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Abstract

Related to complementary therapies, humour and laugh contribute to enhance health status and diminish illness situations. Humour as a therapy is an inexpensive tool in the patient care and it has not secondary effects in most cases. Current tendencies, either about natural ways to health or believes on health care of popular cultures, and who recommendations to patients in the use of traditional and complementary methods to improve population health, make humour and laugh an alternative therapy as an optional care tool. We have reviewed the literature with the aim of recognize the application of humour therapy on health and more specifically on nurse cares.
On the basis of the review we can state that humour is utilized and applied in several professional environments, apart from the health one. This therapy is widely spread in the communication area. We have found few publications on nurse literature although they are high valuable since they work in the fields of research and education. It would be interesting that nurse professionals use this complementary therapy that enhance the quality of cares and offers an independent field favourable for research.

Introduction

     The percentage of the population that turns to "natural" means for preventing or solving their health problems is larger each day. Within the health system, the nurses are the ones that develop their activity in the most direct and continuous contact with the clients/users. Due to this fact, they have the possibility to offer many of the resources existing nowadays. This possibility demands adequate training and research studies to know which are the most suitable resources, and when and how to use them. The positioning of the professionals of the health with regards to these therapies is not unanimous.
     There are many persons within the multicultural society where we live who have a different approach concerning life and health. Many of them plead for "the natural things" and their relationship with the environment, turning down the excessive technicalization. More than a 25% of the population turns to these therapies. The World Health Organization (WHO) recognizes the importance of the traditional medicines for some human groups, and it does recommend carrying out a harmonic and scientific development, and that measures for its regulation and control are taken¹. The nurses are appealed to use all the resources to manage health for all and among those resources, the WHO mentions the "traditional and complementary methods"².
     Among the professional nurses there is no unanimous agreement to designate these therapies. In the IV National Congress of Nursery in Natural and Complementary Therapies it was proposed to call them "optional therapies". Therapy, understood as everything that is therapeutic, would be justified from the nursery point of view. The term "instrument", used by Collière, is employed by Alberdi³ when observing "whatever is the quality and finesse of the instruments, they are inanimate; they are tools animated according to the will of the person driving them". Within the context of the nursery cares, they are named "instruments" considering that they are means -tools- in our hands, to provide cares.
     Using the term "complementary" would mean to extend, improve, complement. Nevertheless if those therapies are named "alternative" we will be pointing out a substitution, an equivalence between the two of them. There is certain unanimity in the term "complementary" among the professionals, which use it as an extension of the resources to provide cares. Another way to designate it is "complementary instruments for the nursery cares" (ICCE), although it would be enough to call them "instruments for cares", understanding that many of the ones we can use are not new but belong to the essence and evolution of the nursery professional care itself⁴.
     The objective of our work is to carry out a bibliographic revision to analyze the use of the laugh therapy in the field of the health, and more specifically in the field of the nursery cares. The humour is something free, unpredictable and surprising and as such it should not be defined. Mingote defines it as not being afraid of thinking; Fernandez Flores says that is an attitude to face life. We would point up other definitions like: "it is a universal language and a contagious emotion with no adverse reactions"⁵, or "it is a clever way to face a difficult situation"⁶. The laughter therapy or gelotherapy is a complementary therapy, necessary to keep the well-being not only in physical but also in mental terms; it is a door towards relax, a path to open the capability to feel, love, to reach silence, to ecstasy, to the creativity.      

Methodology

     The work presented is a descriptive study through a bibliographic revision of humour and laughter seen as complementary therapies, and their effects on health. A search was performed in Medline, Cuiden, Compludoc, Cuidatge, Teseo, National Library, Google, Altavista and Hotbot. The key words used were: Humour, Humour and Health, Complementary Therapy, Nursery and Laughter Therapy, Gelotherapy, Laughter and Health and Therapeutic Humour. Papers published in sanitary magazines and web pages, written in English or Spanish, were included. Pages of humour or comics and publications in languages different from Spanish or English were excluded. A total of 79 documents were analyzed: 29 of them with a scientific profile (20 national articles and 9 international articles) and 48 referred to news and web pages.

