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May 30, 2000

Humor and Laughter for Health with Sherry Hilber, Margaret Stuber and Lonnie Zeltzer

By Sherry Dunay Hilber

Moderator: Welcome to WebMD Live's World Watch and Health News Auditorium. Today we are discussing Humor and Laughter for Health with Sherry Hilber, Margaret Stuber, MD, and Lonnie Zeltzer, MD. Sherry Hilber, who conceptualized and founded Rx Laughter, is an entertainment industry executive who has worked for CBS and ABC. Dr. Margaret Stuber is a cancer researcher and professor in the Department of Psychiatry and Biobehavioral Sciences at the UCLA Neuropsychiatric Institute. Dr. Lonnie Zeltzer is a UCLA cancer researcher, professor of Pediatrics and Anesthesiology, and director of the Pediatric Pain Program at the Mattel Children's Hospital at UCLA.

Sherry Hilber, Dr. Stuber and Dr. Zeltzer, welcome to WebMD Live.

Dr. Zeltzer: I'm excited that the three of us are together to talk not only about the Rx Laughter project, but also more broadly about the role of humor and laughter in health and illness. Maybe we could start with Sherry talking about the whole concept behind the Rx Laughter concept.

Hilber: One of the things that I noticed for other people as well as for myself is that whenever I would go to the doctor, whether it be for outpatient or surgery, there was fear and anxiety. Once we were there at the hospital, I noticed there was a lack of focus on psychological and spiritual aspects of their healing. It seems to me that right now hospitals are becoming more interested in promoting well-being than in the past. That motivated me to believe that now is more of an opportune time to bring Rx Laughter to a hospital like UCLA. That had a lot to do with why I thought Rx Laughter was going to serve a need. Rx Laughter is a project that's going to try and discern how humor can hopefully improve the immune system of children and adolescents for this particular five year project at UCLA, reduce pain, manage pain in specific ways and therapeutically help the patient emotionally. This ties in with fact that if you feel better psychologically, hopefully you'll feel better physically. We are using as our resource funny television series and films, mostly classic ones such as Abbot and Costello, Marx Brothers and others.

Dr. Zeltzer: Dr. Stuber, can you talk about the science end of where you're trying to take this?

Dr. Stuber: As a psychiatrist, it's obvious to me that people's attitude makes a difference in how they approach medical illness. We're trying to see if humor can assist the healing process. We're interested in looking at what physiologic changes happen when they are laughing and when they're not laughing but amused. We want to see whether there are actual immunologic changes in children when they are responding to humor. We're hoping that if there are some changes, not only temporary but long lasting changes, that these could be used to promote healing of children who are receiving medical care at UCLA and other Children's Hospitals.

Dr. Zeltzer: How much do we know about the impact that laughter and humor have on people's physical well-being? We all know we tend to feel better after or while we are watching something funny, but what do we know about what's going on inside our bodies when we feel like this?

Dr. Stuber: The information we have right now is relatively limited. There are lots of stories, anecdotal evidence that laughter is the best medicine, as the Reader's Digest has said for many years. We have a center at UCLA that was founded by Norman Cousins to really explore the whole area of the interrelationship of the brain and the body with a specific emphasis on humor. However, most of the research that's been done that has scientific validity has focused on the other side, the stress side, rather than positive emotions. The research that has been done with positive emotion has been mostly with adults and most of it has focused on AIDS and cancer.

Dr. Zeltzer: I remember reading that there are some studies in healthy adults in laboratory settings where these adults, maybe seven or eight, would be set in front of a video watching something funny and have blood samples taken before and after. I found it interesting that some of the same chemicals in the body that were elevated after watching the funny videos are the same chemicals that are part of the body's natural pain control system and are similar to some of the neurotransmitters that play a role in mood.

