Whoever said, ‘laughter is the best medicine’ never had gonorrhea — cover
Illustration by Barry Blitt
David Goldbloom (PGME’88 Psychiatry), a professor in the Department of Psychiatry, describes this as one of his favourite lines (from the sitcom My Name Is Earl). “It’s incredibly funny,” he says, “but also true.”
For as much as Goldbloom loves to laugh, and make others laugh (his talks and lectures could headline at The Second City), he believes the wildly popular hypothesis that laughter can heal “should be subject to the same rigorous scientific testing as any other potential intervention.”
It’s sobering how little scientific study has been devoted to the health effects of laughter through the years.
Search PubMed for “the physical effects of stress” and more than 42,000 studies come back. Searching for “the physical effects of laughter” turns up 60.
“There simply isn’t enough good scientific evidence showing that humour is an effective medical intervention,” says Professor Trevor Young, Dean of the Faculty of Medicine. “You can ask what’s the harm? But there’s an opportunity cost to everything in medicine. That’s time and money that could be going to mindfulness meditation, psychological support or exercise — practices with more evidence to support their effectiveness on health.”
While the literature may suggest it’s premature to take humour seriously as a medical intervention, the body of evidence supporting the health benefits of laughter is growing — along with patient interest.
While the literature may suggest it’s premature to take humour seriously as a medical intervention, the body of evidence supporting the health benefits of laughter is growing — along with patient interest. In part, the trend reflects the profile of today’s patients, eager to practice self-care and see for themselves if laughter can help heal what ails them. All of which poses a sticky question for doctors, rehab therapists and other providers — should they take it seriously?
William Steig / The New Yorker Collection / The Cartoon Bank
“This appears to be a pile of rubbish …”
Many physicians feel laughter deserves special status in medicine, since it isn’t a drug, has no known negative side effects and is relatively inexpensive. Howard Bennett, an American paediatrician and writer of medical satire, says that while it’s always worth answering whether an intervention offers clinically relevant benefits, “the threshold for thinking about laughter in this way is lower. I don’t want to be selling anything that doesn’t work, but as a practitioner, I would gently suggest it’s worth giving it a try.”
Part of the problem is that in medicine, “much of the attention has traditionally focused on the health effects of negative emotions, sadness, fear, depression and anxiety,” says Mel Borins (MD’73), an associate professor in the Department of Family and Community Medicine. (Borins writes about laughter as the “jest medicine” in his latest book, A Doctor’s Guide to Alternative Medicine.) He feels the paucity of laughter research is due, in part, to a simple fact: “It’s a drug that nobody can patent.”
Those who do manage to find funding for laughter studies aren’t always taken seriously. In 2014, Sophie Scott, a scientist at University College London, described in The Guardian how she’d picked up her laughter study consent forms off the printer at work to discover a colleague had written on them, “This appears to be a pile of rubbish …”
Designing studies to investigate the effects of laughter also poses unique challenges. After all, coming up with methods to make people laugh their heads off involuntarily is every comic’s dream. Pulling it off while subjects are also wired to ECGs or blood pressure monitors is tougher still.
“I think people want to believe that something fun is good for you, and small doses every day are probably helpful, but proving long-term benefits is tricky business,” says laughter researcher Mary Bennett.
In a 2003 study involving 33 women, for instance, Bennett, director of the Western Kentucky University School of Nursing, showed that laughing out loud boosted the immune systems of those who watched a comedy show, as measured by their levels of natural killer cell activity before and after the viewing. But how long the effect lasted, she couldn’t say. “The difficulty in designing studies for measurable effect relies on pre- and post-tests that can be performed quickly,” she says. “I think the spike would be relatively brief and then gone.”
All of this helps to explain why most laughter studies have been small and the observed effects short-term.
Still, no one doubts that laughing feels good, and several studies find laughter therapy to be a mood booster, even among cancer patients. In June, British and Finnish researchers used PET scans to help explain why. Their work showed that laughter, like physical exercise, releases endorphins that act like a feel-good drug on the brain’s opioid receptors, especially when laughing with friends. The more receptors the subjects had, the more they laughed. The researchers also found that a laughter-induced endorphin rush had the added benefit of elevating the subjects’ pain thresholds.
