Issues in Mental Health Nursing, 35:898–901, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.911995
CULTURAL COMPETENCE COLUMN
It’s Funny Here. Is It There? Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA Last month’s column focused on theories of humor – the motivations behind humor – and the therapeutic use of humor and laughter as an adjuvant to medical treatment for patients with a variety of illnesses (Flaskerud, 2014). The theoretical motivations for humor described in the last column included several based on psychology – the expression of negative emotions, such as aggression and superiority; a coping mechanism for tension release; a means to resolve incongruity; a benign violation of various norms; and reverse engineering, an evolutionary development to correct errors in perception, based on neuroscience. The positive aspects of humor and the therapeutic use of laughter were explored also (Flaskerud, 2014). Several reports have demonstrated that laughter appears to improve mood, lessen anxiety, reduce psychological measures of stress, and reduce perception of pain (Christie & Moore, 2005). There are also physiological factors involved. Laughter can lead to changes in heart rate, skin temperature, blood pressure, pulmonary ventilation, skeletal muscle activity, and brain activity, which may improve overall wellbeing. Additionally, laughter may improve immune function by blocking the production of stress hormones, such as cortisol, and by increasing the release of immune-enhancers, such as beta-endorphin (Cancer Treatment Centers of America, 2013; Christie & Moore, 2005). Two other aspects of humor will be addressed here, as they apply to cultural differences and the use of humor. The first is: Are there other theoretical explanations of humor that do not rely on Western psychology and neuroscience? And second: Are humor and laughter used therapeutically in other cultures? It should be noted that humor and laughter are considered human traits: only humans have humor and we communicate it Address correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095–1702 USA. E-mail: [email protected]
with laughter. Humor is universal – it can be found in every society (Billig, 2002). Yet it is also highly specific; there is nothing that is universally funny. Not only are there cultural and individual differences in humor, but these differences are invested frequently with moral meaning. We laugh at particular things and we disapprove of laughter at other things. Humor also can be a matter of disagreement: there is a politics, morality and esthetics of humor (Billig, 2002). How funny somebody finds a certain incident depends on many factors, including age, personal experience, level of education, geographical location, and culture. Therefore, humor is something which is not always transferrable to another country or culture. What somebody from one area may find hilarious may not be amusing at all to someone from another region. Did you hear the one about the American businessman whose tame joke drew a hilarious response from his Japanese audience? The American, curious why they liked the joke so much, later asked his official translator, who replied: ‘The joke was not appropriate, so I did not translate it. I simply said: ‘The gentleman has told a joke. Please laugh.’
Whether or not someone gets a joke is determined by his or her interpretation, filtered by the cultural context. In a multicultural society and a global world, what do we know about the context of humor, when to use it, and what might be considered appropriate and inappropriate? There is little information on non-Western theoretical explanations of humor. Deconstructing humor seems to be largely a Western phenomenon and most of what we know about humor caters to the developed West and all but ignores the global South. Garrison (2011) suggests that this might be because the obsession with studying humor is a cultural tendency specific only to Western countries. She observes that there is an international journal of humor but that the editorial staff and the articles published still skew very Western and predominantly American. However, it should be noted that the exploration and uses of humor have gained attention in the Far East (China, Japan, Hong Kong, Taiwan), where the historical roots of humor are being investigated and research is being conducted (Chiang-Hanisko,
898
IT’S FUNNY HERE. IS IT THERE?