Physiology of the laughter

     On the XXth century, Cannon and Bard discovered the emotional centres of laugh in the base of the brain and their connections with the autonomous nervous system. The expression of the laugh seems to depend on two independent neuronal tracts. The first one is an "involuntary" system that involves the amygdala, the thalamic/hypothalamic and subthalamic areas and the dorsal tegument of the cerebral trunk. The second tract is "voluntary" and has its origin in the opercula's premotor and frontal areas. It and passes across the motor cortex and the pyramidal truck up to the ventral cerebral trunk. These systems and the answer of laughter seem to be coordinated by a centre coordinator of the laughter in the high dorsal horn⁷. The left hemisphere is activated first, and then the right one as well, before the good mood becomes evident as an open and beneficent laugh.

Humour measurement scales

     Among the scales that measure humour we emphasize the one done by Martin Lefcourt which measures the characteristics of laugh is when facing different situations, and the scale "Multidimensional Sense of Humour Scale (MSHS)" done by Thomson Powell. The last one has four sub-scales that measure: the use of humour in social situations, the coping humour, the humour appraisal and the attitude of joke approval.

Benefits of humour

     a) Psychological benefits. It improves the objectivity when considering problems8, it shortens the negative thoughts, it frees from inhibitions, it keeps away the shyness, it eliminates the fear, it helps out with the self-understanding and the understanding of the others. Many studies assure that humour reduces the depression^5,9, the anxiety^5,6 and the stress^10,11. It is an expression of repressed emotions¹², it increases the self-esteem and makes more creative the persons who practice it.
     b) Immunological benefits. The humour increases the proteins that fight the gamma infections. It strengthens the immune system by increasing the IgA^5,14 and the T cells¹⁵.
     c) Respiratory benefits. It reduces the snoring and amplifies the pulmonary capacity^16,17 as it makes the diaphragm vibrate by means of clonal contractions¹⁴ that produce a better oxygenation¹³.
     d) Circulatory benefits. It improves the venous circulation of the blood¹⁸ by means of the vibratory massage and the relaxation of the muscles. It strengthens the heart and reduces the blood preassure^5,15,19.
     e) Hormonal benefits. The humour frees endorphins that fight the pain^{10, 15, 20} and produce well-being. It also frees adrenaline, dopamine and serotonin¹⁵.  
     f) Communication benefits. It enhances the interpersonal relationships^5,12,23 and eases the communication^12,24,25. It helps to change the organizational atmosphere and the hospital environment²⁶.
     g) Muscle-Skeletal benefits.  The humour increases the muscular flexion and tones up¹⁹. It relaxes the muscular tension for the sportsmen^11,27.
     h) Rest and sleep benefits. It produces a release of energy that permits the physical and intellectual rest. It fights the insomnia by producing a healthy fatigue.
     i) Digestion benefits.  A benefit is obtained when producing a vibration in the liver. This vibration favours the secretion of gastric juices and saliva28. It burns out calories¹⁹.
     j) Elimination benefits. It alleviates constipation²¹.
     k) Other benefits. It awakes the intelligence²³.

Nursery and Humour

     The most specific contribution for the nursery is found referred to:

a) Positive attitudes and sense of humour. Carbelo et col.^9,26 propose rules of behaviour that promote a positive relation with the patients:
     - To establish a relation of empathy with the patient and his family.
     - To use the intuition and sensitivity.
     - To adopt positions close to the information and doubts resolution, demythologizing false beliefs about the illness.
     - To strengthen the advances achieved by the patient.
     - To avoid negative attitudes that generate feelings of guilt.
     - To facilitate and use attitudes of active listening
     - To encourage the patient to do pleasant and interesting activities.
     - To learn to laugh about ourselves.   