The report, published in the Journal of Neuroscience, is just one of the latest to suggest that the health benefits of laughing may be wide and diverse: boosting the immune system, blocking harmful stress hormones, protecting the heart, reducing pain, increasing blood circulation, lowering cholesterol in diabetics, improving working memory and even burning calories (no joke). In 2005, Nashville researchers made headlines worldwide after they found 10 to 15 minutes of laughter could burn up to 40 calories a day or four pounds a year.
James Stevenson / The New Yorker Collection / The Cartoon Bank
A Belly Laugh Is Best
When it comes to potential health benefits, however, not all laughter is created equally. Most research suggests it’s the full Monty belly laugh, over the smirk or chuckle, that provides the most benefit. As Borins explains, a hearty laugh is a whole-body experience. “When we laugh, it stimulates the parasympathetic nervous system. Cortisol, serotonin and dopamine are released. Your heart speeds faster, your breathing gets deeper. You start to aerate the dead space in your lungs. A good belly laugh will raise your blood pressure, then lower it down, lower than it was beforehand. When we laugh, the tension in our muscles increases while we laugh, and then afterward, it decreases. It’s an anti-stress response.”
We don’t recommend that you laugh and not exercise, but we do recommend that you try to laugh on a regular basis.
Other research has also linked a good laugh to healthy blood vessels. A study from the University of Maryland found laughter prompts the inner lining of blood vessels, the endothelium, to expand in order to increase blood flow. In contrast, subjects who watched a movie that produced mental stress experienced reduced blood flow as their vessels constricted.
Lead author Michael Miller, a cardiologist, likened the benefit to exercise: “The magnitude of change we saw in the endothelium is similar to the benefit we might see with aerobic activity,” he said. “We don’t recommend that you laugh and not exercise, but we do recommend that you try to laugh on a regular basis. Thirty minutes of exercise three times a week, and 15 minutes of laughter on a daily basis is probably good for the vascular system.”
Why the Laughter Spread
The notion of laughter as therapy has flourished as a branch of positive psychology ever since American journalist Norman Cousins likened it to a powerful drug that helped him overcome a rare disease in the 1970s. Cousins, the long-time editor of the popular Saturday Review magazine, had been diagnosed with ankylosing spondylitis, a painful and life-threatening form of arthritis. Doctors gave him a one-in-500 chance of recovering, but Cousins was determined to beat the odds.
Evidence around at the time suggested that stress and other negative emotions could worsen his condition. So Cousins set out to discover whether positive emotions, humour especially, could improve it. Dosing himself heavily with vitamin C and a regimen of Marx Brothers movies, episodes of Candid Camera and funny books, Cousins later wrote, “I made the joyous discovery that 10 minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep.” He also reported that his unorthodox treatment approach lowered his sky-high levels of inflammation.
In 1976, The New England Journal of Medicine, took the unusual step of publishing the personal findings of a layman, and Cousins followed up with a bestselling book, Anatomy of an Illness: A Patient’s Perspective, which sparked new scientific interest in the therapeutic benefits of positive emotions, particularly laughter.
“It could be one of those things that crawls in your ear and lays eggs, and the eggs hatch and burrow into your — nope. It looks fine.”
Leo Cullum / The New Yorker Collection / The Cartoon Bank
Joke of the Month
A few years after Cousins’ book came out, Borins found himself compelled to attend a conference on the therapeutic effects of laughter. He came away convinced that positive emotions have a role to play if not in healing, then certainly in communication between doctors and patients.
“When I returned (from the conference) I realized my office was a pretty serious place. I would go through a day without much laughter,” he recalls.
Borins decided to make a point of noticing people’s mouths and, when they smiled, he smiled back. This consciousness led to the creation of an unusual practice within his office — a joke contest — that still runs today. He invites patients to share a joke and the best one each month wins a small prize.