Dr. Stuber: There are a number of different approaches that could be done. I think that the most immediate things that we could look at would be looking at the immediate changes in the body, both chemically and immunologically in response to humor. I think that what will be most interesting will be to see if we actually can have more sustained changes in the body as a result of these kinds of interventions. David Spiegel, who is a psychiatrist and professor at Stanford and is on advisory board for Rx Laughter, has done some studies looking at lasting impact on health in adults with very advanced illness with a relatively short series of interventions, in that case not so much geared toward humor as feeling more in control, but those are some of the kinds of things we'd want to look at.

Dr. Zeltzer: It's 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 favorite 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 procedures.

Hilber: I think also another important aspect is that -- my hope is that not only will they enjoy the funny video and hopefully this will help in healing, but that the next time they have to come back to the doctor, it'll be a less frightening memory and they'll be more apt to be okay with coming back.

Dr. Stuber: One of the things we know is that the first association that you have with an event is going to color the way you think about that experience or that place or those people. Absolutely, if we can make the hospital and doctors and even the treatments less frightening and painful from the very start, we reduce the anxiety for the children always after that.

Hilber: Working with children and adolescents with this is very rewarding of a more positive memory of going to a doctor, because we're looking at a whole lifetime of preventive check-ups and things of that nature. I know if I had had more positive memories as a young child, I would probably be much less fearful as an adult and therefore would be more apt to want to get those regular check-ups. I can only speak from a creative standpoint and children love physical humor. I think adults love physical humor, too, and that's why the Marx Brothers and Abbot and Costello and others have been for all ages. They withstood the test of time and also children and adults have enjoyed them. And in terms of the types of tapes that will be used for the children in Rx Laughter, I would say much of it is for physical humor.

Dr. Stuber: I think it's an excellent question and I'm not sure we know. What I'd like to address as a piece of that is that there are lots of physiologic differences between children and adolescents and adults that can change a lot as children mature and develop because of the maturation of their brain and of changing hormonal levels. You can't even talk about the way children respond. There's also another element of complexity here, and that's that individuals respond in different ways to humor and laughter. We were struck with that in some of our preliminary parts of this research, observing some children watching the tape. We had two girls, same age, sitting next to each other and one of them was laughing 2 to 3 times as much as the other. They were both rating the program the same as to humorousness. Does it make a difference if you're somebody who laughs easily? I think we're going to have find some of those things out.

Hilber: I agree, and I think the most interesting thing, creatively, is here is a segment that isn't laugh-out-loud continuous funny but is humorous, and should that be included in the project? Yes, they are, and will be just to see what Dr. Stuber is talking about.

Dr. Zeltzer: I also think that we don't know, as Dr. Stuber said, whether just finding something funny has the same effect as the physical act of laughing out loud. Does that do something different to the body in relation to pain, health and illness? What are the individual differences in ease of laughing out loud? If it's found that the actual act of laughing aloud is an important component in impacting the immune or cardiovascular systems, can those children less prone to laughing aloud be trained to laugh more readily? As Dr. Stuber was saying, throughout childhood, the central nervous system and the brain are developing and changing. Early on, there is much more plasticity -- the ability to change -- than there is in adulthood. We know that young children experience significant pain or events that can alter their system and make them more sensitive to pain. When looking at the role of laughter in reducing pain, we're looking at the potential of altering the nervous system in a more fortified way, maybe to guard against the development of chronic pain. The excitement of studying children, both early on and in adolescence, is that it really will inform us to a great degree about what might be done in a preventive way in dealing with adult chronic pain and adult chronic illnesses in general.

Dr. Stuber: I absolutely agree. Coming from a different angle, I would say very similar things about the prevention of some of the kinds of brain and central nervous system changes that we see in post traumatic disorder. We know that some of those changes are dependent on the way that somebody responds emotionally at the time of the event, that a traumatic event is only traumatic if you experience it that way. In most things, there is some room for interpretation and to the extent that we can make something like a medical procedure less frightening, we can actually make a difference in the way that that memory gets laid down in the brain and make a difference in the way that they approach medical procedures, but also in just their whole level of anxiety or arousal, how much they respond to things they see as threat. We could make a difference in somebody's developing brain. Dr. Zeltzer and I originally met 15 years ago around our mutual interest in hypnosis and other kinds of interventions that could be used for children going through painful procedures. There are a number of interventions that have been tested, and there is evidence that you can get somebody to think about something else during the procedure.

