Hospice techniques Clinical clowning: Humor in hospice care Maiy Ellen Killeen, ACSW
Introduction The attention to humor in the health care field, and particularly in work with terminally ifi clients, is both overdue and extremely welcome. If Norman Cousins is the grandfather of the move to celebrate the impact ofjoyful attitude toward healing, today we see many descendants contributing to the field. Recently I attended a national professional conference and eagerly signed up for a workshop on the use of humor in oncology social work. I was a few minutes late and creptquietly into the hushed room where an intent, serious speaker heldthe attentionof the equally serious audience. My immediate reaction was thatI had walked into the wrong workshop. After all, with humor as a topic, there should be more lightness and relaxation evident. It was
Mary Ellen Killeen, ACSW, Visiting Nurse and Home Care, Inc., 945 AsylumAvenue, Hartford, Connecticut.
the correct workshop and the speaker did a fme job setting out the theoretical underpinnings of humor’s place in casework with oncology patients. And the audience did an admirable, and serious, job, of pondering on humor. But it is not funny when humor is taken so seriously. My reaction to this workshop was that an opportunity was lost in teaching about humor as one would teach mathematics. What I had hoped to find in attending that workshop was greater discussion of concrete ways to apply humor in our daily work. Much of the literature on humor today continues to stress a theoretical basis rather than practical application. Caregivers are still taking themselves and the topic too seriously. “Without humor and joy, there is no health,” asserts one humorist who trains professionals in the health and business worldsin developingbuoyant sense of humor.’ His definition of humor expands beyond the mere telling of jokes and speaks of a carefully cultivated perspective “that allows you to take yourself lightly, while taking your work or your problem seriously.” It is in the spirit of learning how to take oneself lightly while working with seriously ill people that I write this article for fellow caregivers. Hopefully, it will suggest a pathfrom ourheads, where we understand humor, into our guts, the home of good belly laughs. Basic reasons and benefits for using humor with ill people The benefits and rationales for developing this humorous attitude in
people facing serious, often life-threatening, illness are appearing with increasing frequency in the literature. Humor today is viewed as “an effective adjunct therapyinhealthcare and oncology” with potential for healing among a number of areas in a patient’s life.2
“Instead of... survival of the fittest, we should be working for the survival of the wittiest; then we would all die laughing.” —
Lily Tomlin
Specific benefits accrue along physiological, psychological, and interactive dimensions. Norman Cousins richly illustrated how his body, experiencing serious collagen disease, fought back and healed on a diet of deep, regular laughter. Studies show that physical laughter rewards the body with enhanced respiratory and cardiovascular functioning and relaxes the musculoskeletal system.3 Professional research merely validates other students of humanity, such as Groucho Marx who noted that “a clown is like aspirin, only he works twice as fast.”4 Another student of humanity, Lily Tomlin, spoke to psychological health when she observed that “instead of working for the survival of the fittest, we should be working for the survival of the wittiest; then we can all die laughing.”5 Psychologically, humor
The American Journal of Hospice & Palliative Care,May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
23
adds to the inventory ofcopingskills to reduce and manage stress, particularly the anxieties of a terminally ill person undergoing monumental body image changes and impending death. Additionally, laughing in the face of death empowers us to confront a taboo subject and rob it of some of its mysterious hold over us.6 The psychosocial aspect of an ill or dying client’s life is also positively affected by the use of humor. One of the greatest needs expressed by clients themselves is for direct and supportive communication during stressful periods. One important function of humor is communication that can serve as “a bridging mechanism” to greater joy, relaxation, and connectedness. A healthcare professional responding to an ill person with some humor also makes an important statement that the person exists beyond the confmement of the sick role. This recognition of the whole person supports the transition through a period ofoverwhelming physical and emotional pain.7 The relationship itself between client and professional also benefits from constructive humor and lightheartedness. Qualities inherent in a humorous perspective—flexibility, appreciation for the incongruous, spontaneity, humility—reflect well on the therapeutic bond and support empathic response. This use of humor allows for greater intimacy and can overcome resistance or fear. A reciprocal feeling for the comic actsto balance recognition of the tragic and facilitates adaptive response to change and loss.8 As humor has a place in helping clients and their families face the daily challenge of living with serious illness, so does humorplay a vital role in allowing healthcare professionals to face the same challenges and prevent burnout. Particular functions served by humor for professional staff include providing distance in a constructive way and reducing stress. Humor can additionally help
24
with acceptance of the frustrations associated with the work environment.9 One cannot meet clients playfully and joyfully unless those traits are con-
“... humor play[sJ a vital role in allowing healthcare professionals toface the same challenges andprevent burnout.”
