hand therapy: the healing touch with a touch of humor!

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2000 ASHT PRESIDENTIAL ADDRESS Hand Therapy: The Healing Touch with a Touch of Humor! Joan L. Sullivan, MA, OTR, CHT ASHT President, 2000; , Co-owner, Hands-On Rehab Valhalla , New York She knew what all smart women knew: Laughter made you live better longer.-GAIL PARENT I never expected to be here with you today as President of ASHT, because I never intended to be a hand therapist or, for that matter, an occupational therapist. You see, when I was growing up, my dream was to be a clerk typist for the FBI. I applied for a job with them and was offered a position when I was still in high school. My mother, however, had different plans for me. She insisted that I be the first in the family to go to college. She bribed me with promises of a car. So off I went to college, where I majored in education. Of course, I didn't know what I was going to teach-my advisor cringed every time I walked into his office, and said things like, "Now what do you want to be?" Fortunately for my advisor, my mother secured a summer job for me at Creedmoor State Psychiatric Facility, where she worked. I wasn't enamored of the prospect of teaching, but career options for women were somewhat limited in the 1960s. I still had my eye on that clerk typist position at the FBI, so to polish my skills, all I wanted to do that summer was secretarial work. Much to my annoyance, my mother-do you see a pattern here?-changed my job application from a secretarial position to a position as an OT aide. I was furious. My mother said, and I quote, "Oh, shut up. You'll love working in They are always laughing and having a good time!" Well, the rest, as they say, is history. I loved I patients. Even though this was a challeng- mg envIronment, not unlike the hospital portrayed in This paper is a slightly edited versions of the Presidential Address at the 23rd Annual Meeting of the ASHT, on October 6, 2000, III Seattle, Washington. Correspondence and reprint requests to Joan L. Sullivan, Hands-On Rehab, 503 Grasslands Road, Suite 105, Valhalla, NY 10983; e-mail: [email protected]. One Flew over the Cuckoo's Nest, I enjoyed having an impact on these patients, enabling them to be as inde- pendent as possible in this difficult setting. Mother was right. I had a lot of fun with the OT staff and patients. This experience opened my eyes to OT as a better career choice than clerk-typist for the FBI. I was fortunate to be selected by the hospital to receive a full scholarship to the occupational therapy program at New York University. The promise of laughter changed my life. Let me thank my mother publicly now for helping me to find my life's work, because like a typical mother she always complains that I don't give her enough credit. Thanks, Ma! Oh! By the way, my mother never did buy me that car she promised, and the closest I got to a job with the FBI was by marrying one of New York's Finest, Lieutenant Clem Sullivan. The theme of this conference is "Overcoming Adversity-Hand Therapists and Hand Surgeons Shaping the 21st Century." I wanted this address to tie into the overall theme. Because of the ever-chang- ing health care environment, therapists face many challenges. Managed care companies often have little or no understanding of patients' conditions. We are given a limited number of visits to rehabilitate the patient and are often faced with compromising our standards of excellence. Every day, we are faced with shrinking reimbursement dollars while the costs for providing care soar. The paperwork that needs to be completed to secure those limited visits and dollars is overwhelming. I believe that this address will pro- vide you with a strategy to overcome these adversi- ties as well as a strategy to deal successfully with people who have sustained catastrophic and life- altering injuries. When I thought about how hand therapists could overcome adversity and shape the 21st century, I thought about one of the basic tenets of occupational therapy-therapeutic use of self. By using our own strengths and skills, we can overcome adverse situa- January-March 200 I 3

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Page 1: Hand therapy: The healing touch with a touch of humor!

2000 ASHT PRESIDENTIAL ADDRESS

Hand Therapy: The Healing Touch with a Touch of Humor!

Joan L. Sullivan, MA, OTR, CHT ASHT President, 2000; , Co-owner, Hands-On Rehab Valhalla, New York

She knew what all smart women knew: Laughter made you live better longer.-GAIL PARENT

I never expected to be here with you today as President of ASHT, because I never intended to be a hand therapist or, for that matter, an occupational therapist. You see, when I was growing up, my dream was to be a clerk typist for the FBI. I applied for a job with them and was offered a position when I was still in high school. My mother, however, had different plans for me. She insisted that I be the first in the family to go to college. She bribed me with promises of a car. So off I went to college, where I majored in education.

