LOL: It's Good For You

Ever since the writer Norman Cousins’ groundbreaking Anatomy of
an Illness
shed light on laughter’s medicinal qualities nearly 30 years ago,
the sick—and people who don’t want to be—have been mining the benefits
of mirth in greater numbers. Now researchers are drilling deeper to
understand the healing power of humor and laughter, both artificial and real.

By Allan Richter

March 2008

In late January, in a small triangular meeting room of a Philadelphia hospital, a dozen cancer patients and some of their family and caregivers suspended reality for 45 minutes. Urged on by a therapist who assumed the role of tour guide, the group escaped on a much-needed vacation to Hawaii without stepping foot out of the room. They laughed all the way there.

Mimicking an airliner carrying them off, they extended their arms and flew in circles around the room; imaginary welcome drinks awaited their landing. They scampered on sun-baked sand and fished along the Hawaiian shoreline. They fluttered around a tropical garden like butterflies and hummingbirds. At the suggestion of therapist Gerri Delmont to “key down,” they ended the trip, gathering handfuls of sand and gazing calmly into the ocean.

Each exercise began with artificial laughter—a series of prompted “hee hee, ha ha, ho ho” chants. Those gave way to the genuine giggles, cheer and glee that were the real aim of the therapy. A half-hour after the session ended, patient Mary Domina still wore a broad smile that pushed up her round red cheeks. “I feel bright, jubilant, alive,” she said. “It was just like a shot of oxygen. When I get in a bad mood, I’m going to think ‘hee hee, ha ha, ho ho.’”

Standing near Domina in the Philadelphia branch of Cancer Treatment Centers of America, Scot St. Pierre said the laughter therapy was like a religious cleansing of the soul. “It almost feels like you’ve been to church,” said St. Pierre, whose mother Madona, a patient, likened the therapy’s effects to the tranquility she feels from watching the sea.

With chuckles that sometimes lead to bliss, the sick and ailing—as well as those who don’t want to be—have been tapping the healing power of laughter with increasing fervor since the writer Norman Cousins famously recognized laughter as a source of vitality in his groundbreaking 1979 book Anatomy of an Illness (W.W. Norton & Company). In that work, Cousins chronicled his recovery from ankylosing spondylitis, a deterioration of the connective tissue in the spine that struck him in 1964, with the help of loads of vitamin C and pain-reducing laughter sessions that let him sleep peacefully and that he repeated each time his discomfort would return.

Today, laughter is known to have a wide array of healthcare applications. And it has become more apparent why so many comedians who have had troubled and sometimes tragic upbringings, from Charlie Chaplin to Rodney Dangerfield and Carol Burnett, were so drawn to their line of work.

One study by the University of Maryland School of Medicine in Baltimore showed the positive effects of laughter on the functioning of blood vessels and on overall cardiovascular health.

Healthy volunteers watched two movies shown at the extreme ends of the emotional scale: the furiously violent opening D-Day scene of Saving Private Ryan and a segment of the comedy Kingpin. Laughter provoked by the second clip appeared to cause the endothelium, or inner lining of the participants’ blood vessels, to expand in order to increase blood flow.

In contrast, the stress response from watching the first clip triggered vasoconstriction, or reduced blood flow, within the blood vessels. Overall, average blood flow increased 22% during laughter and decreased 35% during stress—even among those who had previously seen Ryan and knew what to expect.

“The act of laughing out loud vigorously has benefits similar to a workout,” says Kelly McGonigal, PhD, a health psychologist at Stanford University. “It increases heart rate and stimulates deep breathing.”

Scientists continue to examine the exact source of the benefits: Is it in the humor, the laughter that expresses the humor, or both? And what precise benefits, if any, come from artificial laughter, that is, laughter in the absence of humor as in the therapy session at the Philadelphia cancer hospital? Nor has research been completed that compares the value of laughter with expressions that might be physically similar, such as crying or yelling.

