38 Ilona Papousek and Günter Schulter altered or not altered at all (Martin, 2001; Ruch and Ekman, 2001; Weisenberg, Tepper, and Schwarzwald, 1995; Zillmann, Rockwell, Schweitzer, and Sundar, 1993). There is also evidence that the short-lived inhibitory effect of exhilaration (or other strong emotions) is only effective with less severe pain. With severe pain, when strong medication is required to bear it, the effect of exhilaration is not observable any more (Rotton and Shats, 1996). But perhaps it is just more difficult to exhilarate patients suffering from severe pain with films and comedy. Cheerfulness as a temporally stable disposition also plays a part in the short-term effect of exhilaration. As individuals that are more cheerful get into an exhilarated mood more easily, they are more likely to reach the required intensity of exhilaration. People with a low degree of trait cheerfulness may not be sufficiently exhilaratable, also with a supposedly very funny film (Ruch and Zweyer, 2001). Certainly, this reduction of pain sensitivity as a concomitant of exhilaration and other intense feelings is only a short-lived and transitory effect. It is only there at the time one is exhilarated, perhaps also for some minutes afterwards. Then everything is as it was before. However, for patients suffering from chronic pain it can also be a relief to have less pain for a short while. Therefore, some worth can be ascribed to the short-term concomitants of exhilaration. It would be better, of course, if the pain could be alleviated more permanently, if it would be less severe also when one is not exhilarated at the moment. But such a durable effect cannot be achieved by watching comedy films twice a week instead of once a month, that is, by just being exhilarated more often (see \"Is exhilaration healthy\"). A distinct sense of humor and the frequency of laughter are not related to pain sensitivity and tolerance, either (Martin, 2001). For a durable alleviation of chronic pain, a sustainable enhancement of affect with associated improved coping and recovery processes is required. That can only be accomplished with more cheerfulness and more serenity in every day life. However, although it can be assumed that a high degree of cheerfulness may have favorable effects on the development and progress of chronic pain, no miracles are to be expected. It does not make you invulnerable. Even the most cheerful people may be hit, because certainly many factors play a part in the developing of chronic pain. However, a high degree of cheerfulness makes it a bit less likely to get chronic pain. If you already suffer from chronic pain, the attempt to enhance cheerfulness alone will surely not be sufficient to get rid of it. It might be promising as an additional measure, complementing medication, physiotherapy, etc. There are also a number of established psychological intervention methods that in part also use one or the other of the above-mentioned mechanisms and have been used successfully for a long time in the therapy of chronic pain (e.g., classical relaxation methods, biofeedback, imagination techniques, cognitive pain management, various techniques of distraction). Ideally, a pain specialist should tie up a comprehensive package of various measures. Training cheerfulness could be a useful component of it or could complement the package.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 39 DON'T TAKE AN X FOR A U Tip 5: What Can Changes of Immune Parameters Say From time to time studies have been reported that showed that under some condition (e.g., while watching a funny film) some parameter of the immune system (e.g., immunoglobulin A) increased a little bit for a few seconds. The media have often used such reports to claim that exhilaration or laughter may \"boost the immune system\". But can the slight increase of a single immune parameter, lasting for a few seconds, really be denoted as \"boost of the immune system\"? And above all: Does this really have anything to do with health, that is, with whether one stays or becomes healthy? The human immune system is a highly complex system, where a number of different components and processes must intertwine to successfully accomplish its numerous complicated tasks. Therefore, there are a number of possible immune parameters that can be measured, which are related to different components fulfilling different functions. In the majority of cases researchers count how many white blood cells of a certain type are in the blood, for instance, natural killer cells, T-cells, or B-cells (just to mention a few), or they determine the amount of a certain type of immunoglobulin. Immunoglobulins are protein molecules that bind to a certain \"enemy\" (e.g., a virus) and, for example, mark it for destruction (which then is accomplished by other components of the immune system). There are various types of immunoglobulins fulfilling different specific functions. Cytokines are substances that are secreted by specific cells of the immune system. They mediate, reinforce, or stop various other processes of the immune response. Of these also different types exist, including various kinds of interleukins. There are also several types of parameters with which it is attempted to quantify the functional capacity of immune cells. This is done outside the body (in vitro). It is determined, for instance, how effectively certain cells proliferate (i.e., divide), or how many natural killer cells are required to destroy a certain number of target cells. And there are many other components of the immune system beyond that. If, for instance, differences are found between groups of people (e.g., between depressed and less depressed individuals), it is never the case that these differences are equally present in all immune parameters. The groups will only differ in some parameters and in others not, and in one group some parameters may be higher than in the other group while at the same time others may be lower. Due to the large number of different components, it is impossible to make a general conclusion on how well \"the immune system\" works by measuring one or a few parameters. But single parameters themselves are difficult to interpret, as well. The measures vary greatly within an individual, that is, if a parameter is repeatedly obtained in the same person, the results will always differ from each other; they are not temporally stable. Therefore, with one single measurement of an immune parameter, it is hard to tell how high the score of the respective individual is in general. Moreover, it is far from unequivocal of which functional significance differences in the number of immune cells are. It is true that a certain minimum number is required of each type of immune cells to enable the organism to respond to threats. But in healthy individuals, the numbers far exceed the required minima, and the numbers very much vary between individuals. The numbers of immune cells (if above the minimum) do not
40 Ilona Papousek and Günter Schulter necessarily correlate with the functional capacity of the immune system. It is also important that the different types of cells be in a certain proportion to each other. The health consequences of small changes in the numbers of immune cells in the blood are unknown. Moreover, changes in the number of a specific cell type may be due to a variety of different mechanisms that have different functional significance. For instance, the concentration in the blood may be higher because more cells migrate from the lymph nodes to some place in the body where they are needed, or more cells may migrate back to the lymph nodes. Interpreting the meaning of the total levels of immunoglobulins is also difficult, because only a small proportion of a certain type of immunoglobulin is effective against a certain disease. It is also doubtful whether the relative small differences and changes in the levels of immunoglobulins that are typically observed in studies have any relevance to health at all. Moreover, a higher value is not always beneficial. Higher values of immune parameters may also indicate that an infection is insufficiently controlled or may indicate systemic inflammation that can reinforce diseases or symptoms. Allergies and autoimmune diseases are the consequence of an overreactive immune system (Ershler and Keller, 2000; Herbert and Cohen, 1993; Papanicolaou, Wilder, Manolagas, and Chrousos, 1998; Segerstrom, 2005; Stein, Miller, and Trostman, 1991; Stiles and Terr, 1991; Weisse, 1992). Transient changes of immune parameters lasting several seconds that may be observed in laboratory studies after stress, exhilaration etc. cannot have any significant health consequences anyway (see \"Is exhilaration healthy\"). Moreover, the short-term effects of emotional arousal on the immune system are essentially the same when it is experienced negatively (e.g., in a stressful situation) as when it is experienced positively (e.g., during exhilaration). In addition, the responses to temporary changes of mood are always complex; some functions are activated, at the same time other functions are inhibited or turned off (Herbert and Cohen, 1993; Segerstrom and Miller, 2004; Stein et al., 1991; Weisse, 1992). In those studies that are readily cited by providers of laughter- or humor-related courses or events, it was only observed, if at all, that during exhilaration individual immune parameters changed very little for a very short time. Moreover, these are exactly the same changes that can be observed during every emotional activation, that is, also during short- lived negative stress, for example. Added to this are often serious methodological flaws (Martin, 2001; Pressman and Cohen, 2005). For the mentioned reasons, existing studies do not justify the claim that exhilaration or laughter might \"boost the immune system\". Only in connection with completely differently constructed studies, such investigations could be meaningfully interpreted and indeed be conclusive. Even if there might be longer lasting differences and changes of immune parameters: Before significant conclusions can be made, it must be verified that these differences or changes are of some relevance for staying healthy or becoming ill; and if so, whether these consequences are positive or negative. If it is claimed that something may \"boost the immune system\", only referring to slightly higher values of individual immune parameters, somebody tries to make an X for a U. Examples of a group of studies from which more unequivocal conclusions can be drawn are the studies of Cohen's group (Cohen, Tyrell, and Smith, 1991; Cohen et al. 2003, 2006). In these studies not only changes of individual immune parameters lasting a few seconds, but the consequences of durable affective traits, in fact, their relevance to staying healthy or becoming ill, were examined. For this purpose, healthy volunteers were individually
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 41 quarantined. On the second day, they were given nasal drops containing a certain amount of rhinovirus. Only part of the infected participants became ill during the following days, that is, developed symptoms of the common cold, determined by objective criteria. In the other participants, the immune system responded to the infection in a way that prevented the illness from developing. Participants with a habitual tendency to feel stressed and experience situations as stressful were more likely to become ill. A greater disposition to positive affect, in line with trait cheerfulness, was associated with greater resistance to developing a cold. However, cheerfulness does not protect from infection by the virus. The greater resistance of more cheerful individuals does not relate to whether one gets infected by the rhinovirus or not, but to the likelihood of developing illness symptoms when infected. There is some evidence that this may be due to the level of certain components of the immune system mediating inflammation (cytokines). In the noses of more cheerful individuals and individuals that are less prone to feel stress, a lower level of a certain type of cytokines is present when they are infected with rhinovirus (Cohen, Doyle, and Skoner, 1999; Doyle, Gentile, and Cohen, 2006). These intriguing findings are related to particular processes that are obviously mediated by particular components of the immune defence. Therefore, these findings only hold for coughs and sneezes and cannot be transferred to other infectious diseases, neither of course to diseases that are not infectious. They also only hold for durable affective traits and have nothing to do with temporary mood swings. It is also important to note that the resistance against the common cold depends on various factors affecting the likelihood of becoming ill independently from the affective traits of an individual. Thus, individuals with a high level of cheerfulness are not invulnerable. It is only that within the boundary conditions given by other factors, more cheerful individuals seem to be less prone to colds when exposed to the virus. SOCIAL LIFE Negative affective traits such as depression are not only related to the tendency towards disengaging from social interaction and to increasingly withdrawing from friends and family. Others retreat from depressed people, because they experience them as unpleasant, little inviting and burdening and sense signals of rejection. People with negative affective traits also notice the difficult atmosphere in their social environment, which can contribute to reinforce and perpetuate their condition - a vicious cycle that is hard to break (Coyne, 1976; Troisi and Moles, 1999). As opposed to that, if someone's behavior (facial expression, posture, gestures, language) radiates positive affect, others interpret this as a signal that this person is open to make contact or is willing to continue the social interaction. Making friends with people radiating a positive affect disposition is more attractive, because people expect them to have also other desirable characteristics such as emotional stability and safety. In existing relationships, shared laughter is believed to be a signal of reassuring relationship partners of mutual emotional support when needed. In groups and teams, the reciprocal signaling of positive mood increases the cohesiveness. However, all this only works if the smile or laughter of others is perceived as authentic, that is, as elicited by cheerful mood. Observers are able to