Of course, I didn't know what I was going to teach-my advisor cringed every time I walked into his office, and said things like, "Now what do you want to be?" Fortunately for my advisor, my mother secured a summer job for me at Creedmoor State Psychiatric Facility, where she worked. I wasn't enamored of the prospect of teaching, but career options for women were somewhat limited in the 1960s. I still had my eye on that clerk typist position at the FBI, so to polish my skills, all I wanted to do that summer was secretarial work.

Much to my annoyance, my mother-do you see a pattern here?-changed my job application from a secretarial position to a position as an OT aide. I was furious. My mother said, and I quote, "Oh, shut up. You'll love working in ~T. They are always laughing and having a good time!"

Well, the rest, as they say, is history. I loved ~T. I ~oved t~e patients. Even though this was a challeng­mg envIronment, not unlike the hospital portrayed in

This paper is a slightly edited versions of the Presidential Address prese~ted at the 23rd Annual Meeting of the ASHT, on October 6, 2000, III Seattle, Washington.

Correspondence and reprint requests to Joan L. Sullivan, Hands-On Rehab, 503 Grasslands Road, Suite 105, Valhalla, NY 10983; e-mail: [email protected].

One Flew over the Cuckoo's Nest, I enjoyed having an impact on these patients, enabling them to be as inde­pendent as possible in this difficult setting. Mother was right. I had a lot of fun with the OT staff and patients. This experience opened my eyes to OT as a better career choice than clerk-typist for the FBI.

I was fortunate to be selected by the hospital to receive a full scholarship to the occupational therapy program at New York University. The promise of laughter changed my life. Let me thank my mother publicly now for helping me to find my life's work, because like a typical mother she always complains that I don't give her enough credit. Thanks, Ma! Oh! By the way, my mother never did buy me that car she promised, and the closest I got to a job with the FBI was by marrying one of New York's Finest, Lieutenant Clem Sullivan.

The theme of this conference is "Overcoming Adversity-Hand Therapists and Hand Surgeons Shaping the 21st Century." I wanted this address to tie into the overall theme. Because of the ever-chang­ing health care environment, therapists face many challenges. Managed care companies often have little or no understanding of patients' conditions. We are given a limited number of visits to rehabilitate the patient and are often faced with compromising our standards of excellence. Every day, we are faced with shrinking reimbursement dollars while the costs for providing care soar. The paperwork that needs to be completed to secure those limited visits and dollars is overwhelming. I believe that this address will pro­vide you with a strategy to overcome these adversi­ties as well as a strategy to deal successfully with people who have sustained catastrophic and life­altering injuries.

When I thought about how hand therapists could overcome adversity and shape the 21st century, I thought about one of the basic tenets of occupational therapy-therapeutic use of self. By using our own strengths and skills, we can overcome adverse situa-

January-March 200 I 3

Page 2: Hand therapy: The healing touch with a touch of humor!

tions and have an impact on the future, whether the difficulties be patient or management related. Hand therapists have mastered one of the ultimate tech­niques in the therapeutic use of self, by the use of a healing touch.

It is the touch of the therapist's hands that helps the patient to relax and make progress.-PAUL BRAND, MDl

When a patient enters the clinic for the first time, we evaluate them. We touch their hands, we feel the skin. We explore their wounds and scars with our hands. We feel how their tendons glide, how the muscles work, and how the joints move. We feel for inflammation. My practice, like many of yours, is composed of patients who have sustained major traumas-such as burns, crush injuries, replants, amputations, and fractures. They have been through devastating injuries and surgeries. Initially, they are physically challenged and emotionally overwrought. Their self-images are impaired. They are unsure whether they can re-enter society as productive per­sons. Through our touch, during that first session and every subsequent session, we let our patients know that we accept them as they are. We are not afraid to share one of the most basic human func­tions-touching other human beings. I believe that this symbolic "laying on of the hands" is as impor­tant as anything else that we do as hand therapists. Through our touch, we validate our patients' worth and start them on the road to recovery!

I believe that it was Sterling Bunnell, MD, who said that a "good therapist looks like Venus de Milo." He said this in the early days of hand surgery, before the advent of the specialty of hand therapy. I'm sure that if Dr. Bunnell were practicing today, he would have a new respect for hand therapists and what they can accomplish with their touch.