Research does show that just the anticipation of laughter is beneficial, says Lee Burk, DrPH, MPH, associate director for the Center for Neuroimmunology at the Loma Linda University School of Medicine, where he is also assistant research professor.

Laughter also appears to ease pain, as Cousins found. In 1989, Burk conducted research to determine if laughter boosted the release of endorphins, chemicals that give the body pleasure. The results were questionable, with only minimal increases recorded. But later research showed that the increases were relatively small after laughter, when measurements were made in the original study, because endorphins were being released before the subjects were even exposed to a stimulus, in this case a funny video.

This information, presented to the American Physiological Society in 2006, showed that people who simply anticipated laughter had a 27% increase in beta-endorphins and 87% more human growth hormone when compared with a control group that was not expecting to laugh.

Though neither that research, nor any other that people interviewed for this story know of, assigns a precise value to artificial versus humor-driven laughter, Burk and others say people undoubtedly benefit from laughter without humor. “You get the physical neurochemical effects relative to the laughter experience,” Burk says. To naysayers, Burk compares artificial laughter to the use of a stationary bicycle or treadmill: They don’t bring anyone anywhere, but provide the same benefit to people who bike or walk the same distance from, say, their homes to their jobs.

With modern origins in India, so-called laughter clubs that do not use a funny stimulus have sprouted up around the world. They appear to work in part because laughter can be infectious. Producers of live television sitcoms used to plant people with infectious laughs into audiences, Burk notes.

Burk’s 1989 study accidentally gave researchers another insight—that a person who is laughing without a funny source appears to gain the same benefit as someone who finds something funny but does not overtly laugh.

“One of our subjects in the early days was a pathologist, and pathologists aren’t necessarily known for having a great sense of humor,” Burk recalled. “When we had IVs in his arm taking the blood sample, and he was watching what he thought was a humorous video, humor he selected, we thought we were wasting the whole experiment because he wasn’t boisterous or laughing out loud.

Yet when we got his data, he was similar in terms of stress hormone reduction to a psychiatrist we had done who was very overt and very boisterous.”

The pathologist’s results support the idea that humor, even without laughter, changes negative emotions such as chronic anger, anxiety and depression. And the research that such “distressing” emotions lead to illness, including heart disease, is well documented, says Steven Sultanoff, PhD, a clinical psychologist and professor at Pepperdine University in Irvine, California.

“My belief is that we are going to eventually find that the most dramatic health benefit of humor is not in laughter,” Sultanoff says. “It’s actually in the cognitive and emotional management that humor gives. Humor changes negative thinking patterns.”

Allen Klein, a self-described San Francisco-based “jollytologist, ”says he teaches humor, not laughter, “to show people that no matter what the situation, you can lighten up.” In contrast, advocates of therapy that incorporates laughter without humor believe the role of humor is limited because it is so subjective.

Humor proponent Sultanoff does not discount the benefits of laughter. “The idea here is that humor stimulates a cognitive shift in perspective, an emotional shift and physical shift,” Sultanoff says, the latter being laughter, which he agrees has been proven to have benefits.

“It appears serum cortisol, the commonly called stress hormone, is secreted when people are under stress,” Sultanoff says. “Some studies in laughter show a decrease in serum cortisol, but one problem is that there were one or two studies that showed the opposite effect, an increase in serum cortisol.”

Other studies, however, have shown an increase in certain antibodies—killer T cells, for example—after deep, heartfelt laughter, he says. Likewise, increases of immunoglobin A, an antibody that fights upper respiratory disease, have been seen with laughter.

“Probably the best research is on pain tolerance,” he says. “With deep heartfelt laughter, tolerance to pain appears to go up.” Sultanoff takes that finding seriously: He plays a Robin Williams CD in his car on the way to the dentist.

When it comes to the debate over artificial, forced laughter versus a more natural expression, Sultanoff comes down on the side of natural, humor-induced laughter. After all, the writer Cousins derived his laughter from a source—Marx Brothers movies.