stantly being developed and nourished in the caregiver. It needs to be stressed that a sense of humor is a skifi to be developed and fme-tuned.’°Apersonal perspective that recognizes absurdity, human frailty, cosmic jokes, and indefatigable human spirit can be learned. Luckily, the world provides us with rich learning material for this education. Barriers to using humor The hesitancy in comfortably using humor as part of one’s clinical repertoire is understandable. Professional training and supervision of healthcare professionals has nottraditionally supported reliance on such non-scientific approaches. In fact, cautious instructors may issue warnings against the use of humor because of the potential for evoking anxiety, masking hostility, or evading problems. While inappropriate humor can be viewed as aimed atbelittling or humiliating the client,’1 the fear about a specific misapplication has often been generalized to an across the board prohibition. Another important barrier is in the acknowledgment of the unarguable seriousness of the situationin which a person faces a terminal illness, marked by physical deterioration, loss of functioning, and ultimately death. The problem oftrusting humor inwork with terminally ill clients is compounded by
the lack of research on effects and application to practice with the specific population rather than the healthy or chronically ill that typically are the subjects of such study. Very little research has focused specifically on effects of humor on work with terminally ill people.12 One other barrier to the integration of humor into clinicians’ repertoire of skills may be confusion about being seen as less thansensitive or responsive to the real painexperienced by people facing serious illness. One study verifies that while humor is an attitude strongly valued by individual nurses in their personal lives, there was hesitancy and uncertainty on the appropriate application of the trait in professional dealings with clients facing the serious stresses of acute and terminal illness.’3 My personal odyssey towards comfortable use of humor with clients encountered all of these barriers. I do not remember ever reading an article or hearinga reference to humor in professional practice during my training. Just as my style of dress was more formal at work than at home, so also was my way of relating. I believed clients (and certainly supervisors) expected a serious attitude from a clinician. As my skills developed and I gained in confidence, I moved into another stage, that of being a closet humorist. Clients and I began to have more fun and it did not interfere in their staying in treatment. I found myselfmoreconsciously using humor as intervention and noticed good results. During one visit my client inquired about the jar of bubble liquid on my desk and I invited her to blow a few bubbles. In the next few minutes, we mutually discovered that holding the bubble wand in front of a window air conditioner expanded the volume of bubbles immeasurably. The shared experience moved the discussion easily into benefits and ways of relaxing and taking time for fun.
The American Journal of Hospice & Palliative Care, May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
That experience also marked the end of days as a closet humorist. A colleagueplayfully disclosed to oursupervisor that I had discovered a new intervention, “bubble therapy.” The supervisor’s raised eyebrows and pursed lips expressed some disapproval, but I received real support from peers for integrating lightness and fun into my practice. My appreciation for humor in therapy has also deepened in proportion to acceptance that caregivers and clients share the samehuman experiences and can call on the same means of coping. When we see how powerful a tool humor is for our clients in facing their pain, how can we continue to not listen to our own voices expressing laughter and spirit? Specific interventions to integrate humor into practice There are many ways humor can benefit clients. Eachhas a rationale. The appropriate uses of humor can be addressed fairly simply. The determinants for the therapeutic use of humor include timing, intent, responsiveness, and content. Humorthat takes into account the level of and effect on anxiety, has a goal of clarification rather than masking feelings, and is oriented to laughing with rather thanat a person safely meets the test of appropriate humor in a therapeutic relationship.’4 How does the clinicianuse humorin daily working situations with people facing terminal illness? To turn the table, how do clients call on and trust theirownapproach to humor in dealing with illness and the associated changes they are facing? Assess the meaning of humor in the person’s life historically, especially before illness occurred. Use a formal assessment tool to examine the patient’s attitudes and practices regarding humor.15 Alternatively, use an informal style by merely listening for references to humor and then fol-
lowing up when clients describe how they have coped in the past and what situations made them laugh. These are precisely the same coping skills that can allow a person to manage current stresses. The wise clinician will look for an opportunity to reinforce such wonderfully adaptive skills.
Clinicians’ use of humor can be focused on reinforcementof clients’ struggles to overcome the devastation of symptoms of cancer During my first meeting with a lady diagnosed with lung cancer and metastasis to brain, she was so concerned that I see not only the woman with a body showing the effects of a strong fight against a strong disease, but more importantly the woman she had always been, a woman with a strong sense of humor. “Ifyou don’tlaugh atyourself,” she told me, “someone else will.’ With that opener, she went on to tell me that as her hair began falling out during her chemotherapy, she envisioned herself in a mad dash to the wigmaker to get there before the final strand left her head. Her questionthenwas ifshe could expect, in return for all hertrouble, that her stick-straight hair might at least grow in curly and blonde. Weeks later, she mentioned going wigless for the firsttime during myvisitand explained, “After all, it’s only hair.” One theme frequently heard is clients’ wish to be acknowledged outside the confining limits of the sick role. They wantto be remembered after death in vibrant, healthy images. Frequent laments are “I wishyou knew me before “One woman shared many stories with me of her working days when she was a nursing assistant in a nursing home, her pride in her work shining clearly through in these anec...