42 Ilona Papousek and Günter Schulter distinguish very quickly and accurately between smiles and laughter devoid of cheerful mood and the genuine expression of a positive affective state. Therefore, it is not the pure behavior (smiles, laughter) that is crucial to the positive effects on social life, but the affective traits and mood states of the respective individual (Harker and Keltner, 2001; Keltner and Bonanno, 1997; LaFrance and Hecht, 1995; Otta, Abrosio, and Hoshino, 1996; Provine, 2000; Reis et al., 1990; Ruch, 1993a; Szameitat et al., 2009; Vinton, 1989). Beyond that, people with a more cheerful disposition socialize more often themselves, and they maintain more and higher quality social ties. Consequently, positive affective traits are associated with greater social connectedness and more social support, and the relationships are perceived as more rewarding by both the more cheerful individuals and their friends than it is the case in relationships in which a person with a less positive affect disposition is involved (Berry and Hanssen, 1996; Berry, Willingham, and Thayer, 2000; Steptoe et al., 2008; Watson, Clark, McIntyre, and Hamaker, 1992). That individuals that are more cheerful have more close social contacts and relationships is promoted by the fact that people radiating cheerful mood also induce positive feelings in their interaction partners: Cheerful mood is contagious. Others are drawn to form attachments with cheerful people, and the social contacts are perceived as particularly attractive and inviting. That, too, only works if the expression of positive mood is perceived as authentic. Simulated cheerful mood, faked smiles or laughter devoid of cheerful mood are recognized as such and do not have the same effects (Harker and Keltner, 2001; Hatfield, Cacioppo, and Rapson, 1994; Kashdan and Roberts, 2004; Keltner and Bonanno, 1997; Provine, 1992). As emotional expressions and moods are \"contagious\", the presence of people expressing cheerful mood via their behavior is one of the most powerful elicitors of exhilaration at all. In part, this is attributed to the fact that people automatically and very quickly mimic the facial expression and other behavior of people with which they are in direct contact, at least a bit. One does not even have to be consciously aware of looking at a worried or cheerful face; the own facial expression will still change towards that of the person one faces. If the facial expression of the other person is authentic, imitating the behavior will advance, again completely automatically, the same mood state in the observer. That is, the observer is also infected with the mood state of the other person. That is why people being with depressed persons are likely to become somewhat depressed themselves. If one is with cheerful people, one becomes a bit more cheerful oneself. Moreover, individuals with a more cheerful disposition are more easily infected with the cheerful mood of others than less cheerful people (Botvinick et al., 2005; Chapman, 1976, 1983; Chartrand and Bargh, 1999; Dimberg, 1990; Dimberg, Thunberg, and Elmehed, 2000; Hatfield et al., 1994; Hess and Blairy, 2001; Hietanen, Surakka, and Linnankonski, 1998; Neumann and Strack, 2000; Ruch, 1997; Ruch and Zweyer, 2001; Wild, Erb, and Bartels, 2001). There is also neuroscientific evidence for automatic emotional contagion processes. It was demonstrated that while looking at a face expressing a certain feeling, those parts of the observer's brain are automatically activated that are active when this person is experiencing the respective feeling him or herself. Moreover, it has been shown that when a person hears someone laughing heartily, parts of the brain that control the movements of the voice box are automatically pre-activated. That is, once people look at or hear other people expressing a certain mood state, their own brain prepares for the experience of this mood and its expression. The relevant parts of the brain are pre-activated, which advances respective changes of their own mood. The same mechanisms are operating with negative feelings and
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 43 mood states, e.g., disgust (Hennenlotter et al., 2005; Meyer, Zysset, vonCramon, and Alter, 2005; Wicker et al., 2003). Thus, if cheerfulness can be durably enhanced by some intervention, it can be expected that, by improving the level of mood, in time beneficial effects on social life will develop, too. Evidence for that is provided by the already mentioned study in teachers, which showed that after a few weeks of cheerfulness training, the quality of social contacts was rated more positively (Papousek, 2008). Apparently, the enhancement of cheerfulness and the related improvement of emotional well-being are also accompanied by positive experiences in social life. The social benefits of cheerfulness can also reinforce other positive effects. Being embedded in a well functioning social network belongs to the most important pathways by which positive affective traits can contribute to health maintenance and physical well-being (see \"Psychosomatics\"). Prospective studies showed that individuals with positive social relations were less likely to become ill; this holds in particular for the development of cardiovascular disease (Berkman, Glass, Brissette, and Seeman, 2000; Berkman, Leo- Summers, and Horwitz, 1992; Frasure-Smith et al., 2000; House, Landis, and Umberson, 1988; Kaplan et al., 1988; Orth-Gomer, Rosengren, and Wilhelmsen, 1993; Pressman and Cohen, 2005; Williams et al., 1992). The social support of friends and family is often helpful to judge symptoms appropriately, to utilize health care facilities, and to remain independent longer; added to this is the emotional support in difficult situations. This can play a part in contributing to experience adverse circumstances as less burdening, which in turn slows down the negative effects of chronic stress on physical health (see also \"The positive side of the psychosomatic coin\" and \"Cardiovascular health\"). Of course, these things can only affect health in the long run; the beneficial effects of social support of friends and family virtually add up over the years. That is why correlations between the quality of social life and health indicators are stronger in older than in younger people. For instance, primarily in older people, the height of blood pressure, which develops over many years, is correlated to the degree of social support. Though blood pressure generally increases with age, the increase is stronger in individuals who are less embedded in a well functioning social life. Thus, a cheerful disposition may be beneficial for health also because it is a component of a protective portfolio of social characteristics (Cohen and Wills, 1985; Steptoe et al., 2008; Uchino, 2006; Uchino, Holt- Lunstad, Uno, Betancourt, and Garvey, 1999). 70 PLUS Older people often have to face multiple burdens. With advancing age, natural aging processes and the accumulation of risk factors lead to an increasing incidence of chronic disease. Added to this are physical impairments that can make everyday life a challenge. With the passing of years, strokes of fate such as threatening illness or death of near relatives and friends become increasingly likely. However, many older individuals succeed in maintaining their emotional well-being in spite of the daily challenges and adversities, or are able to restore it each time. That is supported by the availability of positive personal resources associated with cheerfulness, by
44 Ilona Papousek and Günter Schulter successful coping strategies and recovery processes, by making it easier to escape the always- same thoughts and worries. That more cheerfulness in every day life can help to counteract social isolation and loneliness that often gradually occurs with increasing age, is also part of it. Positive social contacts themselves contribute to the quality of life and help to feel better and stay healthier (see \"Stress and strain\" and \"Social life\"). Scientific studies demonstrated that the maintenance of positive well-being late in life helps to protect against age-related morbidity and to slow down the progress of physical impairments. Older individuals who have a cheerful and serene attitude also feel healthier overall, they recover faster and better from serious diseases such as stroke, heart attacks, or hip fractures, stay independent longer, and even have an increased life expectancy (Fredman et al., 2006; Okun et al., 1984; Ostir et al., 2000, 2002; Pressman and Cohen, 2005; Steptoe and Wardle, 2005; see also \"Cardiovascular health\", \"Functional complaints\", \"Chronic pain\"). Therefore, cheerfulness seems to be especially valuable for older people; and for the purpose of emotional and social well-being and the associated higher quality of the remaining lifetime, it is never too late to try for a bit more cheerfulness. As for physical health, cheerfulness and other psychological factors can only help up to a certain point. In the case of an \"end stage disease\" or acutely life threatening illness, that point is clearly exceeded, because emotional factors can only influence long-term processes (Pressman and Cohen, 2005). DON'T TAKE AN X FOR A U Tip 6: What's the Use of Laughter Clubs, Clownery, and Funny Films A wide variety of courses, seminars, evening events, and workshops which include clownery, jokes, or laughter is offered, using various different names such as laughter club, laughter training, laughter yoga, laughter seminar, laughter workshop, laughter day, laughter school, laughter presentation, laughter principle, laughter event, laughter therapy, laughter coaching, humor seminar, humor therapy, happy mind, and many more. Often the same things are hidden under different names; on the other hand, a \"laughter seminar\" can be everything from joke telling to comedy, clownery, and breathing exercises to lectures and mediation according to Osho (Bhagwan). Those offers, which are often heavily promoted via the media and the internet, typically last from one hour to a few hours, sometimes one day or two days. Also typically, the providers very often hold out the prospect or try to suggest directly or indirectly that participating in their seminar, course, evening event, or workshop will give all that can be desired. As in most cases the promises are identical or nearly identical, the assumption suggests itself that the same things are unscrupulously copied from the internet again and again without ever calling them into question. Who cares whether it is true or at least possible, if it sounds so pleasant: It allegedly makes you happy, successful, healthy, never ill again, beautiful, creative, sometimes even cured from cancer and other serious diseases, alleviates stress, boosts the immune system, and develops potentials of some sort, in companies the productivity is allegedly increased, and you become one with the universe.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 45 Sometimes it is even claimed that by participating in a laughter workshop or club one can improve the world, prevent wars, or contribute to global peace or the protection of nature! Thus, the providers nearly always promise all-embracing happiness and health. But which benefits can laughter, clownery, humor seminars, courses, events, or workshops really have? The answer has already been given in the previous sections of this chapter. One thing should be obvious in any case: Lasting effects that remain, which ever they may be, cannot be achieved by a workshop or a seminar lasting one hour or one or two days, for sure. To expect that a workshop or a seminar lasting one hour or two days could make you healthy or at least healthier, or more successful, or what ever, is absurd. But even attending laughter, clownery, humor seminars, courses, events or workshops every week for several months does by far not imply that any effects will be achieved that are relevant to health or anything else that might be desired (see \"Is laughter healthy\", \"Is exhilaration healthy\", and \"Training of cheerfulness\"). As explained extensively above, taken by itself, neither the motor action of laughing, nor the perception of something as funny, nor the ability to make other people laugh have any benefits that are relevant to health or well-being. Only cheerfulness, a cheerful disposition that is also present in every day life and in stressful and adverse conditions has the potential to slow down adverse developments and perhaps to contribute to the alleviation of certain problems. But typical laughter and humor courses or events do not equip the participants with cheerfulness (see above for the definition of cheerfulness). The use of typical laughter and humor courses is quickly told: Entertainment, a nice experience, short-term distraction. If the provider succeeds in inducing very intense exhilaration, a strong reward effect can arouse the desire to let oneself be exhilarated also on other occasions. That is it; more is not possible. However, amusement, a nice experience, and short-term distraction are not bad either; on the contrary. Very intense exhilaration that is accompanied by a really hearty laugh can give a euphoric feeling, a sense of pleasure. The crucial neurophysiological basis for that experience is the mesotelencephalic dopamine system. It is composed of several brain structures, one of the most well-known being the nucleus accumbens. The system is active when one experiences euphoria. That acts as a strong reward, that is, what ever has triggered activation of the system, one wants to do it again. Therefore, the euphoric state that is mediated by activation of the mesotelencephalic dopamine system also plays an important part in the development of addiction. In an experiment that is particularly well known in that context, rats could directly activate this system by pressing a lever via electrodes in their brain that were connected to the lever. The rats were pressing the lever over and over again in quick succession and did not stop doing it until they were completely exhausted. Humans who (as opposed to rats) can talk about their condition immediately report euphoric feelings when this brain region is directly electrically stimulated (Okun et al., 2004; Olds and Milner, 1954). Like the rats that cannot stop pressing the lever over and over again, humans, too, want to get the euphoric feeling that is mediated by the mesotelencephalic dopamine system again and again. Very few people have electrodes in their brain, however. But the system can also be activated, and, thus, euphoric, sensual feelings can also be induced (in varying degrees) by, e.g., sex, consumption of heroin, alcohol and other drugs, a great meal - or exhilaration. That is, also during exhilaration, the activity of the mesotelencephalic dopamine system increases, and the more intense the exhilaration, the larger is the increase (Mobbs, Greicius, Abdel- Azim, Menon, and Reiss, 2003; Pfaus et al., 1990).