Adamie, & Chiang, 2009; Jiang, Yue, & Lu, 2011; Nevo, Nevo, & Yin, 2001; Yue, 2010). In a historical review of Eastern views of humor, Yue (2010) reported that in Chinese society, humor has been valued largely by Taoism and Buddhism, whereas Confucianism, the dominant philosophy in Chinese society, is culturally responsible for devaluing humor as an act of an uneducated and uncivilized person. Yue (2010) goes on to say that this Confucian Puritan attitude toward humor was reinforced during the Communist era in the mid- to late-1900s. Jiang and colleagues (2011) supported this view when they compared the attitudes toward humor of 60 Chinese undergraduates of Peking University in China with 33 American exchange students of the City University of Hong Kong, using the Implicit Association Test (Jiang et al., 2011). They found that the Chinese group showed a generally negative implicit attitude toward humor. Compared with the Chinese group, the American group had a generally positive implicit attitude toward humor. However, the Chinese group rated their humor appreciation almost the same as the American group. The researchers concluded that the Chinese appreciation of humor derives from the Taoist valuation of humor as a way to achieve peaceful and harmonious interactions. The Chinese devaluation of humor comes from a Confucian disregard for humor as a sign of intellectual shallowness and social informality (Jiang et al., 2011). Yue (2010) concluded his historical review of Chinese humor by arguing that Chinese people need to find ways to enhance and express humor. He goes on to say that more efforts, academic or otherwise, need to be made to promote humor as an effective way of enhancing one’s mental health, creativity, and self-actualization (Yue, 2010). The closest Yue (2010) comes to a theoretical explanation of humor is to say that thoughtful humor is based on the perception of human errors, incongruities, banalities, and hypocrisy. These explanations are close to the Western views described in last month’s column as reflecting negative aspects of humor (Flaskerud, 2014). Some of the non-Western research articles on humor allude to explanations but these are more a discussion of findings rather than an overall theory of humor. For example, Nevo and colleagues (2001) reported that in a study that compared humor in American and Singaporean participants, the Singaporean respondents did not use humor for coping (the Western explanation that humor acts as a coping mechanism for the release/relief of tension). The traditional Chinese approach frames humor as a tool to illustrate a concept, prove a point, or win an argument. It teaches while it entertains. The understated, utilitarian Chinese approach to humor may not lend itself to using humor as a means to relieve stress and cope with difficult life situations (Nevo et al., 2001). An analysis of the content of the Singapore respondent’s jokes reflected cultural norms of conservatism where matters of sexuality were concerned, and a significantly greater use of jokes with aggressive content. A little more than half of Singaporean jokes were aggressive, as compared with only 42% of American jokes (Nevo et al., 2001).
899
One research article published in The International Journal of Humor in 2009, was of some interest because it reported differences in a wide range of cultures and countries, although it did not focus on explanations of humor but on gelotophobia – the fear of being laughed at (Proyer et al., 2009). Set in 73 countries ranging from Western Europe, the Far East, Africa, the Americas, the Middle East, and Australia, the investigators attempted to find out if gelotophobia could be measured and what that might suggest about each country’s sense of humor. They used a 15-question survey (GELOPH 15) translated into 42 different languages, keeping in mind regional differences in language even within countries (Garrison, 2011; Proyer et al., 2009). The GELOPH 15 is a questionnaire assessing the level of the fear of being laughed at consisting of 15 items in a 4-point answer format (1 = strongly disagree; 2 = moderately disagree; 3 = moderately agree; 4 = strongly agree). The sample consisted of 22,610 participants who completed the instrument. Across all samples, the reliability of the 15-item questionnaire was high (mean alpha of 0.85) and in all samples, the scales appeared to be unidimensional. The endorsement rates for the items ranged from 1.31% through 80.00% to a single item. Variations in the mean scores of the items were more strongly related to the culture in the country and not to the language in which the data were collected. Two dimensions were identified that further helped explain the data: insecure vs intense avoidant-restrictive personality (e.g., avoiding places where you had been laughed at, feeling uncomfortable when dealing with people who had laughed at you earlier, taking a long time to recover from being laughed at); and low vs high suspicious tendencies towards the laughter of others (e.g., feeling suspicious if others laugh) (Proyer et al., 2009). A few of the items in the survey and the countries endorsing them are revealing. The first question on the survey stated, ‘When others laugh in my presence, I get suspicious.’ Finland gave the lowest endorsement to this item and Thailand gave the highest. What this might mean is if you laugh in the presence of a Thai person, they may be immediately on their guard, whereas a Finnish person might not even notice (Garrison, 2011). Another item stated, ‘It takes me very long to recover from having been laughed at.’ The lowest endorsement to this item came from the USA and the highest came from Japan. As a more formal culture steeped in manners, it might be reasoned that being laughed at may offend a Japanese person. One more example: ‘I control myself strongly in order not to attract negative attention so I do not make a ridiculous impression.’ Lowest endorsement? Again the USA. Some may argue we lack humility and reserve; two qualities not very valuable in American culture, but of the utmost importance elsewhere around the world. For example, Indonesia, which gave this item the highest endorsement, may value these qualities highly. Other items addressed avoiding people and places where one has been laughed at, a kind of social phobia. The researchers concluded that gelotophobia can be assessed reliably by means of a self-report instrument in crosscultural research, and that the findings provided some evidence