Sometimes, when a patient is referred to me after an unsuccessful course of treatment at a nonspecial­ist facility, and I complete my usual hands-on evalu­ation and treatment, the patient starts experiencing what hand therapy is all about. The patient invari­ably confides in me, saying, "Nobody ever touched me before. All I ever did was work on machines." I believe the former therapists missed out on one of the most fulfilling interactions in the therapeutic rela­tionship-the simple act of touching another human being.

Humor is the antidote to all ills.-PATCH ADAMS, MD

It is certainly not necessary for me to preach to the choir. You must value the power of human touch or you wouldn't be in this area of specialization. What I do want to focus on is the importance of humor in the therapeutic relationship, because I believe that main­taining a good sense of humor and having a little fun with the patients is an integral part of "therapeutic

4 JOURNAL OF HAND THERAPY

use of self." Over the course of 30 years, I've discov­ered when you integrate a healing touch with a touch of humor, you have a very potent therapeutic tool.

I have seen what a laugh can do. It can transform almost unbearable tears into something bearable, even hopeful.­BOB HOPE

Therapeutic humor is inclusive; it brings people together. It decreases prejudice by focusing on the universal human experience. It encourages a positive atmosphere, and builds rapport and trust.2 To use humor effectively in the clinic, the therapist needs to be moderately humorous. There are different strate­gies that can help you develop a more acute sense of humor. Techniques include learning to belly laugh and tell jokes, laughing at yourself, finding humor in the midst of stress, creating a humor library, and associating with people who are funny.2,3

My own sense of humor developed early in life. I can attribute the greater part of my humorous side to my father and his family. I still remember family gatherings as being joyful occasions. As children we were encouraged to participate in the fun by telling jokes and funny stories. My sense of humor was fine­tuned by watching reruns of "Abbott and Costello," "Laurel and Hardy," "The Three Stooges," and "I Love Lucy" on TV after school. I read newspaper comic strips every day. I especially enjoyed reading "Humor in Uniform," "Laughter Is the Best Medicine," and "Campus Comedy" in Reader's Digest.

Humor is the greatest thing, the saving thing, after all. The minute it crops up, all our hardnesses yield, all our irritations and resentments slip away, and a sunny spirit takes their place.-MARK TwAIN

I was well served by a good sense of humor when I worked with my patients. After I graduated from OT school 30 years ago, I returned to Creedmoor and worked in psychiatry for about a year. I realized that the chronically depressed and even the actively psy­chotic patient could still appreciate a good joke or a funny movie. I watched their faces light up and learned that the patients were better able to partici­pate in activities during OT sessions after hearing a funny story or joke or having a little fun. We always laughed and had a good time in OT, because it bene­fited the patients!

Laughter is the shortest distance between two people. -VICTOR BoRGE

I eventually left psychiatry and took a job at New York City's Bellevue Hospital. I was assigned to the Rehabilitation Unit, which dealt primarily with patients with spinal cord injuries. The very first day on the job, the very first patient I worked with had to be taught to move from a wheelchair to bed. John had

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sustained a gunshot wound and was a high para­plegic. He was a convicted felon, he was a large man, and he was angry. So there I was, new to rehab, remembering next to nothing about transfers, and not wanting to admit that I needed help.

Like an idiot, I forged ahead. I explained to John what we were going to do, positioned him, posi­tioned myself, and said, "OK, let's do it." At that pre­cise moment, both of John's lower extremities went into spasm-he went flying over the bed and took me with him. There we were, on the floor, his catheter detached, urine everywhere. My life flashed before my eyes, and I thought, "Oh my God, he's going to kill me the first chance he gets." I looked at John, and he looked at me. When we saw the state we were in, we both burst out laughing.

This embarrassing but humorous situation set the stage for an honest and open therapeutic relation­ship. Many of the patients in that rehabilitation unit had a good laugh at my expense, but it opened the way for me to develop as a therapist. Fortunately, I didn't impede John'S independence in activities of daily living. Thirty years later, he is alive and well and leading a productive life, and he is still one of my best friends.

What exactly is humor? Humor can be in-your-face funny, like the situation I just described, or it can be much subtler. Steven Sultanoff, PhD, a psychologist and mirthologist and founder of Humor Matters, Inc., defines it as the capacity to perceive, appreciate, or express what is funny, amusing, incongruous, and ludicrous.4,5

A joke's a very serious thing.-CHARLES CHURCHILL

In doing research for this presentation, I was amazed at the number of articles and books related to humor. Therapeutic humor has become an art and science unto itself. There are numerous professional organizations specializing in humor, the largest being the American Association for Therapeutic Humor. Countless articles have been published in professional journals in the fields of medicine, nurs­ing, rehabilitation, psychiatry, psychology, research, business, and management. There are even a number of medical professionals who refer to themselves as mirthologists, who study and write prolifically on the value of therapeutic humor.