46 Ilona Papousek and Günter Schulter Really intense exhilaration accompanied by a euphoric feeling is a special experience, which is in any case worth attending a respective course or seminar. There is no need to always try to better oneself or the world. However, not every seminar that promises exhilaration and a hearty laugh can keep the promise. For a great experience, really intense exhilaration is required. That is, one has to be convulsed with laughter, to laugh oneself to tears, to split one's sides laughing, to be rolling in the aisles ... Good laughter courses can induce that to a much higher degree than, for instance, a funny film or comedy. The short-term distracting effect is not to be sneezed at, either. For this purpose, clownery in hospitals has been proved to be successful, particularly for children who are more easily distractable than adults are (Clinic Clowns). The temporary distraction can reduce the anxiety of children that they have, e.g., when an operation is about to happen or they are waiting for anaesthesia (Vagnoli, Caprilli, Robiglio, and Messeri, 2005). The distracting effect of the clowns and perhaps also the strong emotional activation by exhilaration can also effect a temporary alleviation of pain (see \"Chronic pain\"). But the diversion and distraction from the dreary hospital routine alone, which most children gratefully appreciate, justifies sending clowns into the hospitals. Surely most adult patients would appreciate a little amusement distracting them from their worries and pain and thus making their hospital stay a bit less dreadful, either. Not least, the funny events provide a welcome diversion for family members and nursing staff. However, one must not expect more from it than those temporary effects (see \"Is laughter healthy\" and \"Is exhilaration healthy\"). Thus, typical laughter, clownery, or humor related courses or events (in case they are good and meet one's own taste) can provide entertainment, a nice experience, and temporary distraction. But they are not \"healthy\". Apart from that, there is no scientific or otherwise reliable evidence suggesting that the participation (also the repeated participation) in such courses or events might help to become more resistant, successful, beautiful, happy, or the like. Most certainly, not one bomb less will be constructed, not one tree less will be cut down and not one soldier less will be shot. Whoever claims such things, wants to make an X for a U; in most cases also those who claim that participating in their laughter or humor course or event leads to more cheerfulness as a habitual disposition. As affective traits, that is, the disposition to certain moods and certain response patterns to stress can only be changed by systematic training, the typical laughter and humor seminars, events, courses, and workshops are surely not qualified to sustainably enhance cheerfulness (see also \"Training of cheerfulness\"). But also not everything what is done repeatedly or for a longer time qualifies as training. It must be the right things, and they must be trained in the right way. No matter if sport, music, or affective characteristics are concerned: The purpose of training is always to reach lasting and stable effects. For instance, you will not become a good saxophone player, if you blow into a saxophone once; neither, if you do it once every week. You will not become a good saxophone player either, if you listen to one or several lectures on playing the saxophone, or if you practice singing in the local church choir every week. You will only become a good saxophone player if you train properly, that is, if you practice the right things regularly, systematically, and consequently for a long time. Similar applies to cheerfulness (see \"Ways to enhance cheerfulness\"). Providing theoretical information on how it would work if one did it will not change anything. Laughing more frequently about jokes or without jokes has nothing to do with training cheerfulness. Learning and practicing to make others laugh has nothing to do with training cheerfulness. Neither does it suffice to practice seeing the funny sides of things (see
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 47 \"Ways to enhance cheerfulness\"). The labels are not necessarily helpful. If something is called \"cheerfulness training\" or \"humor training\", it does not necessarily mean that cheerfulness or some aspect of cheerfulness will be really trained with it. Now how to recognize good and useful courses? First, to systematically and regularly practice is definitely a basic requirement for acquiring more cheerfulness. Thus, courses or events that last one hour, one evening, half a day or one or two days might be suited to provide amusement, a nice experience, and temporary distraction. But they are a priori ineligible if one aims at sustainable benefits. If one is interested in durable changes, one should look for courses that extend over several weeks. If you want to strengthen your back muscles, you also go for a longer training, and do not just participate in a single session, all the same if you want to learn dancing or playing the piano. Second, nowhere near everything what is offered as a more extended course is indeed suitable to enhance cheerfulness in everyday life, as a durable disposition. To be able to teach people to train the right things in the right way, very much expert knowledge is necessary. It is advisable, therefore, to make sure that professionals with an appropriate qualification (psychologists or psychotherapists with an accredited qualification) instruct the courses. These persons have learnt how emotional processes and ways of thinking can be changed by training; they are able to activate the crucial psychological processes, to plan the training program in an appropriate manner, to judge for whom and for which purpose the program is suitable, and much more. But particularly important is that they have learnt and are able to intervene and do the right things, if something undesired happens with a participant. That can always happen when strong feelings are evoked, also when they are positive. It may not always be easy to determine if providers of laughter or humor related courses have an appropriate and accredited qualification. But one is always free to ask the provider for his or her exact qualification. Masseurs, journalists, life consultants, teachers, clowns, colour and style consultants, actors, etc., but also alternative practitioners and medical doctors without additional accredited psychotherapeutical education are normally not qualified to develop, plan, and instruct a training program for the enhancement of cheerfulness successfully and safely. Also, do not let the label \"therapist\" mislead you. In most countries, it is not legally protected. Therefore, labels such as singing bowl therapist, colour therapist, painting therapist, laughter therapist, reiki therapist, laughter yoga therapist, ayurveda therapist, zen therapist, sex therapist, aroma therapist, energy therapist, gem therapist, breathing therapist, bioresonance therapist, body therapist, dance therapist, etc. do not reliably indicate that people have any successfully completed professional education or even some professional competence. Third, even professional knowledge and competence alone do not guarantee that a training program is indeed suitable to successfully equip the participants with more cheerfulness or (e.g., in the case of humor training) with some important aspect of cheerfulness. To be sure, you can ask the provider which scientific studies do exist that verify that cheerfulness or the respective aspect of cheerfulness may be enhanced with the applied method, and exactly that method which is used by the provider and exactly that way the provider uses it. Fourth, courses can be immediately identified as dubious, if laughter or cheerfulness is touted as a cure-all or a miracle cure; that also applies if someone with an accredited education is behind it. What can be expected and cannot be expected has been extensively
48 Ilona Papousek and Günter Schulter explained above. Another type of courses that must be seen as problematical from the outset are courses in which the participants are urged to weep, to be angry, or to think or speak about their sorrows. In those cases, the course is definitely not a matter of enhancing cheerfulness. If a psychotherapist with an accredited training is behind it, it is all right, but it is not a cheerfulness program, but, e.g., a self-awareness group or psychological group therapy. If people without appropriate qualification offer something like that, it is sensible to refrain from it. For instructors without psychotherapeutical qualification are usually not sufficiently educated to be able to deal with the churned-up emotions in a way to ensure that no harm is done to the participants. For the typical laughter and humor related courses and events with which cheerfulness cannot be trained but that can provide short-term amusement, a nice experience, and distraction, no academic degree and no accredited psychotherapy training is required. Neither for programs with which one can learn and practice to make others laugh. As for the latter, clowns and other comedy pros are much more apt than most psychologists and psychotherapists. However, even if a course is only suitable or intended for amusement or distraction, one should make sure that the minimum standards of quality are met, because even such programs may be associated with certain risks. In seminars and workshops in which intense exhilaration is induced, mood swings including strong negative emotions may sometimes occur. In physically ill people (also in those who perhaps do not know being ill yet), the strong emotional arousal during exhilaration may elicit problems, in rare cases even dangerous events (see \"Cardiovascular health\"). It belongs to the responsibilities of the seminar or workshop facilitator to not leave the affected person alone or let him or her depart on her own, but to look after him or her and to call medical or psychological emergency help, if necessary. But the remaining group must not be left to take care of themselves, either. They have the right to an orderly continuation of the program, for which they have paid. Therefore, a quality criterion is that in seminars and workshops in which intense exhilaration is induced, a second responsible person is present. Then, whatever problems may arise, one person can take care of it, while the other one carries on with the program or brings it to an orderly end. But not only intense exhilaration can be associated with risks. Not properly or not carefully enough applied, humor and comicality may also do harm (see \"Ways to enhance cheerfulness\"). The seminar or workshop facilitators must not only be able to avoid problematic humor styles themselves, but also to monitor and control the humor of the participants. For that, relevant basic knowledge is required, and it is a matter of responsibility. Finally yet importantly, the desire for emotional and social well-being is also misused by sect-like groups and self-proclaimed \"gurus\". Consequently, among the spectrum of laughter and humor related courses and seminars, there are also some that must be rated as dangerous. It is a warning sign, if it is suggested to stop thinking or to \"turn off the intellect\". Those who stop thinking for themselves thoughtlessly follow a leader. Caution should also be exercised, if additional spiritual elements or lay psychological elements such as \"personality building\" are included. Methods with which susceptible people can be made dependent could be hidden behind them. Special caution is required if the dissemination of an \"idea\" or the propagation of a \"movement\" is involved, if the provider promises peace and happiness around the world, if the participants are prompted to connect to higher powers or to abandon themselves to a higher power (instead of thinking), if it is about unfolding the participants' unlimited potential, or if the glorification of a leader or \"guru\" is shining through. Most often, these