“My bias is that we can’t get the same benefit because spontaneous laughter is triggered by a humorous event, and that humorous event is also going to affect cognition and emotion,” he says, “whereas in a forced laugh, you’re not experiencing the same emotional uplift or cognitive shift, though you are having the physical benefit.”

Indeed, hearty laughter, artificial or not, may not replace a sweaty aerobic workout, but it does burn calories. Researchers at Vanderbilt University gathered 90 people who watched comedy video clips, including the movie There’s Something About Mary and episodes of Saturday Night Live.

The researchers concluded that laughing burned about 1.3 calories per minute—about 10 to 20% more than in a calm state. The benefit is akin to what you’d get doing some light indoor gardening, while jogging burns about 10 calories per minute. Still, based on that finding, 10 to 15 minutes of laughter a day could help you drop as much as four pounds a year.

Laughter, says Marshall Brain, author of the How It Works books, has two physical components: gestures and the production of sound. The brain signals the body to do both at the same time, and the effects of hearty laughter can trickle all the way to the arm, leg and trunk muscles. Some 15 facial muscles contract, and the zygomatic major muscle lifts the upper lip.

Laughter, Brain observes, triggers some physical activities that on the surface don’t sound all that great. For instance, the respiratory system becomes upset when the epiglotis closes the larynx halfway. Hearty laughter activates the tear ducts and the face becomes moist and red in the struggle for oxygen that ensues.

Citing a study of laughter’s sonic structure, Brain notes that laughter can trigger “ha-ha-ha” or “ho-ho-ho” sounds, but never a hybrid of the two. That observation underscores the artifice of the “hee hee, ha ha, ho ho” stew of chants practiced at the laughter therapy session at the Philadelphia cancer hospital and among other laughter groups.

Nevertheless, a growing number of proponents of laughter as medicine are embracing the idea that harnessing self-driven laughter can yield tremendous therapeutic benefits.

Laughter enthusiasts trace the movement to Madan Kataria, MD, himself inspired by Cousins. Kataria started a playful form of laughter yoga in Mumbai, India, in 1995. Steve Wilson, a psychologist, met Kataria three years later and picked up the torch, creating a training program ( through which therapists become Certified Laughter Leaders who direct sessions and laughter clubs.

Some 5,000 laughter clubs are organized in 40 countries, according to Kataria’s website, Certified Laughter Leaders have been dispatched to help families of military who have shipped out to Iraq or returned home with permanent injuries. They’ve also helped train teachers to introduce laughter into the classroom, hoping to develop more receptive students.

At the laughter therapy session at the Philadelphia cancer hospital, patients, their family members and hospital staff appeared to shift from the artifical laughter into heartfelt giggles and sincere laughs very quickly. Delmont, a Certified Laughter Leader who led the session, explained that the deeper their anxiety, the more open participants are to laughing. “The higher the stress, the quicker they fly into a relaxed state,”Delmont says. “The pendulum swings equally.”

It may be one reason that Mike Weiss, a New York comedian, says audiences are so receptive to the Middle Age Wasteland comedy shows he produces about the trials of aging. “People would oddly enough much rather hear about somebody’s large prostate than some young comedian on a date,” Weiss says. “Middle age is a bit daunting. We’re not young, we’re not old, and it’s a strange place to be. Things are starting to give out. Our warranty is up, and you can’t renew the warranty so you might as well just laugh about it, and people do.”

Laughter therapy is but one tool in the Cancer Treatment Centers of America psychoneuroimmunology program, which includes naturopathic medicine and Reiki. And even those natural treatments are not meant to work in a vacuum; CTCA provides those treatments only in concert with traditional medicine.

Still, lost in their laughter, the Philadelphia cancer patients and families seemed empowered solely on the cheer that filled the room. Linda Swartz, whose sister is a patient, said after the session, “How you react to what’s happening to you—that’s all you can do.”

Linda Melone contributed to this article.

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