Lucia Cino's workday at The Hospital for Sick Children (SickKids) starts by going through the patient list with a Child Life specialist. "We highlight who the priority patients are, who would benefit most from therapy, and who she would like me to build long-term relationships with." That done, she gets ready to meet the day's young patients.
Cino sterilizes her equipment and hands, dons a colourful suit, and lastly, puts on a bright red nose. At that moment, her alter ego Nuula, one of the therapeutic clowns at SickKids, comes alive.
"One of the cardinal rules is we seek permission before engaging anyone in play," says Cino, who, in addition to being Nuula, manages the therapeutic clown practitioners at SickKids. "Asking permission puts the power in the child's hand." But once the door opens, both figuratively and literally, therapeutic clowns are trained to give the child a safe play space, and provide relief from pain, anxiety, and boredom.
"We follow the lead of the child - there is no one thing - it's wide open for them," says Cino, adding the point of therapeutic clowning is not necessarily getting a child to laugh. Rather it is to transcend the physical and psychological boundaries created by pain. "If laughter is the outcome, wonderful, but if the child is engaged they experience a release and that is positive."
Science agrees: it's about more than being funny
Although the effectiveness of laughter and humour in pain relief has not been extensively studied, distraction has. Children experience less pain when they are distracted from it. Distraction techniques can include everything from video games to music to getting a child to recount a scene from their favourite movie. Other effective non-medical pain relief techniques include deep breathing and blowing bubbles. Given this, it is not a surprise that laughter and humour in general also make great pain relievers. But many clinicians and researchers know that distraction is just one part of psychological pain relief.
"There is engagement and empowerment," says Dr. Margaret Stuber, a child psychiatrist specializing in psychosomatic medicine at the University of California, Los Angeles. "You can see their change in perspective; moving out of powerlessness to empowerment perhaps by telling a clown what to do." Dr. Stuber recently published a study on laughter, humour, and paediatric pain that showed children tolerated pain better if they watched funny videos immediately before or after a painful procedure.
"We found that laughter itself, the number of laughs or how funny the children thought something was, did predict pain perception or pain tolerance," says Stuber, whose research was funded with an unrestricted grant from Comedy Central, the American television channel. "But it's not an either/or: the physical act of laughing makes a difference [in pain perception and tolerance], but it's probably a relatively minor difference." In other words, being engaged in the humorous video was enough to relieve pain.
In addition to asking children to rate their own pain, Dr. Stuber's study also measured cortisol levels in the children's saliva. "An elevated cortisol level is a typical stress response which is antithetical to healing." Most people in pain show an immediate rise in cortisol. In Dr. Stuber's study, cortisol levels were reduced, but not enough to be considered clinically significant.
Less pain or noticing less?
While there is no doubt that pain relief by psychological means such as humour and laughter is useful, many questions remain about why and how it works. For example, is pain and all its associated physiological stressors reduced, or is it just the perception of pain that is reduced? "These are two different phenomena that may not be tightly correlated," says Stuber. This question is difficult to answer, in part because of the subjective nature of both pain and humour. "I think how much you laugh is to some extent a temperamental issue: how outgoing you are, and so on. And in terms of pain, some people are stoic and suffer in silence while their bodies are being ravaged."