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 49 things show up on the homepage of the provider. In such cases, even an academic degree or an accredited job title does not justify to be more trusting or less cautious. WAYS TO ENHANCE CHEERFULNESS The advice to aim for more cheerfulness is not very helpful, if one has no idea how to tackle it. Neither does it help to tell oneself to instantaneously have at least one component of trait cheerfulness, that is, to approach difficult situations and circumstances with humorous serenity, to let one get in a cheerful mood more easily, more often, and for longer times, or to adopt a humorous attitude in social situations (see \"What is meant by cheerfulness\"). It is not as simple as that. If one wants to have more cheerfulness for the longer term or more of the one or other element of cheerfulness, one must really train that. Training cheerfulness means a lot more than simply trying to cheer oneself up, to relax, or to improve one's mood, more than reducing negative feelings. Most of all, it means to improve and expand one's repertoire of psychological resources in a certain direction. Then one can draw on these resources under stressful circumstances, also in the future, without any need to think about it or to make an effort. Consequently, a robust improvement of well-being can be attained that can also withstand future challenges (see \"Emotional well-being\"). The most simple and most efficient way to enhance cheerfulness is a professional cheerfulness training course, just as physical relaxation is learnt most easily and efficiently in a professional relaxation-training course, and sailing in a professional sailing course. Those who do not like that or do not have the opportunity can also try to practice the one or other element of cheerfulness on their own. But in any case, it will only work, if one is doing it over a longer period and systematically and consequently. A higher level of positive mood is not everything but it is part of it. However, people that are more cheerful are not continuously in a happy mood, but primarily let themselves be cheered up more easily, more often, and for longer times than people with a less cheerful disposition (see \"What is meant by cheerfulness\" and \"Overdose of cheerfulness\"). That feels good, considerably contributes to life satisfaction (see \"What's the use\"), and advances the development of emotional and social resources (see \"Stress and strain\", \"Emotional well- being\", and \"Social life\"). What an individual can do on his or her own is primarily to allow him or herself to be in a cheerful mood, especially after stressful or burdensome events, after he or she has allowed sufficient time for the justified anger, or grief, etc. That applies to small mishaps and shortcomings, but also if one has become ill or unemployed or widowed or after a terrible mistake. That also includes allowing oneself to express one's cheerful mood outwardly, that is, to smile or laugh or to whistle to oneself. In most cases, that will not be inappropriate. It substantially helps to recover and also helps the people around (see \"Stress and Strain\" and \"Social life\"). But should it once be inappropriate though, or be considered inappropriate to express exhilaration or cheerful mood outwardly, you can be cheerful, nevertheless: \"Man kann ja im Herzen / stets lachen und scherzen / und denken dabei / die Gedanken sind frei!\" (Lyrics from an old German folk song; literal translation: \"In one's heart one can keep laughing and joking while thinking: Thoughts are free!\"). Of course, that applies for the time after one has allowed an appropriate amount of time for the grief, the anger, the sympathy towards others, perhaps also the regret. Everything at
50 Ilona Papousek and Günter Schulter the proper time (see also \"Overdose of cheerfulness\"). And, certainly, to be in a cheerful mood does not mean to make fun of those who are affected by one's mistake or to crack jokes about the person who died. Sarcasm, cynicism, scorn, and hostility have nothing to do with cheerful mood at all (see \"What is meant by cheerfulness\"). If you allow yourself and have the courage to be in a more cheerful mood again, you will feel the benefits, thereby being rewarded for the courage, making it easier the next time (see \"Don't take an X for a U, Tip 6\"). An important aspect that contributes to the ability to maintain a positive amount of well- being in spite of adversity is to recover fast and efficiently in between times (see \"Stress and strain\"). A simple way to help yourself recover is to let yourself be infected by the positive mood of others, in particular when your mood is frequently affected by adverse events. It is so simple, because it works completely automatically and there is no effort needed. You only have to go to a place where there are people radiating cheerful mood. For the emotional contagion to work effectively, it is essential to have direct personal contact with someone who is in a cheerful mood state and shows it, and the emotional expression has to be genuine and has to be perceived as such (see \"Social life\"). Apart from that, it is only required to not fight the emotional contagion with might and main. That is, you have to allow yourself to be cheered up and to show it. However, the rub is that contagion with cheerful mood does not work properly or not at all, if the level of trait cheerfulness is low. For it is one of the features of trait cheerfulness to get cheered up more easily (Ruch, 1997). Thus, the method of emotional contagion will only be promising, if a person has at least some amount of trait cheerfulness (or at the same time trains it otherwise). In any case, only temporary effects can be achieved. Certainly, no permanent improvements of mood and well-being can be reached by letting oneself be infected by the emotions of merry people now and again. But it can help to recover from negative feelings and mood states more quickly, at least if the level of dispositional cheerfulness is not very low. A very important element of cheerfulness is to take mishaps, difficult situations and adverse circumstances in every day life easier and to approach them with humorous serenity. That includes the appraisal and interpretation of situations and circumstances (see \"Stress and strain\"). In most cases (except for bad disasters), appraisals of situations and events can differ greatly between individuals. For instance, if you are in a team meeting and your boss invites you to give your opinion on the subject that is currently discussed, you may appraise the situation as terribly stressful, your boss as awfully mean, and yourself as horribly exposed. But you may also appraise the situation as a great chance to participate, your boss as admirably fair and yourself as tremendously respected and esteemed. To automatically appraise and interpret situations and circumstances positively or at least a bit more positively can be learned and practiced. You can think of situations that may elicit depressed feelings, anger, or anxiety, and consciously contrive a positive meaning or interpretation of the situation, and picture it to yourself for some time. For instance, you could imagine sitting alone in your flat on a gray, rainy day drinking a cup of coffee, your thoughts wandering ... and then deliberately imagine that your thoughts wander to your last holiday and thereby many happy memories come flooding back. Or you could think of a situation in which you are invited to introduce yourself to a group of people, you are nervous and uncertain what to say ... and then deliberately imagine that everybody congratulates you afterwards and tell you how cool and likeable you appeared. Or, for instance, you could think of walking down a street and catch sight of your usually friendly neighbor, who fails to
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 51 respond although you shout and wave at her ..., and then deliberately imagine that you know that she is like that just because she is preoccupied in thoughts and thus does not notice you. In order to change something, one certainly has to think of many different situations, and to do it every day for some time. But there is evidence that practicing it systematically may improve a person's mood towards more humorous serenity and the levels of anxiety, worry, and tension will decline. But it is particularly important that you more and more will tend to interpret also other situations and circumstances more positively. Thereby, you will gain a resource that will help you deal with uncertain or negative situations (\"Positive interpretation training\", Holmes, Mathews, Dalgleish, and Macintosh, 2006; Murphy, Hirsch, Mathews, Smith, and Clark, 2007). Certainly, that, too, is easier with professional instruction. Another skill you can try to practice on your own is to deliberately see a funny side of things, situations and of yourself. By doing it systematically and regularly for some time, elements of cheerfulness may be promoted. A humorous view of oneself and the things one is stressed or scared of helps to change the perspective, to be able to view things also from a different angle, and thereby to gain distance from oneself and one's problems. Consequently, things and circumstances are experienced less stressful and threatening (see \"Stress and strain\"). By practicing that extensively, a resource may develop that can be used in future stressful situations. In the case of fear of spiders, for instance, examples of exercises would be to list as many uses as you can think of for a deceptively realistic looking rubber spider that squeaks when squeezed, or to imagine what a spider you encounter would think of you, if it could think. In the case of test anxiety, you could imagine the brain and the hand to conduct a dialog in which the hand makes up funny excuses why it trembles so much (Ventis et al., 2001). However, to invent such exercises on one's own and to (appropriately) perform them, and to use humorous views in a beneficial way is not quite easy. Therefore, that, too, works better with professional instruction. If you suffer from very strong specific fears or worries that are a great burden and affect daily living, attempts to deal with them on your own are normally not promising. That would be the case, for instance, if a person does not dare to leave the house any more, if a person must immediately wash his or her hands after touching something that has been used by others, if a person is not able to go to an exam any more, etc. In such cases, it is advisable to visit a specialist who can effectively help. For people who do not have severe problems like that, special humor training is offered with which one can learn and practice to see a funny side of every day situations (mostly of every day work). As using humor may also be problematical, it is important that professionals with an appropriate qualification instruct such training courses (see \"Don't take an X for a U, Tip 6\"). For only certain forms of humor represent a useful and successful strategy to better cope with stressful situations and adverse circumstances. Bitter, sardonic, cynical, or aggressive humor can do harm, promotes negative affective traits such as depression and anxiety in oneself, and is occasionally used to accentuate hierarchies and keep one's distance to other people. Especially if a person is the target of the humor or believes to be the target, humor can do real harm. But cynical and aggressive forms of humor also do more harm than good to those who make such jokes (Franzini, 2001; Holmes and Marra, 2002; Kubie, 1971; Kuiper, Grimshaw, Leite, and Kirsh, 2004; Lefcourt, Davidson, Prkachin, and Mills, 1997; Martin and Kuiper, 1999). Reliable trainers with an appropriate qualification (ideally experienced psychologists or psychotherapists with an accredited qualification) are mindful of the dangers of humor and can make sure that nothing goes wrong.