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of the prevalence and putative causes of gelotophobia within different cultures (Proyer et al., 2009). As noted, this study was included in the discussion of humor because of the wide-ranging cultures that were represented. Last month’s column dealt also with the positive aspects of humor – the therapeutic use of humor with patients with various illnesses. Humor has been recognized by nurse researchers as a therapeutic intervention known to have positive psychological and physiological outcomes for patients. Are there instances of cross-cultural use of therapeutic humor? Cross-cultural research on humor is sparse but nurses are very involved in this effort. In a nurse-led study in Japan, researchers investigated the effects of laughter on post-prandial blood glucose (Hayashi et al., 2003). They conducted a 2-day experiment with 19 patients with type 2 diabetes not receiving insulin therapy and five healthy subjects. On both experimental days, the participants consumed the same 500 kcal meal. On the first day, they attended a monotonous lecture (40 min) without humorous content. On the second day, they attended a cross-talk Japanese comedy show. (Cross-talk is a favored form of comedy in China as well). Unlike modern American stand-up comedy, cross-talk uses two comedians and sometimes even an entire group. Similar to American comedy, it usually employs the ‘double act’ device of a straight man and a stooge perpetually at philosophical odds – think of Abbott and Costello, Martin and Lewis. Cross-talk requires the mastery of four talents: speaking, imitating, teasing, and singing. Crosstalk routines are heavy on puns, sometimes political, and more often insensitive. The investigators found that patients with diabetes who were exposed to the cross-talk comedy show demonstrated a significant suppression of the increase in 2-h post-prandial blood glucose, suggesting that laughter ameliorates the post-prandial glucose excursion in the presence of insufficient insulin action (Hayashi et al., 2003). They concluded that this favorable effect of laughter may include the acceleration of glucose utilization by the muscle motion during the comedy show. However, it is possible also that the positive emotions, such as laughter, acted on the neuroendocrine system and suppressed the elevation of blood glucose level (Hayashi et al., 2003). Adamle, Chiang-Hanisko, Ludwick, Zeller, & Brown (2007) conducted a study to examine how nurses learn about humor. Although there is nursing research that examines the effects of therapeutic humor, they found no research that investigates how nursing students learn about humor and how to use it therapeutically. Their study examined the teaching practices of nursing faculty about humor education in the classroom and in clinical settings (Adamle et al., 2007). Nursing faculty members from four nursing programs, two in the USA, one in Northern Ireland, and one in Taiwan, were surveyed about the inclusion of humor in the nursing curriculum. Findings revealed that substantially more humor education was included in clinical settings in the USA and Northern Ireland than in the classroom. In Taiwan, however, humor education was included more in the classroom than in clinical settings. Younger nurse faculty were more likely
to include content on the use of humor in classrooms than were older nurses, and to expose their own humor abilities in clinical settings. In a follow-up to this study, Chiang-Hanisko, Adamle and Chiang (2009) investigated how nursing faculty members approach teaching therapeutic humor in the classroom and clinical settings in different countries. These investigators proposed that studying nursing faculty teaching practices and viewpoints of therapeutic humor might reveal cultural differences in the use of humor in healthcare settings. Their cross-cultural study included 40 nursing faculty at three nursing programs: two in the USA and one in Taiwan. A qualitative approach was used to perform content analysis on responses to the open-ended questionnaires. Research findings revealed cultural differences between faculties from the two countries. Taiwanese faculty members indicated that they teach more theory and concepts related to therapeutic humor in the classroom than do nursing faculty members from the USA. However, nursing faculty members in Taiwan reported that they observe and practice less therapeutic humor in clinical settings, out of respect for the cultural value of ‘reverence of illness’ operating within Taiwanese society. Therapeutic humor was family-centered and interdependent on relationships, roles, duties, and responsibilities of family members. In contrast, the US faculty members stated that they teach less theory and concepts related to therapeutic humor in the classroom but observe and practice humor more in clinical settings. US faculty approached teaching therapeutic humor in the classroom on an informal basis because the subject was not part of the required nursing curricula. In clinical settings, therapeutic humor was patient-centered and spontaneous in nature (Chiang-Hanisko et al., 2009). Although these studies provide some information on crosscultural variations in the use of humor by nurses, they tell us little about what kind of humor to employ with different age groups, genders, and cultural groups. Jackson (2012) contends that there are some universally appreciated aspects of humor. For example, he says that people of all cultures laugh at incongruities and their resolutions; and that humor techniques like exaggeration, understatement, witty cynicism, verbal irony, disguise, and deception are all viewed as funny in markedly different regions of the world (Jackson, 2012). However, the research on gelotophobia (fear of being laughed at) should caution us that there are different sensitivities to humor (Proyer et al., 2009) and the various Western theories of humor describe many negative aspects of it, e.g., aggression, derision, superiority (Billig, 2002; Yue, 2010). In an exhaustive review of the use of humor for case managers, Craig (2009) examines the research on therapeutic humor as it applies to different age groups, genders, cognitive levels, cultural groups, and settings, such as hospice and assisted living. She observes that successful humor in nursing care depends on infusing the right type of humor under the right delivery conditions to rightly receptive patients at the right time and to the right degree (Craig, 2009). The article’s multipronged
IT’S FUNNY HERE. IS IT THERE?