Dr. Zeltzer: I think that what is interesting, and what has not been studied, is the content of what the distraction involves, and the impact of the content. For example, is it thinking about somewhere fun or nice? Does it have the same effect as just a pleasant image, or watching something interesting versus something really funny? That is going to be a really exciting component of the Rx Laughter research, to look at the kind of emotions elicited during a distracting event, and looking at how the content of the distraction affects the nervous system differently.

Hilber: I'm reminded of a tape that was sent to me by one of the members on the advisory board of Rx Laughter, Madelyn Pugh Davis, who was an original writer of I Love Lucy. She sent me a tape of the sitcom "Ellen" in which Ellen goes for a mammogram and it's painful for her and she's told beforehand that if she thinks of a funny episode in a sitcom, it will help. While she's having the mammogram, she thinks about a Lucy episode and she keeps repeating it and visualizing it and it does help her get through the procedure. I thought that was very funny.

Dr. Zeltzer: Sherry, what you just described reminds me of one of the goals of the Rx Laughter project, which is to show the ways in which humor and laughter influence pain. For example, especially medical procedure pain, we can think about creative ways in which medical treatment rooms might be designed differently to provide a more therapeutic environment that might actually have a physical effect on pain.

Hilber: Absolutely. One of the goals of Rx Laughter is that therapeutic component. We could even take tapes geared to that particular treatment area, sitcoms that have been on that have addressed other areas and use them, absolutely. And that's the large ultimate goal of the therapeutic component.

Dr. Zeltzer: Yesterday, we went with Sherry and Dr. Stuber on a tour of the children's hospital at UCLA with some of the members of the board of advisors for Rx Laugher, and I was really struck by a young boy in the dialysis unit, and he was 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 they asked what his favorite episode was, and he immediately remembered the "Lucy" episode where she was going on an airplane and 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 was describing 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 hemodialysis made me think of the power of laughter.

Hilber: I remember that, and I remember thinking how wonderful the connection was and the additional aspect from the child's point of view. These people care enough to be here to do this, to laugh with me. The hospital, the doctors care enough, and I think that's another aspect of what Dr. Stuber, Dr. Zeltzer and I are trying to do with this project.

Moderator: Are you familiar with the recent research on Child Life Science?

Dr. Stuber: We read that research, and we actually work with the Child Life and Child Development Services at the Children's Hospital at UCLA. Child Life Specialists are in most pediatric hospitals. These are people who have specific training at either a bachelor's or master's level in child development. Their area of expertise is really what children of different ages need and how they develop in normal development. Their job in a pediatric hospital is to provide an environment for children to be able to live and grow and develop normally while they're in the hospital having medical care. Child Life Specialists are an essential part of any children's hospital. They help the pediatricians to remember they have this child they need to be considering. They also coordinate the many people in the community who want to help and they make sure there's an environment within the hospital that includes places to play and learn. Certainly, as the studies have shown that distraction helps children cope with pain, the child life specialist helps children become distracted, provide activities for children while they are hospitalized and help prepare children for medical procedures by helping them practice coping strategies, what to expect so the event doesn't feel as threatening and unknown, and really play a role in helping children cope with pain through a variety of distractions and interventions. Certainly both of us are very indebted to many years of research that's been done with a number of interventions with some of our colleagues like Susan Jay. What we're trying do is actually ask a slightly different question about the specific content of the distraction. Is it really just thinking about something else other than what is happening to you, or is it feeling more control of the situation, or is really there something additional and special about humor and laughter that adds another dimension that makes it more powerful than simple distraction?