As it is not proper to cure the eyes without the head, nor the head without the body, so neither is it proper to cure the body without the soul.-SocRATES

Health promotion through humor has been dis­cussed and written about since ancient times. "A merry heart doeth good like medicine" can be found in the Bible (Proverbs 17:22).

Both Socrates and Plato recognized the importance of humor. In medieval times, the "humors," or bodily

fluids, were said to regulate man's temperaments.6 In 1302, a French surgeon, Henri de Mondeville, wrote "Let the surgeon take care to regulate the whole regi­men of the patient's life for joy and happiness, allow­ing his relatives and special friends to cheer him and by having someone tell him jokes.,,6

In 1905, Sigmund Freud wrote "Jokes and Their Relation to the Unconscious." In it, he described humor's purpose as turning "pain into pleasure.,,7,8 In 1928, Freud wrote another treatise, entitled "Humor.,,8,9 Freud's concept of joking was based on his original theory of repression and unconscious con­flicts. We laugh at things indicative of our problems or inhibitions. Freud states that joking becomes a socially acceptable way to handle problems. Rather than falling into pathologic states of neuroses, psychoses, or intoxication, we use humor to handle our difficulties. In 1977, William Fry, MD}O reported his research on humor physiology, or gelotology, the science of laugh­ter. He analyzed humor and separated it into its three components-the stimulus (the joke or sight gag), the emotional response (mirth), and the accompanying behavior (like laughing, smiling, or giggling).

Despair affects the immune system ... I try to leave patients with something to smile about.-BERNIE SIEGEL, MD

Therapeutic humor came of age in 1979 when Norman Cousins, an editor and author, published a book entitled Anatomy of an Illness as Perceived by the Patient.6,1l,12 Cousins had been diagnosed with anky­losing spondylitis in the mid-1960s. His prognosis was poor, and he was in constant pain.

Cousins had been embroiled in an extremely stress­ful situation when he experienced the first symptoms of the disease. He was familiar with Hans Selye's book The Stress of LifeY Selye explained that stress caused adrenal exhaustion, impairing the function of the adrenal glands, which could in effect lower the body's resistance to diseasep,13 Selye detailed the disruptive effects of negative emotions on body chemistry. Cousins hypothesized that if negative emotions caused adverse chemical changes, why wouldn't positive emotions-like love, hope, faith, laughter, and confidence-produce a beneficial chemical change?

Cousins already had love, hope, faith, and a strong will to live, so he started experimenting with laugh­ter. He noticed that when he laughed, real good belly laughs, his pain diminished for hours and he was able to sleep more restfully. His sedimentation rate actually decreased five to nine points after laughing. He watched movie and TV comedies and read humorous books and articles.

Cousins continued researching and writing about the power of positive emotions and laughter for more than 20 years, was given an honorary degree at UCLA, and was named an adjunct professor of psy­chiatry and behavioral science.

January-March 200 I 5

Page 4: Hand therapy: The healing touch with a touch of humor!

A clown is like an aspirin, only he works twice as fast.­GROUCHO MARX

What is it about laughter that makes us feel better? Sultanoff writes in his many articles that laughter effects us physiologically, cognitively, and emotionally.S,14

Pain is deeper than all thought; laughter is higher than all pain.-ELBERT HUBART

Physiologically, laughter increases the heart rate, blood pressure, and pulse rates, thereby increasing

. 1 t' 316-19 P 1 fu" Clrcu a IOn. ' u monary nctlOn Improves as we breathe deeper and take in more oxygen while expelling more carbon dioxide, which enhances blood oXigen levels much as aerobic exercise does.16,20,2 Laughter exercises muscles in the face, diaphragm, abdomen, arms, legs, and back, toning them and easing tension.16--18 Laughter enhances neu­roendocrine function in patients with rheumatoid arthritis,18,22 acts as a natural pain killer throu§h the release of endorphins and catecholamines,16,18, sand increases the protective action of the immune sys­tem.n,13,18,24,2S,~7,28 Immunoglobulin-A levels increase dramatically in the saliva after a hearty laugh, pro­tecting us from staphylococcal and streptococcal infections. I am living proof that this last statement is true. I left my last job with 122 unused sick days!