dotes. One episode she detailed was of falling in a tray of paint ather nursing home and completely soaking her uniform. While her clothes were being washed and dried, she paraded around in a patient’sjohnny and was the hit of the unit. After she and I both had a good laugh ather story, she looked atme and said, “That’showl want you to remember me.” Clinicians’ use of humor can be focused on reinforcement of clients’ struggles to overcome the devastation of symptoms of cancer or the side effects of treatment. One man with a wry sense of fun taught how perspective can diminish negative changes from sickness. One day I showed up for my visit wearing ashort- sleeved, blueand white striped shirt, which matched his outfit. I commented that we lookedlike twins-for-a-day, buthe added that a real twin would squint up the face and eye, to match his face carrying the signature of his tumor. So, I followed his lead, squinted my eye, and thoroughly confused his sister who, when she came in, surely assigned some unsavory label to the strange social worker visiting her brother. Hopefully my willingness to respond to the man’s sense of playfulness helped him in bridging difficult circumstances. Openness to fun on the clinicians’ part can also helpclients work towards acceptance of their illness. One of the vestiges of denial of the seriousness of a diagnosis of terminal condition is the “if only” syndrome. While this is an understandable stage in the path to acceptance of illness, some clients do seem to be stuck intheir considerations of alternative, but unrealistic, scenarios. With some of those clients so stuck, I have used a technique which gently nudges them from this place of wishful thinking. I have a small plastic wand along with one elbow length white glove which I offer to people with the invitationto outwardlymake a wish.As theylist these deep wishes, they admit
The American Journal of Hospice & Palliative Care, May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
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the play-acting context and are able to explore them in terms of likelihood, fantasy, dreaming, imaging. This allows people to confront wishful thinking and continueon with the hard work of acceptance. A difficult adjustment for hospice patients is the loss of control over physical and cognitive functioning due to the disease. Humor has the potential for giving internal control to the person when the external situation seems so out of control.16 Staff willingness to support humor in this process can reinforce the patient’s empowerment. This theft of cognitive clarity was particularly painful for one of my clients who had been a high school teacher for many happy years. The medicationshe needed for paincontrol produced drowsiness and periodic hallucinations. During one visitshe asked her friend if someone was outside, looking in the window, and the friend very patiently reminded her that this vision resulted from her pifis and after all, she was in a second-floor apartment. Some time later, her attention returned to her vision outside the window. She asked for reassurance from the friend that she was not crazy in spite of her clear sense of a man outside the window. The understanding friend, once again talking about medication side-effects, started towards the window. What a surprise to find, standing unsafely on the narrow window ledge, a painter in white overalls with long grey hair and a grey beard. This patient had a great laugh that she had been relying on her friend to explain away her visions. It was therapeutic when the friend got thejokeand laughed with her. Clients can teachus a great deal about using humor to cope with all facets of illness and stress. “If I could frnd the towel, I’d throw it in” was the approach of one person whose playful spirit had brought her through many dark times. Specific symptoms can bearthe brunt of a sharp retort, therebybeingdemystified.
26
A woman dealing with a reproductive organ cancer was able to share a double entendre joke of a sexual nature, hopefully for the moment giving her the last laugh. One man I visited was frequent-
Humor has the potential for giving internal control to the person when the external situation seems so out of control. ly bothered by rumbling and gurgling from his colostomy. This former car mechanic would apologize and say it was time for a new muffler or a tuneup. He also told me that when he awoke from the surgery in which he had the colostomy done, he mentioned to the hospital staff that it was one way to save on buying toilet paper. Role reversal which accompanies the family adjustments to serious illness can be made less burdensome by a quip, as one wife illustrated when she pointed out to her husband that her original commitment only includeda promise to love and honor him, but havingto wipe his bottom was something else. He laughed with her and they both were able to acknowledge, in a light way, a powerful shift in their relationship. As professional or volunteer staff working with clients, we have frequent opportunities to laugh with them and support their integration of humor and lightness in making difficult situations manageable. As we develop and support ourown comic sense wejoin forces with clients in responding to changes and illness in an adaptive, healthy fashion. A comic sense requires appreciation for the incongruous, an eye for the unexpected and unconventional. Nothing may seem more incongruous or unexpected than the experience of a life threatening illness. Learning to trust and set free a robust comic sense is a reasonable task for both clients and caregivers.17
The comic sense got a nurse and the author through one memorable joint visit. The client was an elderly lady who shared her home with her two elderly sisters but tried not to share the agitation the sisters expressed about her illness. On this particular day, the client had indicated to the nurse and me that the sisters were driving her crazy with their incessant worries. The three ofus the client, the nurse, and I were all sitting on the side of her bed when that antique bed protested our collective weight and broke, and we all landed in a heap on the floor. As quickly as we discovered that blankets and pillows had protected us from injury, we gave in to uncontrollable laughter. It was hard to tell which was more unexpected for the nervous sisters to have the bed break or to find us all enjoying the crash so much. A comic sense skillfully developed and turned on the difficult task of talking about a taboo subject was illustrated beautifully by another client of mine. This talented woman had an acclaimed career intheater arts and was attempting to stay active in her field in spite of her cancer diagnosis. She complained to me how isolated she felt from many friends who detoured conversations when she began to speak abouther illness and the fears she had. She described a resolution to this dilemma in the form of a stage monologue she had written. In this creative piece, a young woman comes out on stage, scans the audience and wonders how she’ll gaintheir attention and not be tuned out. She quickly puts on Groucho Marx glasses and nose and smiles broadly at the audience. They respond immediately to her without distraction. Laughter builds up. She starts, “Tonight’s topic is (more laughter) CANCER!!” Rich creativity had expressed itself in her career and was present for herincoping as a cancer patient. —
—
—
...