I'm not sure all of what I could say to you about what's involved with laughter. We know that it involves breathing differently. We know that it's essential for people to periodically sigh when they breathe, that it's not enough to just breathe at same rate all the time. Certainly the kind of deep breaths that happen when you have a belly laugh makes a difference. It makes a difference if you're breathing by using your abdominal muscles and that is the essence of a belly laugh. What is interesting to me is that probably the less obvious aspects of laughter may be even the more important ones, that is, that it probably changes the chemistry in your brain and when it changes chemistry in brain, that changes way you perceive things around you. You're less irritable, you're happier, things don't bother you as much, you feel less anxious, less pain. That could be evaluated physiologically. I suspect it changes a lot of aspects of the chemistry in the brain and hormones in the body.

Hilber: If there are certain tapes that do bring on outward laughter for the patient -- I think that they might feel like "I'm in control, I'm taking care of myself, I'm enjoying this but as I'm laughing, I'm probably healing myself. I'm giving myself a prescription." There is that feeling of taking control and being a part of the process -- essentially a prescription of laughter they're giving to themselves.

Dr. Zeltzer: What is interesting to me, and certainly has not been answered yet scientifically, is the difference between finding something funny and not showing visible signs with the face or laughing or vocalizations, but just to one's self really enjoying something funny, and what changes take place in the brain and body, how is that different from finding something funny and smiling where you're not laughing but your facial muscles are moving. We know there are certain connections between the facial muscles and the autonomic nervous system. And then the third act of actually laughing out loud, where breathing rate, abdominal wall musculature and probably other parts of the body change as well. We really don't know how those are all linked in terms of physical effects, and whether they are linked to health, illness and the immune system. That will be an exciting thing to look at in the future.

Moderator: What do you see in the future for the Rx Laughter program?

Hilber: Rx Laughter is not only national but international is the goal. This research will help us a great deal towards knowing how the tapes can be used therapeutically. We will be doing that as a complement from here on. We can do that nationally and intend to at other hospitals. I would love to see an in-hospital entertainment viewing system of both already produced videos such as the TV and film shows that we're using now, in addition to newly produced health education videos, comedy health and other entertaining videos. That could be at various hospitals and have an interactive component.

Hilber: The website is www.rxlaughter.org. There is a "contact us" button and if they fill in the information there as to any questions or anything they want us to know, one of us will review it and we will get back to them.

Moderator: As we near the end of our time today, would you care to offer some final thoughts?

Dr. Zeltzer: I will just say that I am certainly very excited to proceed with this project that Sherry Hilber brought to Dr. Stuber and myself. It has created a momentum of its own and we have planned a whole line of research that will be exploring many of the things we talked about today. It will be a fun project. I'm sure the children will enjoy it, and we as investigators are excited about the possible outcomes.

Dr. Stuber: I also am very excited about this project at two levels. I find some of the scientific questions intriguing and some that I think will lead to a lot of other questions that we'll find interesting to pursue for quite some time. The more immediate exciting part of this is that we're coming up with something that I think can have clinical benefits right away for children who really do need our help and working together with other people within pediatric settings can really make an immediate difference in the lives of children with chronic and serious illnesses.

Hilber: The fact that Dr. Stuber and Dr. Zeltzer have been so interested and continue to be supportive and involved puts an incredible stamp of credibility on the project and helps it to increase momentum. It's also exciting to see physicians and entertainment industry executives and performers come together in this project and which will be the Rx Laughter website in a few weeks. Using my experience as a network executive, it's very fulfilling for me that I'm using everything I've done in my career in a way that could very possibly help people physically and emotionally in ways that have not yet been discovered.

Moderator: Ms. Hilber, Dr. Stuber and Dr. Zeltzer, thank you for joining us today.

Dr. Zeltzer: Thank you, goodbye.

Hilber: Thank you.

Dr. Stuber: Thank you.

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