Humor is the healthy way of feeling a "distance" between one's self and the problem, a way of standing off and looking at one's problem with perspective.-RoLLO MAY, PHD

Cognitively, humor allows us to control our reac-tion to those events in the outside world over which we have no contro1.4,s Sultanoff states that humor consists of wit, which is a thought-oriented process. Wit changes how we cognitively process, appreciate, or "think" about life's events and situations. Sultanoff explains that when we listen to a joke, we are guided down one path, only to be tracked over onto an alternative path. It is the discrepancy and even the trickery of the alternative path (the punch line) that we experience as humorous. This alterna­tive thinking process provided by wit provides per­spective and can reduce the negative thinking that is common in depression, anxiety, and anger. Humor provides us with an alternative view of how we per­ceive our problems.

The crisis of today is the joke of tomorrow.-H. G. WELLS

So, have you heard the one about the hand thera­pist who was losing her practice because of poor reimbursement rates? She prayed to God to let her win the lottery. The lottery was drawn on Saturday, but she didn't win. She prayed to God again the next week to win the lottery, because not only had she lost her practice but this week she was going to lose her car. The numbers were drawn on Saturday, but she didn't win again. She was really desperate the third

6 JOURNAL OF HAND THERAPY

week. Not only had she lost her business and her car, but this week she was going to lose her house. She prayed to God again to let her win the lottery, and she heard a voice. "It's me, God! Give me a chance to help you. Buy a ticket!"

Everything is funny as long as it is happening to some­body else.-WILL ROGERS

Emotionally, humor counters the effects of stress, provides a balance in the mind-body-spirit continu­um, and provides a perception of control in stressful 't t' 34614 D'd . f 11 d SI ua Ions. ' , , 1 you ever tnp or a, 0 some-

thing stupid, or watch someone else's pratfalls? What's the first thing you usually do? You laugh or giggle, experiencing an emotional release-it's natures' way of venting stress. Sultanoff14 states that humor and distressful emotions cannot "occupy" the same emotional and psychological space.

If you can laugh at it, you can survive it.-BILL COSBY

I once treated a teenaged boy who should probably be nominated for a Darwin Award. He and his friends decided that it would be great fun to shoot firecrackers into a lake using a bow and arrows. As he pulled back on the bowstring with the lit M80 attached to the tip of the arrow, it exploded. The blast amputated three of his fingers, one of which became embedded in his eye, and subsequently the damaged eye needed to be removed. We received an order to change his dressing and make him a splint prior to discharge. Knowing the stupidity of his accident, we were uneasy about his impending visit to the clinic.

When he finally arrived, a hush fell over the room. He sat down and announced loudly, "Hi! I'm here for eye-hand coordination therapy." There was a preg­nant pause and then patients and staff alike burst out laughing. By starting out with a joke, he immediately dispelled everyone's anxiety. We laughed with him and not at him. That simple witty remark told us that we didn't have to feel sorry for him. We knew he would easily adjust to his handicaps with such a great attitude!

We're all in this together-by ourselves.-LILY TOMLIN

In his article "Keeping Them in Stitches," Rick Rader, MD,B states t4at laughter forms the basis for emotional health by letting people share an enjoyable common experience. Dr. Rader writes that humor makes us more open and receptive to one another and that humor enables human connectivity.

Christine Muhleman shared a story with me about a patient who sustained severe burns of the hands and lived a great distance away from the center where Chris worked. The patient could only be seen sporadically, so Chris had to show him what to do at home. She warned him over and over again about debriding his own hand, because it could easily get

Page 5: Hand therapy: The healing touch with a touch of humor!

infected. One day the patient came in complaining about increased pain in his hand. Chris started taking down the dressing and was horrified to find a great deal of blood and yellow matter in the dressings. The patient couldn't keep a straight face and started laughing. Finally he admitted that he had put ketchup and mustard in the dressings over a very well healed wound. The patient thought it was a riot, and, once she got over the shock, so did Chris. Humor established a connection between the patient and the therapist and actually made it easier for Chris to treat him, even at a distance.