...
The American Journal of Hospice & Palliative Care, May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
Other structured approaches include the sharing of cartoons, tapes, and books with a humorous theme. Jokes and cartoons run the continuum from visual, banana-peel pratfalls to more intellectual puns and plays on words. Information on the type of humor utilized by a person helps us to reinforce a specific adaptive style and communicate in the same language. One intervention I use often which has provided lots of helpful fun with clients is my first aid kit. I would never travel cross-country without road maps, band-aids, a spare tire, and some snacks to munchon. I would feel equaliy unprepared heading off on this existential journey from birth to death without my kit which shows me the rest spots, scenic overlooks, and refueling stations. My first aid kit is a large wicker basket in which I carry cartoons I’ve enjoyed, the magic wand and white glove, Grouch Marx nose and glasses, pictures of my family and some friends, a brightly-colored tinsel wig, and a bottle of bubbleliquid. When I talk with clients about how they use humor, I often suggestthey put together their own first aid kit to indude the things that lifttheir spirits and see them through hard times. At times, I also share the contents of my kit. Clients often find how relaxing it is to get in touch with the child within by blowing bubbles. One ladycomplained to me one day that she had not had a good laugh in a long time and this led to a discussion of her own sense of humor in which she never turned down a dare, no matter how zany. I agreed with her that she sounded overdue for a laugh and asked her to close her eyes while I put on my green wig. She had a great time enjoying this and then I discovered she was a person whocould give as good a dare as she took. She dared me to keep the wig on when I left her apartment and until I was back in my car. Until that day I had never spotted another human
being in that apartment building but the day I had thatwig on, what seemedlike dozens of folks were in the hallways, on the elevator, in the lobby, and on the sidewalk.
Information on the type of humor utilized by a person helps us to reinforce a specific adaptive style and communicate in the same language, Introducing first aid kits can work well in group settings as well. Members of a bereavement group compiled theirs and took sometime atthe end of their meetings to share the items that represented support, renewal, humor, and healing. A hospice staff group benefitted from learning new things from colleagues who shared the contents of their kits. This same staff put together a first aid kit for a member who was undergoing a great deal of family stress at the time. Every benefit of humor is as relevant for staff who deal with the daily stress and losses while working with hospice clients. Resources for staff include informal supports that occur throughout the work day, such as colleagues sharing levity, and planned activities. Theme days can be designated and an office can celebrate Hat Day or Hawaiian Shirt Day. Humor bulletin boards are a good idea. For staff morale, a hospice or hospital might engage the services of a humor consultant. Staff who have a well developed comic sense are good mentors for others and reinforce the idea, the more, the merrier.
she wrote, “Well, if I’m gonna have it, I’ve gona find out what could be funny about it. My life had made me funny and cancer wasn’t going to change that. Cancer, I decided, needed a comedienne to come in there and lighten it up.”17 Hopefully the ideas in this paper will be a springboard for more creative thinldng and use of ourselves in our practice. Barriers, once recognized and confronted, can be worked through. The work we choose with critically or terminally ill people sharpens the sadness stemming from the feelingthat life is so often much too brief. The humor we bring to our work can keep us from succumbing tothat sadness and from taking ourselves too seriously. Let us find those innerresources ofjoy and humor and put them to good use for ourselves and the people with whom we work.LJ References
Conclusion
1. Metcalf CW: Humor, life and death. Oncology Nursing Forum 1987;14(4):19-21 2. BellertIL: Humor: A therapeutic approach in oncology nursing. Cancer Nursing 1989;12(2): 65-70 3. Ferguson 5, Campinha-Bacote J: Humor in Nursing. J of Psychosoc Nursing 1989;27(40): 29-34 4. Goodman J: The Humor Project. Saratoga Springs, New York. 5. Ibid. 6. Klein A: Humor and death: you’ve got to be kidding. The AmJ of HospCare 1986;3(4):42-45 7.HerthK: Contributions ofhumor as perceived by the terminally ill. The Am J of Hosp Care 1990;7(1):36-40 8. Hickson J: Humor as an element in the counseling relationship. Psychology 1977;14(1):6068 9. Simon J: Humor techniques for oncology nurses. Oncology Nursing Forum 1989;16(5): 667-670 10. Metcalf, op cit. 11. Hickson, op cit. 12. Herth, op cit. 13. Simon, op cit. 14. Pasquali EA: Learning to laugit humor as therapy. Jof Psychosoc Nursing 1990;28(3):31-
If any reader stifi has doubts about the use of humor, this can be answered in the writing of Gilda Radner. Noting that cancer had “a terrible reputation,”
15. Bellert, op cit. 16. Peter U, Dana B: The laughter prescription. NY, Ballentine Books, 1982 17. Radner G: It’s always something. NY, Simon and Schuster, 1989
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Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
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Introduction The attention to humor in the health care field, and particularly in work with terminally ifi clients, is both overdue and extremely welcome. If Norman Cousins is the grandfather of the move to celebrate the impact ofjoyful attitude toward healing, today we see many descendants contributing to the field. Recently I attended a national professional conference and eagerly signed up for a workshop on the use of humor in oncology social work. I was a few minutes late and creptquietly into the hushed room where an intent, serious speaker heldthe attentionof the equally serious audience. My immediate reaction was thatI had walked into the wrong workshop. After all, with humor as a topic, there should be more lightness and relaxation evident. It was
Mary Ellen Killeen, ACSW, Visiting Nurse and Home Care, Inc., 945 AsylumAvenue, Hartford, Connecticut.