conclusion is that respectful humor used judiciously can lift clients’ spirits, lighten a situation of seriousness, demonstrate healthcare worker humility that softens the stiff authoritarian semblance of control, and increase patients’ confidence that their exposed vulnerabilities are in safe hands. However, her review of research findings showcases not only the good but also the bad and the ugly, such as interventions to avoid. Concerning the dark side of humor, medical students as healthcare workers were shown capable of doing harm with humor. Wear, Aultman, Variley, and Zarconi (2006) studied the exhibitions of derogatory and cynical humor that medical students direct at patients over time, ostensibly to relieve their own tension. Via videotaped interviews of medical students with patients, several categories of harmful humor usage emerged: humor-cloaked derision also called ‘disparagement humor’ directed toward patients; not-funny humor displayed as sarcasm meant to hurt feelings, caustic cruel remarks, or acrimonious scorn; humor demonstrating superiority from persons of dominance to those in subordinate positions, such as patients and lower status healthcare workers; humor motives, including instant stress relief and maladaptive coping habits expressed in derogatory comments, white-coat attitudes, and flippant behaviors. Craig (2009) cautions case managers to remember to avoid sarcasm, derision, disparagement, belittlement, cynicism, and the maladaptive coping habits of derogatory comments, whitecoat aloofness, and flippant behaviors. What can we learn from all this? The research covered here highlights the possibility for sub-text in humor within each culture. It should caution us on our use of humor when we are with people from other cultures. Humor has been shown to have therapeutic effects on patients with a wide range of illnesses and to be a useful therapy in some cross-cultural research. It also can be used in cruel and destructive ways that can injure people; and when humor is turned against patients, it strikes them at their most vulnerable. It is very apparent that a lot of work still needs to be done to understand the motivations for humor and its therapeutic use cross-culturally. From the studies reported here, this seems to be an area well-suited to nursing research and clinical practice.
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Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES Adamle, K. N., Chiang-Hanisko, L., Ludwick, R., Zeller, R. A., & Brown, R. (2007). Comparing teaching practices about humor among nursing faculty: an international collaborative study. International Journal of Nursing Education Scholarship, 4(Article 2). Epub, January 23. Billig, M. (2002). Freud and the language of humour. The Psychologist, 15(9), 452–456. Cancer Treatment Centers of America. (2013). Laughter therapy. Retrieved from http://www.cancercenter.com/treatments/laughter-therapy/. Chiang-Hanisko, I., Adamie, K., & Chiang, L. C. (2009). Cultural differences in therapeutic humor in nursing education. Journal of Nursing Research, 17(1), 52–61. Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211–218. Craig, K. (2009). Hitch up your humor suspenders, case managers. Professional Case Management, 14(1), 18–29. Flaskerud, J. H. (2014). What’s so funny? And is that bad or good?. Issues in Mental Health Nursing, 35(10). doi: 10.3109/01612840.2014.908442 Garrison, L. T. (2011). Comedy tourism: the myth of universal humor. Splitsider. Retrieved from http://splitsider.com/2011/04/the-myth-of-universal-humor/. Hayashi, K., Hayashi, T., Iwanaga, S., Kawai K., Ishii, H., Shoji, S., et al. (2003). Laughter lowered the increase in postprandial blood glucose. Diabetes Care, 26(5), 1651–52. Jackson, S. B. (2012) What’s funny? Psychology Today: Culture Conscious. Retrieved from http://www.psychologytoday.com/blog/cultureconscious/201205/whats-funny. Jiang, F., Yue, X. D., & Lu, S. (2011). Different attitudes toward humor between Chinese and American students: evidence from the Implicit Association Test. Psychological Reports, 109(1), 99–107. Nevo, O., Nevo, B., & Yin, J. L. (2001). Singaporean humor: a cross-cultural, cross-gender comparison. Journal of General Psychology, 128, 143–156. Proyer, R. T., Ruch, W., Ali, N. S., Al-Olimat, H. S., Amemiya, T., Adal, T. A., et al. (2009). Breaking ground in cross-cultural research on the fear of being laughed at (gelotophobia): A multi-national study involving 73 countries. Humor – International Journal of Humor Research, 22(1–2), 253–279. Wear, D., Aultman, J., Variley, J., & Zarconi, J. (2006). Making fun of patients: Medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine, 81(5), 454–462. Yue, X. D. (2010) Exploration of Chinese humor: historical review, empirical findings, and critical reflections. Humor: International Journal of Humor Research, 23, 403–420.
