Positive Health Online

Earlier this year Grace Adamson (Gawler) delivered an eloquent and persuasive address on the subject of integrated support in healthcare. Speaking at the Penny Brohn Memorial Lecture hosted by the Bristol Cancer Help Centre, she outlined the key elements necessary to transform the culture of care into a more cohesive whole. Of particular significance was the emphasis placed on recognising the three-way relationship between patient, carer and health professional, and the role of the health professional in giving patients and carers a voice with which to articulate their experience.

This voice helps to establish an empathic pathway through which health professionals may gain insight, and is one of the defining factors for establishing and maintaining the therapeutic relationship.

But giving patients and carers a voice brings with it the responsibility of listening to what they say! Listening is sometimes under-rated as a communication skill, but it stands at the gateway of the therapeutic relationship. When we think of humour therapy, listening may not figure at all! But come to that, how often do we think of humour therapy, and if we do, what exactly are we thinking of? As we move towards a greater understanding and acceptance of integrated healthcare, now is an appropriate moment to take stock of humour therapy and consider the potential contributions it could make within this evolving culture.

Humour therapy ... what do we mean by it?

Despite the immense growth of interest in complementary, and more recently, integrated healthcare, humour therapy has nevertheless remained something of a wild-card in the UK. Humour itself has sometimes had a rather uneasy relationship with science – a state of affairs which Jonathan Miller highlighted in his address to the British Association for the Advancement of Science in 1987. He ruefully observes that because humour is associated with enjoyment, it is frequently dismissed as being merely frivolous, adding, wryly that there is an expectation, particularly among journalists, that humour research should in itself be amusing, "rather as if it should be a qualification of a surgeon dealing with cancer that he or she should have the disease before operating upon it".

Some of the more wacky initiatives in business management training have done little to dispel this image, while humour therapy itself has not readily articulated its own objectives. Moreover the distinction between humour therapy and laughter therapy has not been made sufficiently clear. There are currently no sustained and systematic programmes for training humour therapists, and, consequently, no professional body through which to steer practice.

If humour therapy is to achieve even some of its potential and make a real contribution to integrated healthcare, it needs to set out its stall and indicate what it has to offer.

Thankfully, this has started to happen! Jane Mallett's excellent chapter on humour and laughter therapy in The Nurse's Handbook of Complementary Therapies establishes the benchmark.[1] It offers a comprehensive overview of the research literature and also discusses the considerable therapeutic potential of humour and/or laughter therapy in patient care. Crucially, it enables the reader to distinguish between the separate interventions offered by humour and laughter.

Two axes of humour: entertainment and interaction

The ways in which we perceive humour therapy are inevitably influenced by the ways we view humour in general. Humour is a vast and complicated field, but broadly speaking our perceptions of it are ranged across two axes – entertainment along the first, and interaction along the second. Sometimes these axes may intersect, but they also function quite independently of each other. Essentially, entertainment delivers humour to an audience. It is professionally worked, carefully timed and generally designed to make us laugh.

Humorous interaction, or grassroots humour, is spontaneous, individual and provides an alternative channel for interpersonal communication. It permits expanded freedom of expression through the establishment of a 'playframe', within which laughter may be incidental but not inevitable. Possibly, because of the influence of the media, the entertainment axis has tended to dominate the study of humour and, accordingly, grassroots humour has remained relatively unexplored. Nevertheless, it has been recognised as an extremely important channel for communication, for which Hugh Foot (Professor of Psychology at the University of Strathclyde) puts forward a strong case: "The versatility of humour in sharing thoughts and feelings and in conveying intentions and reactions cannot be matched by any other kind of social signal."[2]

It is through this versatility that we are able to voice thoughts and feelings which we might otherwise have difficulty in expressing. While the traditional view of the unwavering British stiff upper lip may be a little out of date, we are nevertheless generally reluctant to make public our personal concerns. Among these, we may harbour anxieties over personal identity, criticism, status and spirituality. But, crucially for this discussion, humour is also used to express thoughts and feelings on illness and on death. In articulating these, our most profound concerns, society places great reliance on the oblique and ambiguous language of humour. But if patients and carers are transmitting their thoughts and feelings on the humour channel, then there has to be some sort of receiver to pick them up! If integrated healthcare is to encourage patients and carers to voice their concerns, then it also needs to be able to tune into the alternative channel through which these concerns may most powerfully, but least conspicuously, be articulated. This is not to deny that many health professionals already use humour intuitively – nurses in particular often establishing good rapport with patients and carers through joking and banter. Nevertheless, scant attention has been paid to the model of humour therapy in which the patient is the transmitter of humour – the more familiar model being the one in which the process is reversed and the patient is the receiver.