the correct workshop and the speaker did a fme job setting out the theoretical underpinnings of humor’s place in casework with oncology patients. And the audience did an admirable, and serious, job, of pondering on humor. But it is not funny when humor is taken so seriously. My reaction to this workshop was that an opportunity was lost in teaching about humor as one would teach mathematics. What I had hoped to find in attending that workshop was greater discussion of concrete ways to apply humor in our daily work. Much of the literature on humor today continues to stress a theoretical basis rather than practical application. Caregivers are still taking themselves and the topic too seriously. “Without humor and joy, there is no health,” asserts one humorist who trains professionals in the health and business worldsin developingbuoyant sense of humor.’ His definition of humor expands beyond the mere telling of jokes and speaks of a carefully cultivated perspective “that allows you to take yourself lightly, while taking your work or your problem seriously.” It is in the spirit of learning how to take oneself lightly while working with seriously ill people that I write this article for fellow caregivers. Hopefully, it will suggest a pathfrom ourheads, where we understand humor, into our guts, the home of good belly laughs. Basic reasons and benefits for using humor with ill people The benefits and rationales for developing this humorous attitude in
people facing serious, often life-threatening, illness are appearing with increasing frequency in the literature. Humor today is viewed as “an effective adjunct therapyinhealthcare and oncology” with potential for healing among a number of areas in a patient’s life.2
“Instead of... survival of the fittest, we should be working for the survival of the wittiest; then we would all die laughing.” —
Lily Tomlin
Specific benefits accrue along physiological, psychological, and interactive dimensions. Norman Cousins richly illustrated how his body, experiencing serious collagen disease, fought back and healed on a diet of deep, regular laughter. Studies show that physical laughter rewards the body with enhanced respiratory and cardiovascular functioning and relaxes the musculoskeletal system.3 Professional research merely validates other students of humanity, such as Groucho Marx who noted that “a clown is like aspirin, only he works twice as fast.”4 Another student of humanity, Lily Tomlin, spoke to psychological health when she observed that “instead of working for the survival of the fittest, we should be working for the survival of the wittiest; then we can all die laughing.”5 Psychologically, humor
The American Journal of Hospice & Palliative Care,May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
23
adds to the inventory ofcopingskills to reduce and manage stress, particularly the anxieties of a terminally ill person undergoing monumental body image changes and impending death. Additionally, laughing in the face of death empowers us to confront a taboo subject and rob it of some of its mysterious hold over us.6 The psychosocial aspect of an ill or dying client’s life is also positively affected by the use of humor. One of the greatest needs expressed by clients themselves is for direct and supportive communication during stressful periods. One important function of humor is communication that can serve as “a bridging mechanism” to greater joy, relaxation, and connectedness. A healthcare professional responding to an ill person with some humor also makes an important statement that the person exists beyond the confmement of the sick role. This recognition of the whole person supports the transition through a period ofoverwhelming physical and emotional pain.7 The relationship itself between client and professional also benefits from constructive humor and lightheartedness. Qualities inherent in a humorous perspective—flexibility, appreciation for the incongruous, spontaneity, humility—reflect well on the therapeutic bond and support empathic response. This use of humor allows for greater intimacy and can overcome resistance or fear. A reciprocal feeling for the comic actsto balance recognition of the tragic and facilitates adaptive response to change and loss.8 As humor has a place in helping clients and their families face the daily challenge of living with serious illness, so does humorplay a vital role in allowing healthcare professionals to face the same challenges and prevent burnout. Particular functions served by humor for professional staff include providing distance in a constructive way and reducing stress. Humor can additionally help
24
with acceptance of the frustrations associated with the work environment.9 One cannot meet clients playfully and joyfully unless those traits are con-
“... humor play[sJ a vital role in allowing healthcare professionals toface the same challenges andprevent burnout.”