     All this aspects are liable to be educated, according to Goleman²⁹, and as a whole indicate emotional intelligence:
     To recognize the own feelings and to develop the capability to administrate them.
     To improve the self-motivation
     To recognize the emotions of the others
     To know how to react correctly to the feelings of the other: empathy
     Following this philosophy, Mª Cruz Roderas -headmistress of the School of Intelligent Health- and the Centre José Elías, are developing different workshops of personal development that offer courses of skills to help to regain the natural laugh, considering it the cheapest and most efficient medicine, without secondary effects. Txaro Uliarte et alt., show us their experience in the implementation of "workshops of humour"³⁰. One lesson of laughter therapy consists of a revision of the different laughter in different cultures. The part of the memory where we store the moments when the laugh was produced is also studied. Skills:
      - Smiling therapy: the skill is to sketch a relaxed and peaceful smile that helps to face the external and internal aggressions, and is useful for relaxation. It only involves 5 or 6 muscles.
      - Laugh therapy: Its aim is to teach how to laugh from the soul; a deep laugh moves 400 muscles. "The laugh must be genuine, if the laughing does not shake, nothing is achieved"¹⁴.
      - Practice: a series of stretching exercises to relax the body, and communication exercises that generate complicity between the students.
      Carbelo^31,32 and his work team have made some studies about the positive effects of the nursery education in the "sense of humour".

b) Nursery cares and sense of humour. The articles found are not that many, but all of them agree that when the nurse develops his capacity for the empathy, the comprehension and the election of positive and optimistic attitudes are facilitated; the patients tend to be more confident and relaxed. The use of humour eases the relation of help between the nurses and the patient or his family^21,33-34.
     When we do the assessment of the patients, according to Carbelo and col¹⁶, we must register data that allow us to recognize the most positive attitudes of the patients. These data will be used to evaluate the changes produced. The sense of opportunity is important to know when humour should not be used. It should be avoided for terminal patients, in the death agony, when communicating a diagnosis, in situations of big anxiety, in case of rape or in case of obsessive-compulsive disorder. The development of sexist, ethnic or mocking humour should be avoided.
     The humour is an excellent vehicle that leads to the creation of an environment with less strains and a better collaboration between the members of the different disciplines^9,12,21. We observe that although the benefits of humour and laugh are described, there are still many fields to investigate³⁵ like they suggest: Dowling³⁶ who recommends the need to investigate further to get to know the interventions of humour as an effective strategy, and Jonson P³³, who thinks that it is necessary to go more deeply into the knowledge about the use of humour and the cultural and environmental influence.

Fields of application of humour

     - Pediatrics³⁷. Children are very receptive and the use of humour makes them overcome more easily their process of illness³⁸.
     - Education. The humour speeds up the learning processes and improves the relation teacher-student. These strategies are applied in the pedagogical practice, due to the big influence that the laugh therapy has in psychopedagogy and speech therapy³⁹.
     - Surgery. It diminishes or eliminates the pain⁴⁰.
     - Patients with AIDS, cancer. It has been proved that they have bigger resistance when they are treated with laugh therapy sessions. (Ottawa, Canada).
     - Psychotherapy.
     - Terminal patients¹⁸. The humour eases the work of the sanitary professionals and helps the patient to accept the limits, to discover his vulnerability in a more tolerant way. Carbelo et al.¹⁴ tell us that the humour, some times, represents the biggest need for terminal patients. Cabodevilla⁴¹, psychologist specialist in units for palliative cares, points out that the use of humour helps the patient to achieve a maturing and improves the quality of life in its last final period, it alleviates the moment of taking leave of their family. Ruiz Irigoyen⁴² points out that the humour takes part in order to live humanly the situation of farewell without scenes (.) it tries to avoid the agony, the sense of suffering something tremendous, the artificial behaviours.