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CULTURAL COMPETENCE COLUMN
It’s Funny Here. Is It There? Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA Last month’s column focused on theories of humor – the motivations behind humor – and the therapeutic use of humor and laughter as an adjuvant to medical treatment for patients with a variety of illnesses (Flaskerud, 2014). The theoretical motivations for humor described in the last column included several based on psychology – the expression of negative emotions, such as aggression and superiority; a coping mechanism for tension release; a means to resolve incongruity; a benign violation of various norms; and reverse engineering, an evolutionary development to correct errors in perception, based on neuroscience. The positive aspects of humor and the therapeutic use of laughter were explored also (Flaskerud, 2014). Several reports have demonstrated that laughter appears to improve mood, lessen anxiety, reduce psychological measures of stress, and reduce perception of pain (Christie & Moore, 2005). There are also physiological factors involved. Laughter can lead to changes in heart rate, skin temperature, blood pressure, pulmonary ventilation, skeletal muscle activity, and brain activity, which may improve overall wellbeing. Additionally, laughter may improve immune function by blocking the production of stress hormones, such as cortisol, and by increasing the release of immune-enhancers, such as beta-endorphin (Cancer Treatment Centers of America, 2013; Christie & Moore, 2005). Two other aspects of humor will be addressed here, as they apply to cultural differences and the use of humor. The first is: Are there other theoretical explanations of humor that do not rely on Western psychology and neuroscience? And second: Are humor and laughter used therapeutically in other cultures? It should be noted that humor and laughter are considered human traits: only humans have humor and we communicate it Address correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095–1702 USA. E-mail: [email protected]
with laughter. Humor is universal – it can be found in every society (Billig, 2002). Yet it is also highly specific; there is nothing that is universally funny. Not only are there cultural and individual differences in humor, but these differences are invested frequently with moral meaning. We laugh at particular things and we disapprove of laughter at other things. Humor also can be a matter of disagreement: there is a politics, morality and esthetics of humor (Billig, 2002). How funny somebody finds a certain incident depends on many factors, including age, personal experience, level of education, geographical location, and culture. Therefore, humor is something which is not always transferrable to another country or culture. What somebody from one area may find hilarious may not be amusing at all to someone from another region. Did you hear the one about the American businessman whose tame joke drew a hilarious response from his Japanese audience? The American, curious why they liked the joke so much, later asked his official translator, who replied: ‘The joke was not appropriate, so I did not translate it. I simply said: ‘The gentleman has told a joke. Please laugh.’
Whether or not someone gets a joke is determined by his or her interpretation, filtered by the cultural context. In a multicultural society and a global world, what do we know about the context of humor, when to use it, and what might be considered appropriate and inappropriate? There is little information on non-Western theoretical explanations of humor. Deconstructing humor seems to be largely a Western phenomenon and most of what we know about humor caters to the developed West and all but ignores the global South. Garrison (2011) suggests that this might be because the obsession with studying humor is a cultural tendency specific only to Western countries. She observes that there is an international journal of humor but that the editorial staff and the articles published still skew very Western and predominantly American. However, it should be noted that the exploration and uses of humor have gained attention in the Far East (China, Japan, Hong Kong, Taiwan), where the historical roots of humor are being investigated and research is being conducted (Chiang-Hanisko,
898
IT’S FUNNY HERE. IS IT THERE?
