the suffering client or who are perhaps new
to the profession. One often develops an appreciation for this humor when
the tension is so great that one must release it or begin to feel crushed
from the pressure. Freud describes the use of this humor as the caregiver's
self-care technique that attempts to convert unpleasant feelings into pleasant
ones. (25) Some of the best collections of "gallows
humor" for the health professions can be found in A Chance to
Cut is a Chance to Cure (36) and Journal of
Nursing Jocularity(see list of "Humor Resources"
at end of chapter).
Samuel Shem's book House of God, gives classic examples of gallows humor. (37) One of my favorites is the "Gomer Assessment Scale -- how do you know someone is a G.O.M.E.R.?" (a definition from Shem's book which stands for Get Out of My Emergency Room)
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How do you know someone is a G.O.M.E.R.?
l. Old chart weighs more than 5 pound
2. Ties foley catheter into pajama strings
3. Has seizure and never drops his cigarette
4. Asks for cigarette during pulmonary function test
5. BUN is higher than I.Q.
6. PO2 is less than respiratory rate
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Perhaps one of the most accurate, poignant, and personal discussions of
the importance of gallows humor for the caregiver was written by a nurse
anesthetist working in an emergency room in Illinois. Wayne Johnson shares
his personal experience and viewpoint in "To the Ones Left Behind". (38)
"You saw me laugh after your father died . . . to you I
must have appeared calloused and uncaring . . . Please understand, much of the stress health care workers suffer comes about because we do care . . . Sooner or later we will all laugh at the wrong time, I hope your father would understand, my laugh meant no disrespect, it was a grab at balance. I knew there was another patient who needed my full care and attention . . . my laugh was no less cleansing for me than your tears were for you."
-- Wayne Johnston
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We have discussed the beneficial physiological changes that laughter creates
within the body -- offsetting the harmful biochemical changes which occur
during stress. We have explored how humor gives us a change of perspective
and a sense of control within our environment, thus increasing our resilience
to stress and burnout. We will now look at the effect of humor and laughter
on the spirit.
Spiritual Effects of Humor
Spirit can be defined as the vital essence or animating force of a living
organism, often considered divine in origin. Spirit can also be regarded
as vivacity or energy. Or it can refer to a characteristic temper or disposition
(the spirit of the group was hostile). The word humor itself is a word of
many meanings. The root of the word is "umor" meaning liquid,
fluid. In the Middle Ages and Renaissance, humor was one of the four principal
body fluids thought to determine human health and dispositions (sanguine,
phlegmatic, choleric, melancholic). One dictionary defines humor as "the
quality of being laughable or comical" or "a state of mind, mood,
spirit". Humor, on all levels, therefore, is something that flows,
involving basic characteristics of the individual which express themselves
in the body, in moods and emotional reactions, and in qualities of feeling,
of mind and of spirit. The qualities of humor and spirit are similar and,
I believe, interdependent. As caregivers we offer therapy to facilitate
the healing processes within the body. To be most effective, we must direct
our efforts to touch the body, mind and spirit. The root of the word "heal"
is "haelen", meaning to make whole. Commenting on the medical
theories of his day, Socrates noted: (in Moody, 39)
"As it is not proper to cure the eyes without the head, nor the head without the body, so neither is it proper to cure the body without the soul."
-- Socrates
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During the Middle Ages, Henri de Mondeville, professor of surgery wrote (in Walsh, 40)
"Let the surgeon take care to regulate the whole regimen of the patient's life for joy and happiness, allowing his relatives and special friends to cheer him, and by having some one tell him jokes. The surgeon must forbid anger, hatred and sadness in the patient and remind him that the body grows fat from joy and thin from sadness."
-- Henri de Mondeville
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Throughout the history of medicine we have discussed the importance of attending to the body, mind, and spirit. Humor is one of the pleasures of life. To dispense laughter will directly enhance the quality of life and perhaps
the will to live -- this may be the most important result of all. The will
to live is a force which is very difficult to define but can be a powerful
influence in the patient's recovery process. Many of us have witnessed the
patient who asserts that he is going to die, despite a fairly normal physical
exam and lab results; and then proceeds to do so, often surprising the professional staff. The opposite can also be the case. A patient is given a grim prognosis by his physicians but announces that he will overcome the condition and then lives for many years beyond his predicted demise. Sometimes mobilizing the will to live can be the most powerful influence one human can offer another. (41) Humor and laughter can create an environment where hope can flourish because it provides a sense of joy, helps us connect with family and friends, and inspires an appreciation and gratitude for life.
Summary
I have attempted to provide information, qualification and inspiration for
the possibility that laughter and humor can be a source of therapy for both
the patient and the caregiver. My intent was to answer the questions: "Why
are humor and laughter important? What happens to the body, mind, and spirit
when we laugh?" You are now probably wondering: "How can I get
myself and others to laugh more? When is humor appropriate to use? Who is
most likely to laugh?" For help in finding answers to these questions,
consult the resource list and references which follow.
Begin to explore your own style and appreciation of humor. Find what works
for you and your patients. Remember, the shortest distance between two people
is a shared laugh.
References (numbers refer to footnotes in text)
[This was published in 1983. For newer items about humor, see PW's "Reading List".]
| 1. | Fry, W. (1971) "Mirth and oxygen saturation of peripheral blood".
Psychotherapy and Psychosomatics, Vol. l9, pp. 76-84.
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| 2. | Fry, W. (1979) "Mirth and the Human Cardiovascular System". In The Study of Humor. (Mindess and Turek eds) Antioch Univ. Press.
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| 3. | Fry, W. (1977) "The Respiratory Components of Mirthful
Laughter". Journal of Biological Psychology, Vol. l9:2,
pp. 39-50.