No matter what your heartache may be, laughing helps you to forget it for a few seconds.-RED SKELTON

My partners and I had treatment tables built that could comfortably seat three patients and a therapist. We did this for a number of reasons. Besides the obvious ones of saving space and increasing produc­tivity, these tables were built to facilitate patient interaction and group cohesion: Over the years, we learned that therapy is a great leveler. No matter how depressed a patient is about his condition, when he looks at the guy sitting next to him and they start comparing injuries, they each appreciate just how lucky they are. There is usually someone sitting close by who has more difficult hardships to overcome.

Perhaps I know why it is man alone who laughs; he alone suffers so deeply that he had to invent laughter.­FRIEDRICH NIETZSCHE

Most patients are emotionally vulnerable when they first begin treatment. Many have had a life-alter­ing injuries, diseases, or surgeries. They have lost control of their lives. They rely on their surgeons to fix the problems, the therapists to restore function, their families to help them with their ADLs. In many cases they are out of work and are not able to provide for their families. These feelings of helplessness and worthlessness are anxiety provoking. Sharing experi­ences with someone in the same boat or at the same table, so to speak, enables the patient to form alliances to work on these problems. Once they start talking about their situations, they invariably start laughing and joking.

When in doubt, make a fool of yourself. There is a micro­scopically thin line between being brilliantly creative and acting like the most gigantic idiot on earth. So what the hell, leap!--CYNTHIA HEIMEL

I'm not exactly sure what unique personality char­acteristics hand therapists have, but in my experience they are fairly rigid about following protocols and enjoy telling patients what to do, how to do it, and when to do it! As a therapist who certainly fits that profile, I just love it when the patients develop enough emotional strength to "revolt" and "gang-

up" on me. This coup d'etat takes the form of humor in our clinic, because it is a safe and emotionally healthy way of dealing with stress and control issues. Humor allows the patient to develop mastery and take charge in the therapeutic milieu. Some days I feel that I am prepping for a stand-up comedy rou­tine rather than for treatment sessions. Patient alliances prevail, and the therapist usually gets voted off the island!

One loses many laughs by not laughing at oneself.-SARA JEANETTE DUNCAN

I am currently treating a patient who is the presi­dent of a large corporation. One day, after a particu­larly difficult treatment session, he presented me with a newly released book entitled The Beasts of Valhalla. That doesn't seem extraordinary, but my clinic is in Valhalla, New York. He and the other patients in the clinic thought the sentiment of the title was apropos and extremely funny. Before long, everyone was making wisecracks. I was the willing victim of their jokes and even joined in the fun by promising them that their next session would be extremely painful!

What's important to realize in a situation like this is that in one small way the patients were developing mastery. We had such a strong therapeutic relation­ship that the patients felt enough control to poke fun at me and the situation in which they found them­selves. I proudly display this book along with other mementos that grateful patients have given me over the years-hand cuffs, whips, riding crops ... !

Trust your gut.-BARBARA WALTERS

There are many other examples of patients taking control of their situations through humorous meth­ods. We see them decorating and personalizing their splints, dressing up for holidays, and mugging it up like the patient who threatened to blow up the clinic by plugging 'his TENS unit leads into his therapy putty! Therapists should encourage this behavior. A research study by Patricia Wooten, RN, found that people who were encouraged and guided to use humor gained a sense of control in their lives.29

Gaiety is the most outstanding feature of the Soviet Union.-JOSEF STALIN

Laughter is so important when you want to put people at ease. We once sublet space for our satellite office in a private general rehab practice. On many occasions we were asked by the owner, a therapist, to keep the laughter to a minimum because her patients wanted to know what they had to do to get treated in my part of the clinic. I think she was afraid that she was going to lose business! She never quite learned the importance of laughter as a therapeutic tech­nique. Now, I'm not going to say for sure that one

January-March 200 I 7

Page 6: Hand therapy: The healing touch with a touch of humor!

thing had anything to do with the other, but we had to move when her practice closed!

Life does not cease to be funny when someone dies, any more than it ceases to be serious when someone laughs.­GEORGE BERNARD SHAW

Is humor ever inappropriate? Yes. SultanoffI4 sug­gests that we avoid negative humor, like sarcasm and put-downs; humor that is insensitive to the emotional experience of the receiver; and humor used to create distance from the emotional experience. Self-directed humor is usually safer than humor directed at another person. Humor directed toward a situation is safer than humor directed at others. In our large therapy clinics, we must be sensitive to others in the environ­ment to be sure that only those for whom the humor was intended experience our humor.19 We do set lim­its on jokes told in the office. We don't allow cultural­ly or ethnically biased jokes, and we discourage jokes that would cause anyone to blush.