52 Ilona Papousek and Günter Schulter Thus, finding or seeing the funny side alone does not suffice to attain durable benefits. On its own, an enhanced sense of humor is not automatically linked with greater emotional well-being, neither with greater physical well-being nor with health (Kuiper and Borowicz- Sibenik, 2005; Kuiper and Martin, 1998; Kuiper et al., 2004; Martin, 2001; Porterfield, 1987; Svebak et al., 2004). Practicing humorous views does only help, if it is associated with the development of favorable and successful coping strategies. Then (and only then), a component of cheerfulness can be enhanced, that is, to approach otherwise frightening or annoying events and circumstances with more humorous serenity. It does not only depend on the kind of humor and how it is used whether successful coping strategies will develop. It is also essential to practice to find a humorous or funny side of events and circumstances on one's own, so that they can be viewed from a different angle and, consequently, one can better cope with them. It is about oneself. It is not about making others laugh. The ability to make other people laugh does not indicate to which extent someone draws on humorous views oneself when exposed to adverse situations and circumstances and is able to use it as a successful coping strategy. Neither do the perception of comicality, listening to jokes, watching humorous films, etc. or laughing by itself have anything to do with favorable coping strategies and, thus, with the training of cheerfulness (Martin and Lefcourt, 1983; Newman and Stone, 1996; Nezu, Nezu, and Blisset, 1988). Those things can only induce temporary exhilaration and distraction, without longer-term consequences (see \"Is exhilaration healthy\", \"Training of cheerfulness\", and \"Don't take an X for a U, Tip 6\"). Finally, you can also try to enhance the third aspect of cheerfulness, that is, the cheerful and humorous attitude in social situations. By practicing it systematically and regularly for some time, one can benefit from the favorable consequences of positive social contacts and social support (see \"Social life\"). What you can try to practice on your own is mainly to approach other people in a friendly and open manner. The simplest attempt is to smile at the checkout girl in the supermarket or at the bus driver while getting on the bus or at the customer at the counter. The world will immediately change a little. The expression of cheerful and friendly mood has an effect on the interaction partner and will instantaneously bounce back to you (see \"Social life\"). A humorous attitude in social situation means, for instance, that people are laughing together about mishaps or mistakes instead of being angry or calling the other person names, or to make friendly, humorous comments when meeting each other, instead of just nodding one's head grouchily. For instance, if you are jostled and pushed aside in the crowd at the market, you may get angry and look at the other person furiously or even snap at him or her – or you may smile at him or her, thereby signaling that you know how difficult it is today to get through, or say something along these lines (\"There is no getting through today, isn't it, though there is nothing for free here\"). However, even that is not without risk. In no case may the other person have the feeling that he or she is laughed at or that jokes are made at his or her expense. Laughing at somebody and jokes with hostile, aggressive, or cynical undertones do never have positive but always only negative consequences (see \"Social life\"). It is not a matter of how it is meant, but how the person concerned perceives it. Classical jokes are usually hostile and made at other peoples' expense. These are different things that should not be mixed up: Friendly-humorous comments are completely different from cracking jokes. And laughing together about a mishap or a mistake is completely different from laughing at other people.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 53 Thus, there are several ways to enhance cheerfulness. If one aims at durable improvements of one or the other element of cheerfulness, the suggested things must be really trained, that is, they must be practiced regularly, systematically, and consequently for some time. Otherwise, nothing will be achieved. Professional instruction will make it easier. EXAMPLE FOR A SCIENTIFICALLY FOUNDED METHOD FOR THE TRAINING OF CHEERFULNESS The 1-2-H Cheerfulness Training® 2 was developed over several years according to scientific principles and has been systematically tested and further developed at the Karl Franzens University of Graz. It was developed to specifically and sustainably advance and strengthen cheerfulness and associated personal resources, in contrast to most other psychological intervention methods that predominantly aim at reducing stress and negative affect. In the long run, the collection of resources accompanying cheerfulness does not only put a brake on the development of the permanent feeling of stress and other negative affective traits such as depression and worry, but also directly fosters several positive affective traits and thereby may contribute to a lasting and robust enhancement of emotional well-being (see \"Stress and strain\" and \"Emotional well-being\"). The training method follows a behavioral therapy approach and is roughly comparable to relaxation training (autogenous training). It is conducted in a group setting. The core of the method is to first learn and practice a technique to efficiently self-induce cheerful mood by one's own behavior, that is, by imagining and voluntarily producing motor and vocal expressions of cheerful mood (facial expression, laughter). Then, in many repetitions, imaginations of personal shortcomings, annoyances, and unpleasant situations are coupled with the positive affective state by conditioning. During the training sessions, the trainers lead the participants to the imagination of the situations by telling a little story of which the participants themselves are the leading character. The story is always different, because the participants partly contribute the used annoying and unpleasant situations by anonymously writing them on cards that can be inserted into a provided box during the whole training period. Additionally, the imaginations are accompanied by small, simple corresponding gestures, while the participants are applying the previously practiced technique to self-induce cheerful mood via their own behavior. For instance, during the imagination that already the third traffic light turns red, the participants illustrate the changing traffic lights with a little gesture. Or while imagining sitting alone at home stirring their tea, they are stirring their imaginary tea with an imaginary spoon. The story may be humorous, but it is essential that the participants do not simply laugh at jokes of the trainers (or of other participants), but learn and practice to self-induce a more cheerful mood, even when they are thinking of situations in which they normally would be angry or worried. In the course of time the imaginations of adversities (conditioned stimuli), and later also corresponding situations in every day life (transfer) automatically trigger a cheerful and composed mood on their own, at least a more positive mood than before (conditioned response). 2 The name is protected as a registered trade mark, in order to ensure that the name can not be misused, that only the scientifically proved and effective method is applied under this name, and courses under this name are exactly conducted in the proved way. Using the name without permission is an offence.
54 Ilona Papousek and Günter Schulter Further psychological processes are used to advance the effectiveness of the method and the transfer into every day life. For instance, after an initial learning period most participants experience intense exhilaration during practicing. This is an utmost positive, euphorizing experience, acting as a strong positive reinforcer (Custers and Aarts, 2005) that helps the participants learn the technique and stay motivated (operant conditioning; see also \"Don't take an X for a U, Tip 6\"). Like classical and operant conditioning, all other processes that are purposefully used in the training program are scientifically founded. The neuroscientific network model of exhilaration (Papousek, Lang, Zitzenbacher, Kogler, 2004; Papousek and Schulter, 2006) provides a theoretical explanation for several elements of the method. Cheerful mood, humor (in the sense of perceiving something as funny), and smiles and laughter can be viewed as components of a network that - after appropriate practice - can promote each other when one or several of the components are activated. Humor, cheerful mood and smiles or laughter can also occur independently of each other, different brain regions are involved in each of the three aspects, and their concomitants differ (see \"What is meant by cheerfulness\"). But in the course of our lives, the brain structures that are active during humor, cheerful mood, smiles and laughter are often co-activated. It is known from brain research that brain regions that are very often concurrently active, in time will establish connections, so that the activation of one of these brain regions and the respective connections gradually will also automatically favor activation of the other areas (Goodman and Shatz, 1993). That is, in time, network-like connections will be established between the brain structures that are active during humor (perceiving something as funny, cognition), cheerful mood (emotion), and smiles and laughter (behavior). It not necessarily and not always will be the case that, for instance, when someone perceives something as funny, he or she will also be exhilarated and laughing. But the gradually established and strengthened connections increase the likelihood that perceiving something as funny will be accompanied by transient exhilaration and that smiles or laughter will be easier elicited. The network may also be activated by one of the other components. Also through cheerful mood and through one's behavior, that is, through the voluntary expression of cheerful mood (facial expression, laughter) the co-activation of the other two components can be favored. Above all, activation of the connections can be trained, so that, in time, the co-activation of the other components become more and more likely, faster, and stronger. That explains why it is possible to learn and practice to efficiently self-induce cheerful mood via one's own (motor and vocal) behavior (see Figure 7). The assumption that voluntary expressions of emotions can in fact produce or advance genuine feelings of these emotions is supported by the findings of many scientific studies. When a person produces an emotional facial expression, this is accompanied by a stronger experience of the corresponding emotion and by characteristic changes of physiological measures that are associated with these emotions. If the activation has spread to the corresponding mood state, then the respective parts of the brain that mediate the current emotional state are also active (Coan, Allen, and Harmon-Jones, 2001; Duclos et al., 1989; Ekman and Davidson, 1993; Hess, Kappas, McHugo, Lanzetta, and Kleck, 1992; Levenson, Ekman, Friesen, 1983, 1990; Soussignan, 2002). According to the network model, the cheerful affective state and the behavioral elements also promote humor, in the sense of more easily seeing the funny side of things or circumstances. This effect, too, is proven by scientific evidence. It has been shown, for instance, that persons whose facial expression had been manipulated to a smile without their