Organizations devoted to humour

     They are several the associations or organizations that work with the humour in different fields related to health. The URL http://Risoterapia.20m.com/favorite_links.html⁴³ gives us access to various organizations with a common philosophy as starting point: "to make humour a complementary therapy that eases the overcoming of adversities in different health situations". At this moment the Spanish contribution is fundamental. It is carried out through the foundations "Theodora", "Clowns without borders" and the "Fundación General de la Universidad de Alcalá de Henares", which are working in the research, training and application of the therapeutic humour in different social areas.
     Foundation Theodora: www.theodora.org/index.html. It was founded in the Canton of Vaud, Switzerland, in 1993 by the brothers Jan and Andre Poulie in the memory of their mother Theodora. Its objective is to relieve the suffering of the hospitalized children by means of the laugh. The foundation Theodora organizes and defrays visits of professional artists, the known Doctors Smile, who devote some time to hospitalized children. Their activities in Spain started in March 2000 and they count on the collaboration of the School of Nursery of the "Hospital de la Paz" that teaches the sanitary training module, and the "Hospital Niño Jesús" that teaches the artistic training module. Students are taught to know the inside of a hospital: they are familiarized with the rules, structures, medical vocabulary and measures of hygiene and asepsis at the hospital; but specially they learn to know the ill children⁴⁴. In Spain, the foundation Theodora is present, besides the "Hospital de la Paz" and "Hospital Niño Jesús de Madrid, at the "Clínico San Carlos, "San Rafael" and "Gregorio Marañón" also in Madrid. In Toledo it is present at the "Hospital Virgen de la Salud, and in Malaga it is present at the "Hospital Materno Infantil".
     "Clowns without borders": www.clowns.org⁴⁵. This non-governmental arts association is devoted to carrying smiles to zones of conflict. It was founded in 1993 and its objectives are: to improve the psychological situation of populations living in refugees camps, zones of conflict, marginalization and exclusion, and to make our society aware by promoting supportive attitudes. In Spain, spectacles with groups of professional artists with the aim of unblocking psychologically the persons assisted (ill people or refugees), are presented in 25 hospitals.
     "Fundación General de la Universidad de Alcalá de Henares": www.fgua.es. This foundation is carrying out a big human and economic effort by developing a program with several work lines: awards, education and research, publications, exhibitions and expositions. In the field of health, the conferences and workshops are given by Begoña Carbelo or by José Elías, who is a psychologist.
     The Association for Applied and Therapeutic Humour: www.aath.org. It is made up by doctors, nurses, psychologists and professionals of humour. Its head office is in the USA. Among its objectives it includes: to teach the therapeutic value of humour for the health to professionals; to develop, promote and identify the need to research about the role of humour and laugh in the well-being; to spread programs that incorporate the use of therapeutic humour and to create protocols of information about the humour and laugh related to the well-being.
     Gesundheit Institute. It was founded by Dr. Adams, www.patchadams.org. His experience was taken to the screens. The film "Patch Adams" contributed to popularize and disclose the concept of laugh therapy and its clinical usage.
     "El Placer de SaludArte": www.puntoclasico.com/Archivo/Saludarte_entrevista.html. This organization works in several fields: health, art and humour, with special emphasis in the area of the promotion of the health and prevention.  It was constituted in Montevideo in 1999. The objective raised by SaludArte in its activity in hospitals is: to promote the self-care and the patients' responsibility for their own health⁴⁶.
     Humormatters. American Association of therapeutic Humour: www.humormatters.com. We can find very complete information about humour, its therapeutic applications and the ways to promote it.
     Other organizations are: "Doctors without Borders", "Payasopital" in Valencia, "Pallapupas" in Barcelona, "Pupaclown" in Murcia or Organization "Recicla-Alicante".

Conclusions

     Among the professionals that work with these therapies there are psychologists, psychiatrists, nurses, professionals of humour and professionals of the education. We would like to underscore Begoña Carbelo and her team due to their work in the fields of the welfare nursery, the teaching and the research.
     The ones who publish the most about this issue are the professionals of the world of communication: journalists and writers. This is not an obstacle to think that the information arriving to the general public is complete enough, well based and coincident with the one published by professionals and experts on the field. Nevertheless, the bibliographic references are scarce and we consider them indispensable.
     We observe that there are not that many scientific studies about the effects of the application of humour and laugh therapy. Our opinion is that this could be due to the professionals' fear of introducing tools that escape the classic concepts as those have not been well appreciated. This could also be due to having considered the sanitary career with an excessive seriousness, or to the need of a specific qualification for the use of such therapies. It is clearly perceived that the situation is changing since the universities are introducing subjects dealing with complementary therapies.
     It would be interesting that the professionals of health started to use these therapies in the cares, because of their many benefits, their low cost and their absence of secondary effects.

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