Adamie, & Chiang, 2009; Jiang, Yue, & Lu, 2011; Nevo, Nevo, & Yin, 2001; Yue, 2010). In a historical review of Eastern views of humor, Yue (2010) reported that in Chinese society, humor has been valued largely by Taoism and Buddhism, whereas Confucianism, the dominant philosophy in Chinese society, is culturally responsible for devaluing humor as an act of an uneducated and uncivilized person. Yue (2010) goes on to say that this Confucian Puritan attitude toward humor was reinforced during the Communist era in the mid- to late-1900s. Jiang and colleagues (2011) supported this view when they compared the attitudes toward humor of 60 Chinese undergraduates of Peking University in China with 33 American exchange students of the City University of Hong Kong, using the Implicit Association Test (Jiang et al., 2011). They found that the Chinese group showed a generally negative implicit attitude toward humor. Compared with the Chinese group, the American group had a generally positive implicit attitude toward humor. However, the Chinese group rated their humor appreciation almost the same as the American group. The researchers concluded that the Chinese appreciation of humor derives from the Taoist valuation of humor as a way to achieve peaceful and harmonious interactions. The Chinese devaluation of humor comes from a Confucian disregard for humor as a sign of intellectual shallowness and social informality (Jiang et al., 2011). Yue (2010) concluded his historical review of Chinese humor by arguing that Chinese people need to find ways to enhance and express humor. He goes on to say that more efforts, academic or otherwise, need to be made to promote humor as an effective way of enhancing one’s mental health, creativity, and self-actualization (Yue, 2010). The closest Yue (2010) comes to a theoretical explanation of humor is to say that thoughtful humor is based on the perception of human errors, incongruities, banalities, and hypocrisy. These explanations are close to the Western views described in last month’s column as reflecting negative aspects of humor (Flaskerud, 2014). Some of the non-Western research articles on humor allude to explanations but these are more a discussion of findings rather than an overall theory of humor. For example, Nevo and colleagues (2001) reported that in a study that compared humor in American and Singaporean participants, the Singaporean respondents did not use humor for coping (the Western explanation that humor acts as a coping mechanism for the release/relief of tension). The traditional Chinese approach frames humor as a tool to illustrate a concept, prove a point, or win an argument. It teaches while it entertains. The understated, utilitarian Chinese approach to humor may not lend itself to using humor as a means to relieve stress and cope with difficult life situations (Nevo et al., 2001). An analysis of the content of the Singapore respondent’s jokes reflected cultural norms of conservatism where matters of sexuality were concerned, and a significantly greater use of jokes with aggressive content. A little more than half of Singaporean jokes were aggressive, as compared with only 42% of American jokes (Nevo et al., 2001).
899
One research article published in The International Journal of Humor in 2009, was of some interest because it reported differences in a wide range of cultures and countries, although it did not focus on explanations of humor but on gelotophobia – the fear of being laughed at (Proyer et al., 2009). Set in 73 countries ranging from Western Europe, the Far East, Africa, the Americas, the Middle East, and Australia, the investigators attempted to find out if gelotophobia could be measured and what that might suggest about each country’s sense of humor. They used a 15-question survey (GELOPH 15) translated into 42 different languages, keeping in mind regional differences in language even within countries (Garrison, 2011; Proyer et al., 2009). The GELOPH 15 is a questionnaire assessing the level of the fear of being laughed at consisting of 15 items in a 4-point answer format (1 = strongly disagree; 2 = moderately disagree; 3 = moderately agree; 4 = strongly agree). The sample consisted of 22,610 participants who completed the instrument. Across all samples, the reliability of the 15-item questionnaire was high (mean alpha of 0.85) and in all samples, the scales appeared to be unidimensional. The endorsement rates for the items ranged from 1.31% through 80.00% to a single item. Variations in the mean scores of the items were more strongly related to the culture in the country and not to the language in which the data were collected. Two dimensions were identified that further helped explain the data: insecure vs intense avoidant-restrictive personality (e.g., avoiding places where you had been laughed at, feeling uncomfortable when dealing with people who had laughed at you earlier, taking a long time to recover from being laughed at); and low vs high suspicious tendencies towards the laughter of others (e.g., feeling suspicious if others laugh) (Proyer et al., 2009). A few of the items in the survey and the countries endorsing them are revealing. The first question on the survey stated, ‘When others laugh in my presence, I get suspicious.’ Finland gave the lowest endorsement to this item and Thailand gave the highest. What this might mean is if you laugh in the presence of a Thai person, they may be immediately on their guard, whereas a Finnish person might not even notice (Garrison, 2011). Another item stated, ‘It takes me very long to recover from having been laughed at.’ The lowest endorsement to this item came from the USA and the highest came from Japan. As a more formal culture steeped in manners, it might be reasoned that being laughed at may offend a Japanese person. One more example: ‘I control myself strongly in order not to attract negative attention so I do not make a ridiculous impression.’ Lowest endorsement? Again the USA. Some may argue we lack humility and reserve; two qualities not very valuable in American culture, but of the utmost importance elsewhere around the world. For example, Indonesia, which gave this item the highest endorsement, may value these qualities highly. Other items addressed avoiding people and places where one has been laughed at, a kind of social phobia. The researchers concluded that gelotophobia can be assessed reliably by means of a self-report instrument in crosscultural research, and that the findings provided some evidence
900