Comedy is tragedy plus time.-CARoL BURNETT

Once in a while, though, humor that seems irrever­ent or even "sick" is acceptable. We once treated two patients named Walter. Walter #1 was a security guard who had been shot nine times during an armed robbery, and Walter #2 had sustained third­degree burns over 70% of his body when he tried to clean fleas from his dog's rug with gasoline and it ignited. Somewhere along the line, the Walters start­ed calling one another "Holey" Walter and "Crispy" Walter. At first, other patients and staff were taken aback. Once they experienced the compassion and kindness in the way the Walters treated one another, though, the "sick" humor became an acceptable way for them to deal with their stressful situations.

Life must be lived as a play.-PLATO

There are many forms of humor you can use in your clinics. You need to determine what type of humor you are most comfortable with.3 Patch Adams, MD,30 and his disciples are proponents of clowning. Some doctors, nurses, and therapists wear big red noses or funny hats. Others have humor carts containing props, funny books, and movies. Karen Schultz Johnson told me that she has a "humor book" in her clinic that contains funny stories, jokes ,and cartoons. Everyone is encouraged to read and con­tribute to the book. Some medical professionals do nothing at all but act their natural, funny selves. You just have to find your own style.

Everybody knows if you are too careful you are so occupied in being careful that you are sure to stumble over some­thing.-GERTRUDE STEIN

It is important, especially for the younger therapist or student, to learn that being professional doesn't

8 JOURNAL OF HAND THERAPY

necessarily mean you have to be cold or distant.19

Humor can foster strong professional and therapeu­tic relationships. A recent study by Levinson et al.18,3I reported on physicians who did not incur malprac­tice suits. Humor and time spent with patients were identified as the variables responsible for lower rates of suits filed against physicians. A well-placed joke or witty remark can provide the groundwork for a productive collaboration with doctors, lawyers, insurance companies, and others who create stress and other adverse conditions in our lives.

Our humor turns our anger into a fine art.-MARY KAy BLAKELY

Through the use of that basic treatment tenet, "therapeutic use of self," hand therapists have the power to reach out to others, the power to touch, the power to laugh, and the power to heal all at our fingertips. Every pun intended!

REFERENCES

1. Brand P. Hand rehabilitation: management by objectives. In: Hunter I, Mackin E, Callahan A (eds). Rehabilitation of the Hand, 4th ed. St Louis, Mo: Mosby, 1995.

2. Ferguson E. Health and spirituality. Alt Med. 2000;(1),70-4. 3. McGhee P. Health, Healing and the Amuse System. 3rd ed.

Dubuque, Iowa: Kendall Hunt, 1999. 4. Sultanoff S. Exploring the land of mirth and funny: a voyage

through the interrelationships of wit, mirth, and laughter. Laugh It Up [newsletter of the American Association for Therapeutic Humorl. 1994;7:3.

5. Sultanoff S. Tickling our funny bone: humor matters in health. AhHa! Furthering the Understanding of Holistic Health [newsletter of the American Holistic Health Associationl. 1999;5 (1):4.

6. Wooten P. Humor: an antidote for stress. Holistic Nurs Pract. 1996;10(2):49-56.

7. Freud S. Jokes and their relation to the unconscious. In: Strachey J (ed). The Complete Psychological Works of Sigmund Freud, vol 8. London: Hogarth Press, 1905 (reprinted 1961).

8. Rader R. Keeping them in stitches. The Exceptional Parent. 1999;29(6):57-61.

9. Freud S. Humor. In: Strachey J (ed). The Complete Psycho­logical Works of Sigmund Freud, vol 21. London: Hogarth Press, 1928 (reprinted 1961).

10. Fry W. The appeasement function of mirthful laughter. In: Chapman AI, Foot HC (eds). It's a Funny Thing, Humour. Oxford, UK: Pergamon, 1977.

