Using Humor to Ease Painful Medical Procedures with Children
Many medical procedures produce some level of pain. Such procedures are difficult for all of us to get through, but they can be an especially big source of distress for children. To take just one condition -cancer in children - as an example, there are many painful procedures that have to be endured, including inserting and removing catheters and drug delivery systems, injections, bone marrow aspirations and lumbar punctures. Children who go through these procedures experience a great deal of distress and pain; and the distress generally increases over time with the need to repeat the procedures.71
Given the strong evidence that humor helps manage many forms of pain, some hospitals and researchers have started to look at ways of using humor to help manage this pain. The use of clowns in pediatric units of hospitals (discussed in Humor and Nursing II) is - at this point - the most common approach to helping kids cope. The clowns are used to boost the children's spirits and take their minds off their pain or discomfort. Some hospitals have also explored other approaches to bringing humor to pediatric patients.26
An exciting study has now been underway for several years at the Mattel Children's Hospital at the University of California at Los Angeles. This ongoing project - called Rx Laughter - is studying the power of humor to help children manage painful medical procedures and to support patients' wellness in general. One of the researchers, Dr. Lonnie Zeltzer, noted that she could recall many children finding their own ways to use humor to cope with medical procedures over the years before Rx Laughter was begun.
"It is interesting that many years ago, in the early 1980s, when I was studying the impact of children using their imagination to control severe medical procedure pain, many children would spontaneously imagine themselves watching a TV program, and almost invariably these imaginary programs were funny. Many of these children would be smiling or even giggling during the procedure, and when asked they would describe the funny things they were seeing on their imaginary program. Children who did this had significantly less pain and discomfort during the medical procedure."27 (Italics are McGhee's.)
Consistent with Dr. Zeltzer's observation, research has shown that some children do learn to use humor to manage pain on their own. These children also tend to initiate other adaptive ways to distract themselves from the pain.28 One group of researchers developed a test which specifically measures the extent to which children use humor to cope with pain. They found that among pre-adolescent children going through various painful procedures while hospitalized, those scoring higher on the humor measure rated the procedures gone through to be less "unpleasant" than children with lower humor scores.29 So their own humor coping style served them well in reducing the unpleasantness of their hospital experience. Data from Dr. Zeltzer's own Rx Laughter Project have shown that children are able to leave their hands in painful ice water longer while watching comedy videos.30 Interestingly, children who watched the comedy video with their hands in the ice water did not rate the procedure as being less painful. But the fact that they left their hand in longer suggests that they were distracted enough by the video to not notice the painfulness of the ice water until it became more intense.
Dr. Zeltzer shared an observation from Rx Laughter which captures the way in which humor can transform a child's experience in a pediatric unit.
"Yesterday we went ... on a tour of the children's hospital at UCLA with some of the members of the board of advisors for Rx Laughter, and I was really struck by a young boy in the dialysis unit, and he was just sitting there quietly. Two of the former writers from I Love Lucy had come up to him and asked him if he ever watched the show. He said he loved the show . . . [and that his favorite episode was] where she was going on an airplane and was trying to hide a huge cheese she was bringing on board, so she put it under her blouse and pretended she was pregnant. He was laughing as he described the story. The writers began to tell him how they got the idea for that episode, and the child was laughing. Watching this boy, who was in his teens, and these writers, who were probably in their late 70s or early 80s, laughing hysterically while he was in the middle of hemomdialysis made me think of the power of laughter."77
What Causes the Pain Reduction Associated with Humor and Laughter?
For those who do experience pain reduction following humor and laughter, why does it occur? We have known for a long time that emotional stress makes pain worse for many conditions, so part of the pain-reducing impact of humor may be due to humor's amazing ability to help cope with stress (this is discussed in Humor and Nursing II). But what is the physiological mechanism that is responsible for humor's pain reducing power? There has been no definitive answer to this question, but the four most likely candidates are discussed below.
• Mental Distraction. One possibility is distraction. Humor - especially humor that is fully engaging and really cracks you up - is a very effective means of drawing attention away from the source of pain or discomfort and there is every reason to think that this influences the brain's pain channeling mechanisms.78 There is some evidence that humor, music and a mentally-engaging arithmetic task result in comparable levels of increased tolerance of painful stimulation; this is consistent with the view that the key to humor's pain reducing power may be distraction.79
• Release of Endorphins? It has long been speculated that humor - or perhaps the act of hearty laughter itself - causes the release of endorphins or other endogenous opioids (natural pain killers) in the body, and that this provides an analgesic effect for some period of time. The net effect of this would be reduced pain. This explanation makes good sense, but as of early 2009, there are no published data documenting the endorphin effect. Investigators who have tried to show the endorphin-humor connection have failed to do so.80
• Muscle Relaxation. Regardless of whether laughter does or does not trigger the release of endorphins into the blood stream, its ability to reduce pain is undoubtedly partly due to its reduction of muscle tension. Even brief relaxation procedures (in the absence of humor) have been shown to reduce pain - both in laboratory and clinical settings.81 Many pain centers around the country now use meditation and other relaxation techniques to reduce the level of pain medication needed by patients. Laughter is just one additional technique for achieving the same effect. There is some evidence that genuinely mirthful laughter (i.e., laughter associated with the experience of humor) triggers a stronger muscle relaxation effect than laughter without mirth.82
As already noted, this muscle relaxation effect has its practical side in hospitals. Some nurses tell patients jokes before giving them shots, because they know it keeps them from tightening up their muscles in anticipation of the shot.
• Activation of Pleasure Centers in the Brain. Recent research (discussed below) has documented that humor activates known pleasure or reward centers in the brain. The elevation of dopamine levels by humor in connection with these pleasure centers may either directly or indirectly reduce the level of pain experienced. This view is strengthened by recent findings that pleasurable and painful (or otherwise aversive) stimuli appear to share some of the same neural circuitry.83
Lower Blood Pressure
Another clear byproduct of stress is elevated blood pressure. As might be expected, there is evidence that humor and laughter over an extended period of time help lower blood pressure. As your heart beats more rapidly during laughter, it pumps more blood through your system, producing the familiar flushed cheeks. Not surprisingly, blood pressure increases during laughter, with larger increases corresponding to more intense and longer-lasting laughs.84 If this were a lasting increase, it might point to a harmful effect of laughter; but, consistent with the relaxation effect associated with humor and laughter, this increase does not persist. The best test of the capacity of humor and laughter to generate a lasting blood pressure lowering effect would come from studying the effect of increased amounts of humor and laughter over an extended period of time.
In an especially important finding along these lines, watching a comedy video three times a week while participating in a one-year cardiac rehab program was found to significantly lower blood pressure in individuals who had suffered heart attacks.85 While this kind of long-term outcome is important for everyone, it is especially important for those suffering from coronary heart disease. (This research is discussed in detail in the section on cardiac health below.) On the other hand, a six-week laughter exercise intervention was not effective in lowering blood pressure over this period.86 This may mean that a period longer than six weeks is required to show a real blood pressure lowering effect. But since the former study emphasized humor, while the latter focused on laughter exercises, this may point to the relatively greater importance of humor than laughter alone in managing one's blood pressure. Again, with the present level of research, it's too early to tell.
In another important study, a better sense of humor among a group of middle-aged police chiefs was associated with lower blood pressure - in spite of the fact that those with a better sense of humor also smoked more and consumed more alcohol.87