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of the prevalence and putative causes of gelotophobia within different cultures (Proyer et al., 2009). As noted, this study was included in the discussion of humor because of the wide-ranging cultures that were represented. Last month’s column dealt also with the positive aspects of humor – the therapeutic use of humor with patients with various illnesses. Humor has been recognized by nurse researchers as a therapeutic intervention known to have positive psychological and physiological outcomes for patients. Are there instances of cross-cultural use of therapeutic humor? Cross-cultural research on humor is sparse but nurses are very involved in this effort. In a nurse-led study in Japan, researchers investigated the effects of laughter on post-prandial blood glucose (Hayashi et al., 2003). They conducted a 2-day experiment with 19 patients with type 2 diabetes not receiving insulin therapy and five healthy subjects. On both experimental days, the participants consumed the same 500 kcal meal. On the first day, they attended a monotonous lecture (40 min) without humorous content. On the second day, they attended a cross-talk Japanese comedy show. (Cross-talk is a favored form of comedy in China as well). Unlike modern American stand-up comedy, cross-talk uses two comedians and sometimes even an entire group. Similar to American comedy, it usually employs the ‘double act’ device of a straight man and a stooge perpetually at philosophical odds – think of Abbott and Costello, Martin and Lewis. Cross-talk requires the mastery of four talents: speaking, imitating, teasing, and singing. Crosstalk routines are heavy on puns, sometimes political, and more often insensitive. The investigators found that patients with diabetes who were exposed to the cross-talk comedy show demonstrated a significant suppression of the increase in 2-h post-prandial blood glucose, suggesting that laughter ameliorates the post-prandial glucose excursion in the presence of insufficient insulin action (Hayashi et al., 2003). They concluded that this favorable effect of laughter may include the acceleration of glucose utilization by the muscle motion during the comedy show. However, it is possible also that the positive emotions, such as laughter, acted on the neuroendocrine system and suppressed the elevation of blood glucose level (Hayashi et al., 2003). Adamle, Chiang-Hanisko, Ludwick, Zeller, & Brown (2007) conducted a study to examine how nurses learn about humor. Although there is nursing research that examines the effects of therapeutic humor, they found no research that investigates how nursing students learn about humor and how to use it therapeutically. Their study examined the teaching practices of nursing faculty about humor education in the classroom and in clinical settings (Adamle et al., 2007). Nursing faculty members from four nursing programs, two in the USA, one in Northern Ireland, and one in Taiwan, were surveyed about the inclusion of humor in the nursing curriculum. Findings revealed that substantially more humor education was included in clinical settings in the USA and Northern Ireland than in the classroom. In Taiwan, however, humor education was included more in the classroom than in clinical settings. Younger nurse faculty were more likely
to include content on the use of humor in classrooms than were older nurses, and to expose their own humor abilities in clinical settings. In a follow-up to this study, Chiang-Hanisko, Adamle and Chiang (2009) investigated how nursing faculty members approach teaching therapeutic humor in the classroom and clinical settings in different countries. These investigators proposed that studying nursing faculty teaching practices and viewpoints of therapeutic humor might reveal cultural differences in the use of humor in healthcare settings. Their cross-cultural study included 40 nursing faculty at three nursing programs: two in the USA and one in Taiwan. A qualitative approach was used to perform content analysis on responses to the open-ended questionnaires. Research findings revealed cultural differences between faculties from the two countries. Taiwanese faculty members indicated that they teach more theory and concepts related to therapeutic humor in the classroom than do nursing faculty members from the USA. However, nursing faculty members in Taiwan reported that they observe and practice less therapeutic humor in clinical settings, out of respect for the cultural value of ‘reverence of illness’ operating within Taiwanese society. Therapeutic humor was family-centered and interdependent on relationships, roles, duties, and responsibilities of family members. In contrast, the US faculty members stated that they teach less theory and concepts related to therapeutic humor in the classroom but observe and practice humor more in clinical settings. US faculty approached teaching therapeutic humor in the classroom on an informal basis because the subject was not part of the required nursing curricula. In clinical settings, therapeutic humor was patient-centered and spontaneous in nature (Chiang-Hanisko et al., 2009). Although these studies provide some information on crosscultural variations in the use of humor by nurses, they tell us little about what kind of humor to employ with different age groups, genders, and cultural groups. Jackson (2012) contends that there are some universally appreciated aspects of humor. For example, he says that people of all cultures laugh at incongruities and their resolutions; and that humor techniques like exaggeration, understatement, witty cynicism, verbal irony, disguise, and deception are all viewed as funny in markedly different regions of the world (Jackson, 2012). However, the research on gelotophobia (fear of being laughed at) should caution us that there are different sensitivities to humor (Proyer et al., 2009) and the various Western theories of humor describe many negative aspects of it, e.g., aggression, derision, superiority (Billig, 2002; Yue, 2010). In an exhaustive review of the use of humor for case managers, Craig (2009) examines the research on therapeutic humor as it applies to different age groups, genders, cognitive levels, cultural groups, and settings, such as hospice and assisted living. She observes that successful humor in nursing care depends on infusing the right type of humor under the right delivery conditions to rightly receptive patients at the right time and to the right degree (Craig, 2009). The article’s multipronged
IT’S FUNNY HERE. IS IT THERE?