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| 4. | Guillemin, R. (1985) Neural Modulation of Immunity.
New York NY: Raven Press.
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| 5. | Lefcourt, H. (1986) Humor and Life Stress.
New York NY: Springer-Verlag.
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| 6. | Lefcourt, H. (1990) "Humor and immune system functioning".
International Journal of Humor Research, Vol.3, No. 3 .
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| 7. | McGhee, P. (ed) (1983) The Handbook of Humor Research.
Vol. I & II. New York NY: Springer-Verlag.
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| 8. | Selye, H. (1956) The Stress of Life. New
York, NY: McGraw-Hill.
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| 9. | Cousins, N. (1979) Anatomy of an Illness.
New York NY: W..W. Norton & Co.
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| 10. | Cousins, N. (1989) Head First - the Biology of
Hope. New York NY: Dutton.
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| 11. | Berk, L. (1989) "Neuroendocrine influences of
mirthful laughter". American Journal of Medical Sciences,
Vol. 298, pp 390-396.
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| 12. | Berk, L. (1989) "Eustress of mirthful laughter
modifies natural killer cell activity". Clinical Research,
Vol.37: ll5 A l989.
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| 13. | Locke, S. (1984) "Life change stress, psychiatric
symptoms, and natural killer cell activity". Psychosomatic Medicine,
Vol.46, No. 5.
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| 14. | Irwin, M. (1987) "Life events, depressive symptoms
and immune function". American Journal of Psychiatry,
April Vol 144:4.
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| 15. | Glaser, J. (1987) "Psychosocial moderators of
immune function". Journal of Behavioral Medicine, l987,
Vol. 9, pp. 16.
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| 16. | Glaser, R. (1985) et.al. "Stress-related impairments
in cellular immunity". Psychiatry Resident, Vol. 16, pp. 233.
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| 17. | Stein, M. (1985) "Stress and immunomodulation:
The role of depression and neuroendocrine function". Journal
of Immunology, Vol. 135, p. 827
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| 18. | Schleifer, S. (1983) "Suppression of lymphocyte
stimulation following bereavement". J.A.M.A., Vol. 250,
pp. 374-377.
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| 19. | Bartrop, R. (1977) "Depressed lymphocyte function
after bereavement". Lancet, No. 1, pp. 834-836.
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| 20. | Stone, A. (1987) "Evidence that IgA antibody is
associated with daily mood". Journal of Personality and Social
Psychology, Vol. 52, No. 5.
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| 21. | Dillon, K. (1985) "Positive emotional states and
enhancement of the immune system". International Journal Psychiatry in Medicine, Vol.15:1.
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| 22. | Martin, R. (1988)" Sense of humor, hassles, and immunoglobulin A: evidence for a stress-moderating effect of humor". International Journal of Psychiatry in Medicine, Vol. 18, p. 93.
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| 23. | Cushing, J. (1940) The Life of Sir William Osler
. New York NY: Oxford University Press.
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| 24. | Robinson, V. (1990) Humor and the Health Professions
. Thorofare, NJ: C.B. Slack.
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| 25. | Freud, Sigmund (1905) Jokes and Their Relation
to the Unconscious . (James Strachey, trans; 1960), New York NY:
W.W. Norton Co., Inc.
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| 26. | Henry, J. (1984) Surviving the Cure .
Cope Inc., Cleveland, (216) 663-0855.
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| 27. | Grizzard, L. (1982) They Tore Out My Heart and
Stomped that Sucker Flat . New York NY: Warner Books.
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| 28. | Jackson, T. (1984) Patient's at Large .
Jackson's Corner, P.O. Box 504, Pacifica, CA 94044.
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| 29. | Stewart, D. (1982) Please Don't Stand on My Catheter
. (Sponsored by Orange Co. Chapter of American Heart Assn.) Fullerton,
CA: Sultana Press.
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| 30. | Nehmer, W. (1988) Have a Heart . Cudahy, WI:
Reminder Enterprise Printing. Or write to author at: 5362 Cedardale Dr.,
West Bend, WI 53095.
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| 31. | Parfitt, J.M. (1990) "Humorous preoperative teaching:
Effect on recall of postoperative exercise routines". AORN Journal
, Vol. 52, No. 1.
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| 32. | Kelly, W. (1988) Laughter and Learning: Humor
in the classroom . Portland, ME: J.Weston Walsh.
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| 33. | Parkins, C. (1989) "Humor, health, and higher
education: Laughing matters". Journal of Nursing Education ,
Vol. 28, pp. 229-230.
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| 34. | Kobassa, S. (1983) "Personality and social resources
in stress resistance". Journal of Personality and Social Psychology
, Vol. 45, pp. 839.
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| 35. | McDougall, W. (1922) "A New Theory of Laughter".
Psyche , Vol. 2, l922, pp. 298-300.
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| 36. | Pfeiffer, R. (1983) A Chance to Cut is a Chance
to Cure . A funny book about medicine, surgery, hospitals, and patients;
written by a cardiovascular surgeon.
To order, send check for $5.00 to:
Rip Pfeiffer, M.D., 171 Louiselle St., Mobile, AL 36607
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| 37. | Shem, S. (1978) The House of God . New
York, NY: Dell Publishing.
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| 38. | Johnston, W. (1985) "To the Ones Left Behind".
American Journal of Nursing , A pp. 936.
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| 39. | Moody, R. (1978) Laugh After Laugh . Jacksonville,
FL: Headwaters Press.
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| 40. | Walsh, J. (1928) Laughter and Health .
New York NY: D. Appleton & Co., pp. 147-148.
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