Laughter therapy: The entertainment model

The familiar model of humour therapy has its roots in the United States and focuses principally on the beneficial effects of laughter. Norman Cousins' autobiographical account Anatomy of an Illness and the work of Dr Patch Adams (later popularised in the eponymous film) provided much of the driving force behind laughter therapy in the United States. Working on the principle that 'laughter is the best medicine', both men championed the power of its restorative properties – Cousins attributing his remarkable recovery from ankylosing spondylitis to laughter-inducing videos of Candid Camera and the Marx Brothers; Adams founding the Gesundheit Institute to promote humorous laughter as an adjunct to healing within the hospital environment. Subsequently, physiological research has given some credence to claims that humorous laughter is therapeutic. There are indications that it may indeed be of benefit to the immune system and may also lower cortisol levels.

Deriving from the axis of entertainment as distinct from interaction, the American model is designed to make us laugh; so patients are the recipients of humour therapy in much the same way that audiences are the recipients of professional humour. While patients may be free to choose a preferred genre of humour, their responses are nevertheless circumscribed by that choice. Moreover, by definition, laughter therapy can only really be appropriate to those patients who are willing and able to be made to laugh.

Humour therapy: the interaction model

The philosophy underpinning integrated healthcare places considerable emphasis on empowerment and self-help. Within this context, Grace Adamson discussed how best to deal with uninvited change and coping with fear, and stressed the need to give patients and their carers a voice with which to share and to reframe their experience.

But is there a role for humour therapy within this new paradigm? Is humour relevant to the process of change, the handling of fear and the sharing of experience? When we look more closely at the axis of interaction outside healthcare, we discover significant parallels. Those who find themselves caught up in change, for whatever reason, often resort to humour. The 'play-frame' which it affords allows the creation of an alternative reality through which they can explore unfamiliar territory. For example, the British abroad will sometimes make fun of foreign food or foreign customs. This is to help themselves come to terms with the unfamiliar and the threatening, and to provide themselves with some personal space in which to readjust. Humour enables people to reframe their experiences and to view their perceived predicament from an alternative angle.

The use of humour as a coping strategy is well attested – rich traditions being found in stressful occupations such as the police, teaching and, of course, nursing. In some ways coping humour resembles a catalytic converter – stress, fear or anger go in at one end and emerge from the other as laughter! While in practice it is rarely that straightforward, humour nevertheless is immensely valuable in helping people reframe traumatic and stressful experiences – transforming them through humorous narrative and discourse. Equally valuable is the feeling of mutual support and bonding which is established through sharing these experiences. Such episodes, in turn, feed into and nourish the culture from which they originally sprang.

Since humour is already acknowledged as a channel through which people make powerful statements about their personal worlds, these parallels cannot help but invite us to give serious consideration to the interaction model of humour therapy. It offers a tool which is capable of providing a unique insight into the thoughts and feelings implicit in the humour created by patients and carers. To take advantage of this tool would be very much in the spirit of Carl Rogers: "the therapist senses accurately the feelings and personal meanings which the client is experiencing and communicates this acceptant understanding to the client."[3]

If we consider the three-way relationship of patient, carer and health professional mentioned earlier, there is a strong case to be made in support of humour therapy as a diagnostic tool. Mapping and interpreting grassroots humour inevitably contributes to our understanding of those who create it. It follows that, by responding to it and encouraging it, the therapeutic relationship will not only be enhanced but also reinforced.

Mapping humour and constructing a humour profile: practical considerations

Recent research in the field of humour studies has lead to the development of a diagnostic tool which is particularly suited to humour therapy. Originally devised for an M.Ed research project at the University of Cambridge School of Education, it has since been further developed to provide a precise but user-friendly system for mapping and interpreting humour. Underpinned by a system of Humorous Interaction Categories (HICS), the method was designed to offer practitioners a flexible investigative tool with which to 'unwrap' humorous interaction layer by layer. Because it enables humour to be readily broken down into a number of component parts, it can assist practitioners to assess not only how and why patients and carers may be using humour, but also to identify the genres and techniques which they may employ. Thus, it enables practitioners to construct the humour profile of a given individual within the context of an integrated healthcare programme. This humour profile provides a unique perspective on an individual's behaviour. It can indicate how a patient may perceive their condition, their treatment and their hopes and fears for the future. Similarly it can indicate the concerns of a carer who may be riding a roller coaster of conflicting emotions including sadness, helplessness, guilt and resentment. It provides a window of understanding with therapeutic implications that are difficult to ignore. It's a short step from understanding humour to understanding through humour.

Postscript

When Grace Adamson spoke of integrated care she chose a quotation from Robert Louis Stevenson to illustrate its charter:

"Life is like a card game. It is not about how you play a good hand, but how you play a bad hand well."

She went on to ask,

"How can we help people to play their bad hand well?"

Maybe by taking their humour seriously.

References

1. Mallett J. Humour and Laughter Therapy. in Rankin-Box D ed. The Nurse's Handbook of Complementary Therapies. Baillière Tindall. Edinburgh. pp195-207. 2001.
2. Foot H. Humour and Laughter. in Hargie O ed. A Handbook of Communication Skills. Croom Helm. London. pp355-382. 1986.