11. Cousins N. Anatomy of an Illness as Perceived by the Patient. New York: Bantam Books, 1979.

12. Robinson V. Humor and the Health Professions. 2nd ed. Thorofare, NJ: Slack, 1991.

13. Selye H. The Stress of Life. New York: McGraw-Hill, 1956. 14. Sultanoff S. Choosing to be amusing: assessing an individual's

receptivity to therapeutic humor. J Nurs Jocularity. 1994;4(4):34-5. 15. Sultanoff S. Survival of the witty-est: creating resilience

through humor. Therapeutic Humor [newsletter of the American Association for Therapeutic Humorl. 1997;11(5):1-2.

16. Fry W. The physiologic effects of humor, mirth, and laughter. JAm Med Assoc. 1992;267(13):1857-9.

17. Fry W, Savin WM. Mirthful laughter and blood pressure. Int J Humor Res. 1988;1(1):49-62.

18. Leber D. Mend with medical mirth [course notesl. American

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Occupational Therapy Association 80th Annual Conference; Seattle, Washington; Mar 31-Apr 3,2000.

19. McGhee P. RX: laughter. RN. 1998;61(7)50:3. 20. Fry W. The respiratory components of mirthful laughter. J Bioi

PsychoL 1977;19(2):39-50. 21. Leber 0, Vanoli E. Therapeutic use of humor: occupational ther­

apists' perspectives and practices. Am J Occup Ther. In press. 22. Yoshino JF, Fujimori J, Kohada M. Effects of mirthful laughter

on neuroendocrine and immune systems in patients with rheumatoid arthritis. J RheumatoL 1996;23(4):793-4.

23. Adams ER, McGuire FA. Is laughter the best medicine? A study of the effects of humor on perceived pain and affect. Activities, Adaptation, and Aging. 1986;8(3):157-75.

24. Berk L, Tan S, Fry W, et al. (1989). Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci. 1989;298(6):390--6. •

25. Berk L. Eustress of mirthful laughter modifies natural killer cell activity. Clin Res. 1989;37(115).

26. Cousins N. Head First:The Biology of Hope. New York: Dutton, 1989.

27. Dillon K, Minchoff B, Baker K. Positive emotional states and enhancement of the immune system. rnt J Psychiatry Med. 1985;15(1):13-8.

28. Lefcourt MM, Davidson-Katz K, Kueneman K. Humor and immune-system functioning. Int J Hum Res. 1990;3(3):305-21 .

29. Wooten P. Does a humor workshop affect nurse burnout? J Nurs Jocularity. 1992;2(2):42-3.

30. Adams P. Gesundheit! Rochester, Vt: Healing Arts Press, 1993. 31. Levinson W, Roter 0, Mulloly J, Dull V, Frankel R. Physician­

patient communication: the relationship with malpractice claims among primary care phYSicians and surgeons. J Am Med Assoc. 1997;277(7);553-9.

Additional Readings

Buffman M, Brod M. Humor and well-being in spouse caregivers of patients with Alzheimer's disease. Appl Nurs Res. 1998;11(1):12-8.

Draheim M. Humor: a powerful tool for health-care professionals and patients. Diabetes Spectrum. 1995;8(3):137:42.

Kerivan L. Rise and laugh. Natural Health. 1999;29(3):26. Moody R. Laugh after Laugh. Jacksonville, Fla: Headwaters Press,

1978. Stone A, Cox OS, Neale JM, Valdimarsdottir H, Jandorf L.

Evidence that secretory IgA antibody is associated with daily mood. J Pers Soc Psychol. 1987;52(5):988-93.

Vergeer G, MacRae A. Therapeutic use of humor in occupational therapy. Am J Occup Ther. 1993;47(8):678-83.

Wooten P. Laughter as therapy for patient and caregiver. In: Hodgkin J, Connors G, Bell C (eds). Pulmonary Rehabilitation. Philadelphia, Pa: Lippincott, 1993.

Selected Humor Resources

American Association for Therapeutic Humor, 4534 W. Butler Drive, Glendale, AZ 85302. Web site: www.aath.org.

The Humor Project, Inc., 480 Broadway, Suite 210, Saratoga Springs, NY 12866. Web site: www.humorproject.com.

HumorMatters, Stephen M. Suitanoff, PhD, 3972 Barranca Parkway, Suite J-221, Irvine, CA 92606. Web site: www.humor­matters.com.

HUMORx, P.O. Box 1273, Hannibal, MO 63401. Web site: www.humorx.com.

The Laughter Remedy, Paul McGhee, PhD. Web site: www.laughterremedy.com.

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