conclusion is that respectful humor used judiciously can lift clients’ spirits, lighten a situation of seriousness, demonstrate healthcare worker humility that softens the stiff authoritarian semblance of control, and increase patients’ confidence that their exposed vulnerabilities are in safe hands. However, her review of research findings showcases not only the good but also the bad and the ugly, such as interventions to avoid. Concerning the dark side of humor, medical students as healthcare workers were shown capable of doing harm with humor. Wear, Aultman, Variley, and Zarconi (2006) studied the exhibitions of derogatory and cynical humor that medical students direct at patients over time, ostensibly to relieve their own tension. Via videotaped interviews of medical students with patients, several categories of harmful humor usage emerged: humor-cloaked derision also called ‘disparagement humor’ directed toward patients; not-funny humor displayed as sarcasm meant to hurt feelings, caustic cruel remarks, or acrimonious scorn; humor demonstrating superiority from persons of dominance to those in subordinate positions, such as patients and lower status healthcare workers; humor motives, including instant stress relief and maladaptive coping habits expressed in derogatory comments, white-coat attitudes, and flippant behaviors. Craig (2009) cautions case managers to remember to avoid sarcasm, derision, disparagement, belittlement, cynicism, and the maladaptive coping habits of derogatory comments, whitecoat aloofness, and flippant behaviors. What can we learn from all this? The research covered here highlights the possibility for sub-text in humor within each culture. It should caution us on our use of humor when we are with people from other cultures. Humor has been shown to have therapeutic effects on patients with a wide range of illnesses and to be a useful therapy in some cross-cultural research. It also can be used in cruel and destructive ways that can injure people; and when humor is turned against patients, it strikes them at their most vulnerable. It is very apparent that a lot of work still needs to be done to understand the motivations for humor and its therapeutic use cross-culturally. From the studies reported here, this seems to be an area well-suited to nursing research and clinical practice.
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Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES Adamle, K. N., Chiang-Hanisko, L., Ludwick, R., Zeller, R. A., & Brown, R. (2007). Comparing teaching practices about humor among nursing faculty: an international collaborative study. International Journal of Nursing Education Scholarship, 4(Article 2). Epub, January 23. Billig, M. (2002). Freud and the language of humour. The Psychologist, 15(9), 452–456. Cancer Treatment Centers of America. (2013). Laughter therapy. Retrieved from http://www.cancercenter.com/treatments/laughter-therapy/. Chiang-Hanisko, I., Adamie, K., & Chiang, L. C. (2009). Cultural differences in therapeutic humor in nursing education. Journal of Nursing Research, 17(1), 52–61. Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211–218. Craig, K. (2009). Hitch up your humor suspenders, case managers. Professional Case Management, 14(1), 18–29. Flaskerud, J. H. (2014). What’s so funny? And is that bad or good?. Issues in Mental Health Nursing, 35(10). doi: 10.3109/01612840.2014.908442 Garrison, L. T. (2011). Comedy tourism: the myth of universal humor. Splitsider. Retrieved from http://splitsider.com/2011/04/the-myth-of-universal-humor/. Hayashi, K., Hayashi, T., Iwanaga, S., Kawai K., Ishii, H., Shoji, S., et al. (2003). Laughter lowered the increase in postprandial blood glucose. Diabetes Care, 26(5), 1651–52. Jackson, S. B. (2012) What’s funny? Psychology Today: Culture Conscious. Retrieved from http://www.psychologytoday.com/blog/cultureconscious/201205/whats-funny. Jiang, F., Yue, X. D., & Lu, S. (2011). Different attitudes toward humor between Chinese and American students: evidence from the Implicit Association Test. Psychological Reports, 109(1), 99–107. Nevo, O., Nevo, B., & Yin, J. L. (2001). Singaporean humor: a cross-cultural, cross-gender comparison. Journal of General Psychology, 128, 143–156. Proyer, R. T., Ruch, W., Ali, N. S., Al-Olimat, H. S., Amemiya, T., Adal, T. A., et al. (2009). Breaking ground in cross-cultural research on the fear of being laughed at (gelotophobia): A multi-national study involving 73 countries. Humor – International Journal of Humor Research, 22(1–2), 253–279. Wear, D., Aultman, J., Variley, J., & Zarconi, J. (2006). Making fun of patients: Medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine, 81(5), 454–462. Yue, X. D. (2010) Exploration of Chinese humor: historical review, empirical findings, and critical reflections. Humor: International Journal of Humor Research, 23, 403–420.
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