stantly being developed and nourished in the caregiver. It needs to be stressed that a sense of humor is a skifi to be developed and fme-tuned.’°Apersonal perspective that recognizes absurdity, human frailty, cosmic jokes, and indefatigable human spirit can be learned. Luckily, the world provides us with rich learning material for this education. Barriers to using humor The hesitancy in comfortably using humor as part of one’s clinical repertoire is understandable. Professional training and supervision of healthcare professionals has nottraditionally supported reliance on such non-scientific approaches. In fact, cautious instructors may issue warnings against the use of humor because of the potential for evoking anxiety, masking hostility, or evading problems. While inappropriate humor can be viewed as aimed atbelittling or humiliating the client,’1 the fear about a specific misapplication has often been generalized to an across the board prohibition. Another important barrier is in the acknowledgment of the unarguable seriousness of the situationin which a person faces a terminal illness, marked by physical deterioration, loss of functioning, and ultimately death. The problem oftrusting humor inwork with terminally ill clients is compounded by
the lack of research on effects and application to practice with the specific population rather than the healthy or chronically ill that typically are the subjects of such study. Very little research has focused specifically on effects of humor on work with terminally ill people.12 One other barrier to the integration of humor into clinicians’ repertoire of skills may be confusion about being seen as less thansensitive or responsive to the real painexperienced by people facing serious illness. One study verifies that while humor is an attitude strongly valued by individual nurses in their personal lives, there was hesitancy and uncertainty on the appropriate application of the trait in professional dealings with clients facing the serious stresses of acute and terminal illness.’3 My personal odyssey towards comfortable use of humor with clients encountered all of these barriers. I do not remember ever reading an article or hearinga reference to humor in professional practice during my training. Just as my style of dress was more formal at work than at home, so also was my way of relating. I believed clients (and certainly supervisors) expected a serious attitude from a clinician. As my skills developed and I gained in confidence, I moved into another stage, that of being a closet humorist. Clients and I began to have more fun and it did not interfere in their staying in treatment. I found myselfmoreconsciously using humor as intervention and noticed good results. During one visit my client inquired about the jar of bubble liquid on my desk and I invited her to blow a few bubbles. In the next few minutes, we mutually discovered that holding the bubble wand in front of a window air conditioner expanded the volume of bubbles immeasurably. The shared experience moved the discussion easily into benefits and ways of relaxing and taking time for fun.
The American Journal of Hospice & Palliative Care, May/June 1991 Downloaded from ajh.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on April 9, 2015
That experience also marked the end of days as a closet humorist. A colleagueplayfully disclosed to oursupervisor that I had discovered a new intervention, “bubble therapy.” The supervisor’s raised eyebrows and pursed lips expressed some disapproval, but I received real support from peers for integrating lightness and fun into my practice. My appreciation for humor in therapy has also deepened in proportion to acceptance that caregivers and clients share the samehuman experiences and can call on the same means of coping. When we see how powerful a tool humor is for our clients in facing their pain, how can we continue to not listen to our own voices expressing laughter and spirit? Specific interventions to integrate humor into practice There are many ways humor can benefit clients. Eachhas a rationale. The appropriate uses of humor can be addressed fairly simply. The determinants for the therapeutic use of humor include timing, intent, responsiveness, and content. Humorthat takes into account the level of and effect on anxiety, has a goal of clarification rather than masking feelings, and is oriented to laughing with rather thanat a person safely meets the test of appropriate humor in a therapeutic relationship.’4 How does the clinicianuse humorin daily working situations with people facing terminal illness? To turn the table, how do clients call on and trust theirownapproach to humor in dealing with illness and the associated changes they are facing? Assess the meaning of humor in the person’s life historically, especially before illness occurred. Use a formal assessment tool to examine the patient’s attitudes and practices regarding humor.15 Alternatively, use an informal style by merely listening for references to humor and then fol-
lowing up when clients describe how they have coped in the past and what situations made them laugh. These are precisely the same coping skills that can allow a person to manage current stresses. The wise clinician will look for an opportunity to reinforce such wonderfully adaptive skills.
Clinicians’ use of humor can be focused on reinforcementof clients’ struggles to overcome the devastation of symptoms of cancer During my first meeting with a lady diagnosed with lung cancer and metastasis to brain, she was so concerned that I see not only the woman with a body showing the effects of a strong fight against a strong disease, but more importantly the woman she had always been, a woman with a strong sense of humor. “Ifyou don’tlaugh atyourself,” she told me, “someone else will.’ With that opener, she went on to tell me that as her hair began falling out during her chemotherapy, she envisioned herself in a mad dash to the wigmaker to get there before the final strand left her head. Her questionthenwas ifshe could expect, in return for all hertrouble, that her stick-straight hair might at least grow in curly and blonde. Weeks later, she mentioned going wigless for the firsttime during myvisitand explained, “After all, it’s only hair.” One theme frequently heard is clients’ wish to be acknowledged outside the confining limits of the sick role. They wantto be remembered after death in vibrant, healthy images. Frequent laments are “I wishyou knew me before “One woman shared many stories with me of her working days when she was a nursing assistant in a nursing home, her pride in her work shining clearly through in these anec...