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 55 notice perceived cartoons considerably more funny than persons whose facial expression had been manipulated in the direction of a grim, bad tempered expression. In a controlled case study it was reported that during electrical stimulation of a certain spot in the cerebral cortex (in the supplementary motor area), the patient smiled and laughed, before reporting that she found something funny, depending on what she was currently looking at (e.g., \"You guys are just so funny standing around\"). That is, the patient laughed first and then made up a story that was funny to her. When the respective spot was not stimulated, the patient did not laugh and did not view her current situation and surroundings funny at all (Fried, Wilson, MacDonald, and Behnke, 1998; Strack, Martin, and Stepper, 1988). Those automatic processes additionally advance the exhilaration during the training, but are also purposefully used to promote that the participants meet adverse circumstances with humorous serenity, allowing a change of perspective, greater distance and a more positive reappraisal, and, consequently, helping to view adverse circumstances as less serious and less threatening (see \"Stress and strain\"). Importance is attached to directing the spontaneously emerging humor in channels that correspond to positive, \"healthy\" forms of humor (see \"Ways to enhance cheerfulness\"). Figure 7. Another psychological process that is purposefully used and promoted in the 1-2-H Cheerfulness Training® is emotional contagion. The presence of other participants showing behavioral expressions of cheerful mood and thereby \"infecting\" the others with exhilaration additionally facilitates the experience of exhilaration and cheerful mood during the training. This very effective and completely automatic process is also scientifically proven (see \"Social life\"). It is promoted during the training, for instance, by permanently establishing direct face- to-face contact among the participants and by preventing them from pulling inappropriate faces. Beyond that, the exercises are consequently alternated with short structured breaks, by which the participants also learn to control and regulate their exhilaration. This helps to get a feeling of security and controllability and prevents habituation and exhaustion. Through the special method of the training, the reinforcement by the positive experience, and a balanced proportion of repetition and variation, the potential to induce cheerful mood does not decline
56 Ilona Papousek and Günter Schulter over time; it is possible to evoke a substantial degree of cheerful mood repeatedly, over many days and weeks (Papousek and Schulter, 2008). The use of fully automatic processes such as the induction of cheerful mood and humor by behavioral elements, emotional contagion, and conditioning has several advantages over more cognitively oriented intervention methods. The participants do not have to make conscious efforts to change moods and attitudes, find another perspective, etc. Consequently, the method also works for participants in which the readiness to be in a cheerful state of mood is reduced because of the current circumstances and the corresponding social role (e.g., patient, sufferer, failed,). To support abandoning an inhibiting social role (it may also be the role as a teacher, politician, boss, professor, etc.), it is important, among other things, to conduct the training in a protected environment. Consequently, 1-2-H Cheerfulness Training® is never conducted in rooms where the participants can be watched from the outside, neither of course in public space. Beyond that, as opposed to many cognitively oriented methods, the training does not include any cultural, educational, religious, or ideological barriers. The training program starts with an intense introductory session lasting eight to twelve hours that are ideally spread over two consecutive days. In tests of the method, this extensive introductory session turned out to be essential, in order to enable all participants to learn the technique so well from the beginning onwards that they can apply it fast and efficiently in each of the subsequent training sessions. Moreover, this longer introductory session is essential to make sure that all participants have the chance to overcome their possible initial insecurity or embarrassment. Finally, it is important to enable all participants to reach a state of substantial exhilaration and the associated positive experience, which is an important supporting factor for the continuation of the training. A very careful composition of the training in the introductory session ensures that the technique is learnt thoroughly and at the same time cautiously enough so that the participants feel as secure and well as possible. It is also important to take care that nobody is overchallenged. Gaining control of the insecurity of the participants is very important. Tests showed that it does not only depend on the degree of exhilaration how positive the participants perceive the training, but to the same extent on the degree to which they feel insecure (Papousek et al., 2004). Consequently, much importance is attached to prevent feelings of insecurity; by the above-mentioned training of controllability, but also by avoiding excessive demand. Insecure participants are constantly supported, for instance, by permanently involving them actively. That is important, because the other participants tend to withdraw from insecure persons, in order to not become insecure themselves. Thus, insecure participants would be more and more marginalized, by which an unfavorable process would be established that would act counter to the aims of the training. As a result, feelings of insecurity, which (in spite of the unusual character of the training) are rated rather low from the second introductory day onwards, decline even more in the course of the training. Mean ratings dropped from 3.9 on the second day of the introductory session to 2.7 at the end of the whole training course (12- point rating scale ranging from \"did not feel uneasy at all\" to \"felt extremely uneasy\"; Papousek and Schulter, 2008). In order to reach the aims of the training, that is, to sustainably promote cheerfulness and serenity in everyday life, periodical training sessions must follow the introductory session for several weeks (lasting about one hour each). The sessions can be conducted once or twice a week (Lederer, 2007; Nograsek, 2006; Papousek, 2008). Participation in the introductory
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 57 session alone without participating in the subsequent regular training sessions is without effect (see also \"Don't take an X for a U, Tip 6\"). After having attended the training for some time, the participants automatically approach also normally unpleasant or difficult situations in every day life that are accompanied by feelings of anger, tension, depression, or of being overtaxed with more humorous serenity. They act in a composed manner and are able to smile to themselves or even laugh, when they cannot remember what they need to know urgently, when their boss asks them in for afternoon coffee, when already the third traffic light turns red, when the scales show a four pound gain, when a family member spills the milk, when a mile-long to do list is waiting for them, when their partner is again late, when they are sitting alone at home stirring their tea, when they are introduced to an important person, etc. They gain a more cheerful attitude towards themselves, their lives, and the adversities of every day life, and do not lose their balance so quickly any more. It becomes easier to switch to a more cheerful mood, and humorous serenity finds its way into encounters with other people. Those are all features of trait cheerfulness. Scientific studies demonstrated that the 1-2-H Cheerfulness Training® could effectively enhance cheerfulness. Several days after the end of the training period, cheerfulness (as assessed by a standardized questionnaire; Ruch, Köhler, and vanThriehl, 1997) was increased by an average of 30 percent, whereas in a control group not participating in the training cheerfulness did not change during the same period. Beyond that, studies provided scientific evidence that the pronounced enhancement of cheerfulness is accompanied by reduced feelings of stress both in every day life and in the job, by faster and more efficient recovery, and a more general improvement of psychological well-being. (These and other findings have already been reviewed in previous sections of this chapter). Stress and recovery indicators that were considerably improved after the end of the eight-week training period remained unchanged until at least four weeks after the intervention (last measurement). The improvements were even accompanied by characteristic changes in brain activity that objectively confirmed the self-reported ratings of the course participants. Participants who had already reached a pronounced enhancement of cheerfulness and serenity also felt physically better and reported less symptoms. Finally, it was shown that the training of cheerfulness and the associated improvement of emotional well-being was accompanied by positive experiences in social life. The positive effects on social life that in time develop as a consequence of the enhanced level of positive mood (see \"Social life\") are added to the fact that the training group by itself is perceived as a source of positive social contacts (Lederer, 2007; Papousek, 2008; Papousek and Schulter, 2006; 2008; in preparation). From participants' ratings of the training, it can be concluded that the intervention itself is, on average, positively experienced, and becomes even more enjoyable during the course of the training. On the second day of the introductory session, the participants rated the degree to which they enjoyed the training with an average of 9.6. After 7 / 15 training sessions, the average rating increased to 10.4 / 10.6 (12-point rating scale ranging from \"not at all\" to \"extremely\"). The degree to which the participants felt exhilarated during the training sessions remained constantly at a high level over the whole training period. The ratings ranged from 9.1 (second day of introductory session) to 9.7 (after 15 training sessions; Papousek and Schulter, 2008). These findings indicate that the intervention can be conducted over longer periods without losing its effectivity and without difficulties to make the participants hold out to the end.