“The patients love it,” Borins says, noting that kids bring knock-knock jokes, and the adults bring all sorts. One of his favourites: A guy goes to the doctor and says I bark like a dog, I sometimes believe I’m a dog. I sometimes pee on fire hydrants. My family thinks I’m crazy. The doc asks how long has this been going on? The guy says ever since I was a puppy.
“So much of our lives we are conditioned not to laugh,” Borins says. “In school, we’re told ‘to wipe that smile off your face,’ or ‘I’ll give you something to cry about.’ We’re trained to believe that laughing is often inappropriate… We take life perhaps too seriously, so any opportunity to laugh or giggle is welcome.”
Laughter is “not medicine per se,” but it is both relaxing and healing and deserves further study
Borins believes laughter is “not medicine per se,” but it is both relaxing and healing and deserves further study. In his own experience, just thinking about a funny video when he is at his dentist, he says, “I can laugh myself out of the need for pain medication.”
Could laughter be an overlooked key to developing new anti-depressants? U of T researchers Donald Stuss and Prathiba Shammi (MA’92, PhD’97) have done seminal work identifying the frontal lobe as the place where humour is processed and laughter is generated in the brain. Stuss, founding director of Baycrest’s Rotman Research Institute, and Shammi were exploring how brain injuries, such as a stroke, affect our appreciation of humour. But if scientists could understand more about how humour works, could they also tune up the brain’s laughter network to fight depression? After all, you can’t be depressed in the exact moment you’re laughing. And we know that frontal lobe functioning is affected by depression.
It’s a possibility that intrigues David Mikulis, Director of the Functional Neuroimaging Lab in the Department of Medical Imaging, who conducts functional MRI studies of the brain. “Could humour strengthen anti-depression networks or weaken ones that stimulate depression?” he asks. “With deep-brain stimulation using implanted electrodes, we’re understanding the power of turning on and off these networks. If the electrode is in the right spot in the brain in a Parkinson’s patient with incapacitating tremor, for example, you can completely restore the ability to write again.” Perhaps laughter could work in a similar fashion, by turning down overactivity in the depression network.
“It’s a very hip disease, so it’s good we caught it early, before everyone’s talking about it.”
Jason Adam Katzenstein / The New Yorker Collection / The Cartoon Bank
The Second-Best Medicine?
While debate continues around laughter’s therapeutic value in the clinic, most doctors believe humour can often be a boon to communicating with patients.
“Medicine, by its nature, sets up a weird dynamic — in comes a stranger and you have to care and the stranger has to trust you. But if you can share laughter, that’s therapeutic, likely for you both,” says Jeremy Rezmovitz (PGME’11 Family Medicine), an assistant professor in the Department of Family and Community Medicine.
Rezmovitz (who claims “I’m hilarious, but most people don’t know it”), trained and worked as a stand-up comedian on his long road to medical school, and says deciding how or if to use humour with patients is like any good performance: “It’s about knowing your audience.”
Just as not all doctors are funny, not all patients are receptive to jokes. And sarcasm, Rezmovitz says, “has no place in medicine. It’s just confusing for 99.9 per cent of patients.”
For health providers to become more attuned to their patients, Rezmovitz recommends improv — the art of acting out an unplanned skit, often a comedy scene, on the fly. “It helps doctors to deal with uncertainty and communication. It allows you to practise reflection until its reflexive.
“In an improv sketch, we play with the power dynamic — so how do you give more power to the patient? You try to be less pretentious, more humble. I’m 6’3, so I sit on a foot stool because I want the patient to look down at me,” says Rezmovitz, who has run improv sessions for his peers. In January, he’ll teach it to Family and Community Medicine residents for the first time.
Participants don’t have to be funny, clever or witty, he stresses, just supportive of each other and ready to try it — from there, “laughter naturally flows.” And as everyone knows, laughter tends to be contagious. Studies suggest people are 30 times more likely to laugh with others than by themselves.
Rezmovitz calls laughter “the second-best medicine.” The first best, he says, “is medicine.”
“I firmly believe there’s a right drug for the right patient at the right time. Laughter may not be it, but sometimes, it might be.”