dotes. One episode she detailed was of falling in a tray of paint ather nursing home and completely soaking her uniform. While her clothes were being washed and dried, she paraded around in a patient’sjohnny and was the hit of the unit. After she and I both had a good laugh ather story, she looked atme and said, “That’showl want you to remember me.” Clinicians’ use of humor can be focused on reinforcement of clients’ struggles to overcome the devastation of symptoms of cancer or the side effects of treatment. One man with a wry sense of fun taught how perspective can diminish negative changes from sickness. One day I showed up for my visit wearing ashort- sleeved, blueand white striped shirt, which matched his outfit. I commented that we lookedlike twins-for-a-day, buthe added that a real twin would squint up the face and eye, to match his face carrying the signature of his tumor. So, I followed his lead, squinted my eye, and thoroughly confused his sister who, when she came in, surely assigned some unsavory label to the strange social worker visiting her brother. Hopefully my willingness to respond to the man’s sense of playfulness helped him in bridging difficult circumstances. Openness to fun on the clinicians’ part can also helpclients work towards acceptance of their illness. One of the vestiges of denial of the seriousness of a diagnosis of terminal condition is the “if only” syndrome. While this is an understandable stage in the path to acceptance of illness, some clients do seem to be stuck intheir considerations of alternative, but unrealistic, scenarios. With some of those clients so stuck, I have used a technique which gently nudges them from this place of wishful thinking. I have a small plastic wand along with one elbow length white glove which I offer to people with the invitationto outwardlymake a wish.As theylist these deep wishes, they admit
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the play-acting context and are able to explore them in terms of likelihood, fantasy, dreaming, imaging. This allows people to confront wishful thinking and continueon with the hard work of acceptance. A difficult adjustment for hospice patients is the loss of control over physical and cognitive functioning due to the disease. Humor has the potential for giving internal control to the person when the external situation seems so out of control.16 Staff willingness to support humor in this process can reinforce the patient’s empowerment. This theft of cognitive clarity was particularly painful for one of my clients who had been a high school teacher for many happy years. The medicationshe needed for paincontrol produced drowsiness and periodic hallucinations. During one visitshe asked her friend if someone was outside, looking in the window, and the friend very patiently reminded her that this vision resulted from her pifis and after all, she was in a second-floor apartment. Some time later, her attention returned to her vision outside the window. She asked for reassurance from the friend that she was not crazy in spite of her clear sense of a man outside the window. The understanding friend, once again talking about medication side-effects, started towards the window. What a surprise to find, standing unsafely on the narrow window ledge, a painter in white overalls with long grey hair and a grey beard. This patient had a great laugh that she had been relying on her friend to explain away her visions. It was therapeutic when the friend got thejokeand laughed with her. Clients can teachus a great deal about using humor to cope with all facets of illness and stress. “If I could frnd the towel, I’d throw it in” was the approach of one person whose playful spirit had brought her through many dark times. Specific symptoms can bearthe brunt of a sharp retort, therebybeingdemystified.
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A woman dealing with a reproductive organ cancer was able to share a double entendre joke of a sexual nature, hopefully for the moment giving her the last laugh. One man I visited was frequent-
Humor has the potential for giving internal control to the person when the external situation seems so out of control. ly bothered by rumbling and gurgling from his colostomy. This former car mechanic would apologize and say it was time for a new muffler or a tuneup. He also told me that when he awoke from the surgery in which he had the colostomy done, he mentioned to the hospital staff that it was one way to save on buying toilet paper. Role reversal which accompanies the family adjustments to serious illness can be made less burdensome by a quip, as one wife illustrated when she pointed out to her husband that her original commitment only includeda promise to love and honor him, but havingto wipe his bottom was something else. He laughed with her and they both were able to acknowledge, in a light way, a powerful shift in their relationship. As professional or volunteer staff working with clients, we have frequent opportunities to laugh with them and support their integration of humor and lightness in making difficult situations manageable. As we develop and support ourown comic sense wejoin forces with clients in responding to changes and illness in an adaptive, healthy fashion. A comic sense requires appreciation for the incongruous, an eye for the unexpected and unconventional. Nothing may seem more incongruous or unexpected than the experience of a life threatening illness. Learning to trust and set free a robust comic sense is a reasonable task for both clients and caregivers.17