58 Ilona Papousek and Günter Schulter However, it should not go unmentioned that the training method does not suit all people equally. An important prerequisite for beneficial effects of the training is that the participants attend the training voluntarily and without great resistance. Moreover, benefits going beyond the mood enhancement depend on the participants' personality. Individuals with a less \"serious\" personality are more responsive to the training and, hence, effects are stronger or more rapid (Papousek and Schulter, 2008). Individuals high in trait seriousness are characterized by a preference for reasonable activities and a reserved attitude towards humor- related matters or doing things \"just for fun\" (Ruch and Köhler, 1999). In addition, the training method is ineligible for people with a pathological fear of being laughed at or of exposing oneself to ridicule (Gelotophobia; Ruch and Proyer, 2008; Papousek et al., 2009). REFERENCES Arendt, H. (1986). Communicative power. In: S. Lukes (Ed.), Power (pp. 59-74). New York: New York University Press. Ashby, F. G., Isen, A. M., and Turken, A. U. (1999). A neuropsychological theory of positive affect and its influence on cognition. Psychological Reviews, 106, 529-550. Barefoot, J. C., Helms, M. J., Mark, D. B., Blumenthal, J. A., Califf, R. M., Haney, T. L., et al. (1996). Depression and long-term mortality risk in patients with coronary artery disease. American Journal of Cardiology, 78, 613-617. Benyamini, Y., Idler, E. L., Leventhal, H., and Leventhal, E. A. (2000). Positive affect and function as influences on self-assessments of health: Expanding our view beyond illness and disability. Journal of Gerontology, 55B, 107-116. Bergman, S., Herrstrom, P., Hogstrom, K., Petersson, I. F., Svensson, B., and Jacobsson, L. T. (2001). Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. Rheumatology, 28, 1369-1377. Berkanovic, E., Telesky, C., and Reeder, S. (1981). Structural and social psychological factors in the decision to seek medical care for symptoms. Medical Care, 21, 693-709. Berkman, L. F., Glass, T., Brissette, I., and Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social Science and Medicine, 51, 843-857. Berkman, L. F., Leo-Summers, L., and Horwitz, R. I. (1992). Emotional support and survival after myocardial infarction: A prospective, population-based study of the elderly. Annals of Internal Medicine, 117, 1003-1009. Berry, D. S., and Hansen, J. S. (1996). Positive affect, negative affect, and social interaction. Journal of Personality and Social Psychology, 71, 796-809. Berry, D. S., Willingham, J. K., and Thayer, C. A. (2000). Affect and personality as predictors of conflict and closeness in young adults' friendships. Journal of Research in Personality, 34, 84-107. Blumenthal, J. A., Lett, H. S., Babyak, M. A., White, W., Smith, P. K., Mark, D. B., et al. (2003). Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet, 362, 604-609. Booth-Kewley, S., and Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101, 343-362.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 59 Botvinick, M., Jha, A. P., Bylsma, L. M., Fabian, S. A., Solomon, P. E., and Prkachin, K. M. (2005). Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain. Neuroimage, 25, 312-319. Brady, S. S., and Matthews, K. A. (2006). Chronic stress influences ambulatory blood pressure in adolescents. Annals of Behavioral Medicine, 31, 80-88. Bremner, J. D, Randall, P., Vermetten, E., Staib, L., Bronen, R.A., Mazure, C., et al. (1997). Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorders related to childhood physical and emotional abuse - a preliminary report. Biological Psychiatry, 41, 23-32. Brosschot, J. F. (2002). Cognitive-emotional sensitization and somatic health complaints. Scandinavian Journal of Psychology, 43, 113–121. Brosschot, J. F., Gerin, W., and Thayer, J. F. (2006). The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health. Journal of Psychosomatic Research, 60, 113-124. Brosschot, J. F. and van den Doef, M. (2006). Daily worrying and somatic health complaints: Testing the effectiveness of a simple worry reduction intervention. Psychology and Health, 21, 19-31. Brummett, B. H., Babyak, M. A., Siegler, I. C., Mark, D. B., Williams, R. B., and Barefoot, J. C. (2003). Effect of smoking and sedentary behavior on the association between depressive symptoms and mortality from coronary heart disease. American Journal of Cardiology, 92, 529-532. Bush, D. E., Ziegelstein, R. C., Tayback, M., Richter, D., Stevens, S., Zahalsky, H., et al. (2001). Even minimal symptoms of depression increase mortality risk after acute myocardial infarction. American Journal of Cardiology, 88, 337-341. Campbell, L. C., Clauw, D. J., and Keefe, F. J. (2003). Persistent pain and depression: A biopsychosocial perspective. Biological Psychiatry, 54, 399-409. Cechetto, D. F., and Saper, C .B. (1990). Role of the cerebral cortex in autonomic function. In A. D. Loewy and K. M. Spyer (Eds.), Central Regulation of Autonomic Functions (pp. 208-223). New York: Oxford University Press. Chapman, A. J. (1976): Social aspects of humorous laughter. In A. J. Chapman, and H. C. Foot (Ed.), Humour and Laughter: Theory, Research and Applications. London: Wiley. Chapman, A. J. (1983): Humor and laughter in social interaction and some implications for humor research. In P. E. McGhee, and J. H. Goldstein, J. H. (Eds.), Handbook of Humor Research. Vol. 1 (pp. 135-157). New York: Springer. Chartrand, T. L., and Bargh, J. A. (1999). The chameleon effect. The perception-behavior link and social interaction. Journal of Personality and Social Psychology, 76, 893-910. Clauw, D. J., and Chrousos, G. P. (1997). Chronic pain and fatigue syndromes: Overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation, 4, 134-153. Coan, J. A., Allen, J. J., and Harmon-Jones, E. (2001). Voluntary facial expression and hemispheric asymmetry over the frontal cortex. Psychophysiology, 38, 912-925. Cogan, R., Cogan, D., Waltz, W., and McCue M. (1987). Effects of laughter and relaxation on discomfort thresholds. Journal of Behavioral Medicine, 10, 139-144. Cohen, S., Alper, C. M., Doyle, W. J., Treanor, J. T., and Turner, R. B. (2006). Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza A virus. Psychosomatic Medicine, 68, 809-815.
60 Ilona Papousek and Günter Schulter Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., and Kotler, M. (2000). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96, 1-13. Cohen, S., Doyle, W. J., and Skoner, D. P. (1999). Psychological stress, cytokine production, and severity of upper respiratory illness. Psychosomatic Medicine, 61, 175-180. Cohen, S., Doyle, W. J., Skoner, D. P., Fireman, P., Gwaltney, J. M., and Newsom, J. T. (1995). State and trait negative affect as predictors of objective and subjective symptoms of respiratory viral infections. Journal of Personality and Social Psychology, 68, 159- 169. Cohen, S., Doyle, W. J., Turner, R. B., Alper, C. M., and Skoner, D. P. (2003). Emotional style and susceptibility to the common cold. Psychosomatic Medicine, 65, 652-657. Cohen, S. and Rodriguez, M. S. (1995). Pathways linking affective disturbances and physical disorders. Health Psychology, 14, 374-380. Cohen, S., Tyrrell, D. A. J, and Smith, A. P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 606-612. Cohen, S., and Williamson, G. M. (1991). Stress and infectious disease in humans. Psychological Bulletin, 109, 5-24. Cohen, S., and Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357. Cohn, M. A., Fredrickson, B. L., Brown, S. L., Mikels, J. A., and Conway, A. M. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9, 361-368. Compton, R. J., Wirtz, D., Pajoumand, G., Claus, E., and Heller, W. (2004). Association between positive affect and attentional shifting. Cognitive Therapy and Research, 28, 733-744. Coyne, J. C. (1976). Depression and the response of others. Journal of Abnormal Psychology, 85, 186-193. Cummings, N. S., and van den Bos, G. R. (1981). The twenty years Kaiser-Permanente experience with psychotherapy and medical utilization: Implications for national health policy and national health insurance. Health Politics Quarterly, 1, 159-175. Custers, R., and Aarts, H. (2005). Positive affect as implicit motivator: On the nonconscious operation of behavioral goals. Journal of Personality and Social Psychology, 89, 129- 142. Danner, D. D., Snowdon, D. A., and Friesen, W. V. (2001). Positive emotions in early life and longevity: Findings from the nun study. Journal of Personality and Social Psychology, 80, 804-813. Darwin, C. (1872). The expression of the emotions in man and animals (3rd ed., Ed. P. Ekman, 1997). London: Murray. Davidson, K., Jonas, B. S., Dixon, K. E., and Markovitz, J. H. (2000). Do depression symptoms predict early hypertension incidence in young adults in the CARDIA study. Archives of Internal Medicine, 160, 1495-1500. Davidson, R. J., Jackson, D. C., and Kalin, N. H. (2000). Emotion, plasticity, context, and regulation: Perspectives from affective neuroscience. Psychological Bulletin, 126, 890- 909.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 61 Depue, R. A., and Monroe, S. M. (1986). Conceptualization and measurement of human disorder in life stress research: The problem of chronic disturbance. Psychological Bulletin, 99, 36-51. Derryberry, D. and Tucker, D. M. (1994). Motivating the focus of attention. In: P. M. Neidenthal, and S. Mitoyama (Eds.), The heart's eye: Emotional influences in perception and attention (pp. 167-196). San Diego: Academic Press. Diener, E., and Larsen, R. J. (1993). The experience of emotional well-being. In: M. Lewis, and J. M. Haviland (Eds.), Handbook of emotions (pp. 405-415). New York: Guilford. Dienstbier, R. A. (1989). Arousal and physiological toughness: Implications for mental and physical health. Psychological Reviews, 96, 84-100. DiMatteo, M. R., Lepper, H. S., and Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101-2107. Dimberg, U. (1990). Facial electromyography and emotional reactions. Psychophysiology, 27, 481-494. Dimberg, U., Thunberg, M., and Elmehed, K. (2000). Unconscious facial reactions to emotional facial expressions. Psychological Science, 11, 86-89. Doyle, W. J., Gentile, D. A., and Cohen, S. (2006). Emotional style, nasal cytokines, and illness expression after experimental rhinovirus exposure. Brain, Behavior and Immunity, 20, 175-181. Drossman, D. A., Corazziari, E., Talley, N. J., Thompson, G., and Whitehead, W. E. (Eds.) (2000). The functional gastrointestinal disorders: Diagnosis, pathophysiology, and treatment: A multinational consensus (2nd ed.). McLean, Virginia: Degnon Associates. Drossman, D. A., Li, Z., Andruzzi, E., Temple, R. D., Talley, N. J., Thompson, W. G. et al. (1993). U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Digestive Diseases and Sciences, 9, 1569-1580. Duclos, S. E., Laird, J. D., Schneider, E., Sexter, M., Stern, L., and vanLighten, O. (1989). Emotion-specific effects of facial expressions and postures of emotional experience. Journal of Personality and Social Psychology, 57, 100-108. Ekman, P., and Davidson, R. J. (1993). Voluntary smiling changes regional brain activity. Psychological Science, 4, 342-345. Eriksen, H. R., Svendsrod, R., Ursin, G., and Ursin, H. (1998). Prevalence of subjective health complaints in the Nordic European countries in 1993. European Journal of Public Health, 8, 294-298. Ershler, W. B., and Keller, E. T. (2000). Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annual Review of Medicine, 51, 245-270. Fields, H. L. (2000). Pain modulation: expectation, opioid analgesia and virtual pain. Progress in Brain Research, 122, 245-253. Filippelli, M., Pellegrino, R., Landelli, I., Misuri, G., Rodarte, J. R., Duranti, R., et al. (2001). Respiratory dynamics during laughter. Journal of Applied Physiology, 90, 1441-1446. Folkman, S., and Moskowitz, J. T. (2000). Positive affect and the other side of coping. American Psychologist, 55, 647-654. Forabosco G. (1992). Cognitive aspects of the humor process: The concept of incongruity. Humor, 5, 45-68.