The comic sense got a nurse and the author through one memorable joint visit. The client was an elderly lady who shared her home with her two elderly sisters but tried not to share the agitation the sisters expressed about her illness. On this particular day, the client had indicated to the nurse and me that the sisters were driving her crazy with their incessant worries. The three ofus the client, the nurse, and I were all sitting on the side of her bed when that antique bed protested our collective weight and broke, and we all landed in a heap on the floor. As quickly as we discovered that blankets and pillows had protected us from injury, we gave in to uncontrollable laughter. It was hard to tell which was more unexpected for the nervous sisters to have the bed break or to find us all enjoying the crash so much. A comic sense skillfully developed and turned on the difficult task of talking about a taboo subject was illustrated beautifully by another client of mine. This talented woman had an acclaimed career intheater arts and was attempting to stay active in her field in spite of her cancer diagnosis. She complained to me how isolated she felt from many friends who detoured conversations when she began to speak abouther illness and the fears she had. She described a resolution to this dilemma in the form of a stage monologue she had written. In this creative piece, a young woman comes out on stage, scans the audience and wonders how she’ll gaintheir attention and not be tuned out. She quickly puts on Groucho Marx glasses and nose and smiles broadly at the audience. They respond immediately to her without distraction. Laughter builds up. She starts, “Tonight’s topic is (more laughter) CANCER!!” Rich creativity had expressed itself in her career and was present for herincoping as a cancer patient. —
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Other structured approaches include the sharing of cartoons, tapes, and books with a humorous theme. Jokes and cartoons run the continuum from visual, banana-peel pratfalls to more intellectual puns and plays on words. Information on the type of humor utilized by a person helps us to reinforce a specific adaptive style and communicate in the same language. One intervention I use often which has provided lots of helpful fun with clients is my first aid kit. I would never travel cross-country without road maps, band-aids, a spare tire, and some snacks to munchon. I would feel equaliy unprepared heading off on this existential journey from birth to death without my kit which shows me the rest spots, scenic overlooks, and refueling stations. My first aid kit is a large wicker basket in which I carry cartoons I’ve enjoyed, the magic wand and white glove, Grouch Marx nose and glasses, pictures of my family and some friends, a brightly-colored tinsel wig, and a bottle of bubbleliquid. When I talk with clients about how they use humor, I often suggestthey put together their own first aid kit to indude the things that lifttheir spirits and see them through hard times. At times, I also share the contents of my kit. Clients often find how relaxing it is to get in touch with the child within by blowing bubbles. One ladycomplained to me one day that she had not had a good laugh in a long time and this led to a discussion of her own sense of humor in which she never turned down a dare, no matter how zany. I agreed with her that she sounded overdue for a laugh and asked her to close her eyes while I put on my green wig. She had a great time enjoying this and then I discovered she was a person whocould give as good a dare as she took. She dared me to keep the wig on when I left her apartment and until I was back in my car. Until that day I had never spotted another human
being in that apartment building but the day I had thatwig on, what seemedlike dozens of folks were in the hallways, on the elevator, in the lobby, and on the sidewalk.
Information on the type of humor utilized by a person helps us to reinforce a specific adaptive style and communicate in the same language, Introducing first aid kits can work well in group settings as well. Members of a bereavement group compiled theirs and took sometime atthe end of their meetings to share the items that represented support, renewal, humor, and healing. A hospice staff group benefitted from learning new things from colleagues who shared the contents of their kits. This same staff put together a first aid kit for a member who was undergoing a great deal of family stress at the time. Every benefit of humor is as relevant for staff who deal with the daily stress and losses while working with hospice clients. Resources for staff include informal supports that occur throughout the work day, such as colleagues sharing levity, and planned activities. Theme days can be designated and an office can celebrate Hat Day or Hawaiian Shirt Day. Humor bulletin boards are a good idea. For staff morale, a hospice or hospital might engage the services of a humor consultant. Staff who have a well developed comic sense are good mentors for others and reinforce the idea, the more, the merrier.
she wrote, “Well, if I’m gonna have it, I’ve gona find out what could be funny about it. My life had made me funny and cancer wasn’t going to change that. Cancer, I decided, needed a comedienne to come in there and lighten it up.”17 Hopefully the ideas in this paper will be a springboard for more creative thinldng and use of ourselves in our practice. Barriers, once recognized and confronted, can be worked through. The work we choose with critically or terminally ill people sharpens the sadness stemming from the feelingthat life is so often much too brief. The humor we bring to our work can keep us from succumbing tothat sadness and from taking ourselves too seriously. Let us find those innerresources ofjoy and humor and put them to good use for ourselves and the people with whom we work.LJ References
Conclusion
1. Metcalf CW: Humor, life and death. Oncology Nursing Forum 1987;14(4):19-21 2. BellertIL: Humor: A therapeutic approach in oncology nursing. Cancer Nursing 1989;12(2): 65-70 3. Ferguson 5, Campinha-Bacote J: Humor in Nursing. J of Psychosoc Nursing 1989;27(40): 29-34 4. Goodman J: The Humor Project. Saratoga Springs, New York. 5. Ibid. 6. Klein A: Humor and death: you’ve got to be kidding. The AmJ of HospCare 1986;3(4):42-45 7.HerthK: Contributions ofhumor as perceived by the terminally ill. The Am J of Hosp Care 1990;7(1):36-40 8. Hickson J: Humor as an element in the counseling relationship. Psychology 1977;14(1):6068 9. Simon J: Humor techniques for oncology nurses. Oncology Nursing Forum 1989;16(5): 667-670 10. Metcalf, op cit. 11. Hickson, op cit. 12. Herth, op cit. 13. Simon, op cit. 14. Pasquali EA: Learning to laugit humor as therapy. Jof Psychosoc Nursing 1990;28(3):31-
If any reader stifi has doubts about the use of humor, this can be answered in the writing of Gilda Radner. Noting that cancer had “a terrible reputation,”
15. Bellert, op cit. 16. Peter U, Dana B: The laughter prescription. NY, Ballentine Books, 1982 17. Radner G: It’s always something. NY, Simon and Schuster, 1989
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