62 Ilona Papousek and Günter Schulter Forseth, K. O., Forre, O., and Gran, J. T. (1999). A 5.5 year prospective study of self-reported musculoskeletal pain and of fibromyalgia in a female population: Significance and natural history. Clinical Rheumatology, 18, 114-121. Franzini, L. R. (2001). Humor in therapy: The case for training therapists in its uses and risks. Journal of General Psychology, 128, 170-193. Frasure-Smith, N. and Lesperance, F. (2005). Reflections on depression as a cardiac risk factor. Psychosomatic Medicine, 67, S19-S25. Frasure-Smith, N., Lesperance, F., Gravel, G., Masson, A., Juneau, M., Talajic, M., et al. (2000). Social support, depression, and mortality during the first year after myocardial infarction. Circulation, 101, 1919-1924. Frasure-Smith, N., Lesperance, F., and Talajic, M. (1995). The impact of negative emotions on prognosis following myocardial infarction: Is it more than depression. Health Psychology, 14, 388-398. Frazier, T. W., Strauss, M. E., and Steinhauer, S. R. (2004). Respiratory sinus arrhythmia as an index of emotional response in young adults. Psychophysiology, 41, 75-83. Fredman, L., Hawkes, W. G., Black, S., Bertrand, R. M., and Magaziner, J. (2006). Elderly patients with hip fracture with positive affect have better functional recovery over 2 years. Journal of the American Geriatrics Society, 54, 1074-1081. Fredrickson, B. L. (2004). The broaden-and-build theory of positive emotions. Philosophical Transactions of the Royal Society London, Biological Sciences, 359, 1367-1377. Fredrickson, B. L., and Joiner, T. (2002). Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13, 172-175. Fredrickson, B. L., and Levenson, R. W. (1998). Positive emotions speed recovery from the cardiovascular sequelae of negative emotions. Cognition and Emotion, 12, 191-220. Fried, I., Wilson, C. L., MacDonald, K. A., and Behnke, E. J. (1998). Electric current stimulates laughter. Nature, 391, 650. Friedman, B. H., and Thayer, J. F. (1998). Anxiety and autonomic flexibility: A cardiovascular approach. Biological Psychology, 49, 303-323. Fuchs, E., and Fluegge, G. (1995). Modulation of binding sites for corticotropin-releasing hormone by chronic psychosocial stress. Psychoneuroendocrinology, 20, 33-51. Gabbay, F. H., Krantz, D. S., Kop, W. J., Hedges, S. M., Klein, J., Gottdiener, J. S., et al. (1996). Triggers of myocardial ischemia during daily life in patients with coronary artery disease: Physical and mental activities, anger and smoking. Journal of the American College of Cardiology, 27, 585-592. Gallo, L. C., Ghaed, S. G., and Bracken, W. S. (2004). Emotions and cognitions in coronary heart disease: Risk, resilience, and social context. Cognitive Therapy and Research, 28, 669-694. Gendolla, G. H., Abele, A. E., Andrei, A., Spurk, D., and Richter, M. (2005). Negative mood, self-focused attention, and the experience of physical symptoms: The joint impact hypothesis. Emotion, 5, 131-144. Gendolla, G. H. E., and Krüsken, J. (2001a). Mood state and cardiovascular response in active coping with an affect-regulative challenge. International Journal of Psychophysiology, 41, 169-180. Gendolla, G. H. E., and Krüsken, J. (2001b). The joint impact of mood state and task difficulty on cardiovascular and electrodermal reactivity in active coping. Psychophysiology, 38, 548-556.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 63 Goel, V., and Dolan, R.J. (2001). The functional anatomy of humor: Segregating cognitive and affective components. Nature Neuroscience, 4, 237-238. Goodman, C. S., and Shatz, C. J. (1993). Developmental mechanisms that generate precise patterns of neuronal connectivity. Cell, 72, 77-98. Graham, J., Potts, H. W., and Ramirez, A. J. (2002): Stress and burnout in doctors. Lancet, 360, 1975–1976. Harker, L. and Keltner, D. (2001). Expressions of positive emotions in women's college yearbook pictures and their relationship to personality and life outcomes across adulthood. Journal of Personality and Social Psychology, 80, 112-124. Hatfield, E., Cacioppo, J. T., and Rapson, R. L. (1994). Emotional Contagion. Cambridge: University Press. Hennenlotter, A., Schroeder, U., Erhard, P., Castrop, F., Haslinger, B., Stoecker, D., et al. (2005). A common neural basis for receptive and expressive communication of pleasant facial affect. Neuroimage, 26, 581-591. Heponiemi, T., Elovainio, M., Pulkki, L., Puttonen, S., Raitakari, O., and Keltikangas- Järvinen, L. (2007). Cardiac autonomic reactivity and recovery in predicting carotid atherosclerosis: The cardiovascular risk in young finns study. Health Psychology, 26, 13- 21. Herbert, T. B. and Cohen, S. (1993). Stress and immunity in humans: A meta-analytic review. Psychosomatic Medicine, 55, 364-379. Hess, U., and Blairy, S. (2001). Facial mimicry and emotional contagion to dynamic emotional facial expressions and their influence on decoding accuracy. International Journal of Psychophysiology, 40, 129-141. Hess, U., Kappas, A., McHugo, G. J., Lanzetta, J. T., and Kleck, R. E. (1992). The facilitative effect of facial expression on the self-generation of emotion. International Journal of Psychophysiology, 12, 251-265. Hietanen, J. K., Surakka, V., and Linnankonski, I. (1998). Facial electromyographic responses to vocal affect expressions. Psychophysiology, 35, 530-536. Hirdes, J. P., and Forbes, W. F. (1993). Factors associated with the maintenance of good self- rated health. Journal of Aging and Health, 5, 101-122. Hobfoll, S.E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44, 513-524. Hoehn-Saric, R., and McLeod, D. R. (1988). The peripheral sympathetic nervous system. Its role in normal and pathological anxiety. Psychiatric Clinics in North America, 11, 375- 386. Hoehn-Saric, R., and McLeod, D. R. (2000). Anxiety and arousal: Physiological changes and their perception. Journal of Affective Disorders, 61, 217-224. Holmes, E. A., Mathews, A., Dalgleish, T., and Macintosh, B. (2006). Positive interpretation training: Effects of mental imagery versus verbal training on positive mood. Behavioral Therapy, 37, 237-247. Holmes, J., and Marra, M. (2002). Over the edge? Subversive humor between colleagues and friends. Humor: International Journal of Humor Research, 15, 65-87. House, J. S., Landis, K. R., and Umberson, D. (1988). Social relationships and health. Science, 241, 540-545.
64 Ilona Papousek and Günter Schulter Hoyos, T., and Kallus, K. W. (2005). Burnout risk factors: Stress-recovery-state and coping among teachers. Research report, Department of Psychology, Karl-Franzens-University, Graz Austria. Hubbard, J. R., and Workman, E. A. (Eds.) (1998). Handbook of stress medicine. An organ system approach. Boca Raton: CRC Press. Hubert, W., Moller, M., and deJong-Meyer, R. (1993). Film-induced amusement changes in saliva cortisol levels. Psychoneuroendocrinology, 18, 265-272. Hughes, J. W., and Stoney, C. M. (2000). Depressed mood is related to high-frequency heart rate variability during stressors. Psychosomatic Medicine, 62, 796-803. Iwase, M., Ouchi, Y., Okada, H., Yokoyama, X., Nobezawa, S., Yoshikawa, E., et al. (2002). Neural substrates of human facial expression of pleasant emotion induced by comic films: A PET study. Neuroimage, 17, 758-768. Jain, S., Mills, P. J., von Känel, R., Hong, S., and Dimsdale, J. E. (2007). Effects of perceived stress and uplifts on inflammation and coagulability. Psychophysiology, 44, 154-160. Jänig, W., and Häbler, H. J. (2000). Specificity in the organization of the autonomic nervous system: A basis for precise neural regulation of homeostatic and protective body functions. Progress in Brain Research, 122, 351-367. Janssen, S. A. (2002). Negative affect and sensitization to pain. Scandinavian Journal of Psychology, 43, 131-137. Jasmin, L., Rabkin, S. D., Granado, A., Boudak, A., and Ohara, P. T. (2003). Analgesia and hyperalgesia from GABA-mediated modulation of the cerebral cortex. Nature, 424, 316- 320. Jonas, B. S., Franks, P., and Ingram, D. D. (1997). Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Archives of Family Medicine, 6, 43-49. Jonas, B. S., and Lando, J. F. (2000). Negative affect as a prospective risk factor for hypertension. Psychosomatic Medicine, 62, 188-196. Jonas, B. S. and Mussolino, M. E. (2000). Symptoms of depression as a prospective risk factor for stroke. Psychosomatic Medicine, 62, 463-471. Joynt, K. E., Whellan, D. J., and O'Connor, C. M. (2003). Depression and cardiovascular disease: Mechanisms of interaction. Biological Psychiatry, 54, 248-261. Kallus, K. W. (2002). Impact of recovery in different areas of application. In M. Kellman (Ed.), Enhancing recovery: Preventing underperformance in athletes (pp. 283-300). Champaign, IL: Human Kinetics. Kamphuis, M. H., Kalmijn, S., Tijhuis, M. A., Geerlings, M. I., Giampaoli, S., Nissinen, A., et al. (2006). Depressive symptoms as a risk factor of cardiovascular mortality in older European men: The Finland, Italy and Netherlands Elderly (FINE) study. European Journal of Cardiovascular Prevention and Rehabilitation, 13, 199-206. Kaplan, G. A., Salonen, J. T., Cohen, R. D., Brand, R. J., Syme, S. L., and Puska, P. (1988). Social connections and mortality from all causes and from cardiovascular disease: Prospective evidence from Eastern Finland. American Journal of Epidemiology, 128, 370-380. Kashdan, T. B., and Roberts, J. E. (2004). Trait and state curiosity in the genesis of intimacy: Differentiation from related constructs. Journal of Social and Clinical Psychology, 23, 792-816.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 65 Kawachi, I., Sparrow, D., Spiro, A., Vokonas, P., and Weiss, S. T. (1996). A prospective study of anger and coronary heart disease. The Normative Aging Study. Circulation, 94, 2090-2095. Keltner, D. and Bonanno, G. A. (1997). A study of laughter and dissociation: Distinct correlates of laughter and smiling during bereavement. Journal of Personality and Social Psychology, 73, 687-702. Klußmann, R. (1992). Psychosomatische Medizin. Berlin: Springer. Kop, W. J., Gottdiener, J. S., Tangen, C. M., Fried, L. P., McBurnie, M. A., Walston, J., et al. (2002). Inflammation and coagulation factors in persons > 65 years of age with symptoms of depression but without evidence of myocardial ischemia. American Journal of Cardiology, 89, 419-424. Korotkov, D. and Hannah, T. E. (1994): Extraversion and emotionality as proposed superordinate stress moderators: A prospective analysis. Personality and Individual Differences, 16, 787-792. Kritz-Silverstein, D., Barrett-Connor, E., and Corbeau, C. (2001). Cross-sectional and prospective study of exercise and depressed mood in the elderly: The Rancho Bernado study. American Journal of Epidemiology, 153, 596-603. Kroenke, K., and Harris, L. (2001). Symptoms research: A fertile field. Annals of Internal Medicine, 134, 801-802. Kubie, L. (1971). The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 172, 861-866. Kubzansky, L. D., Davidson, K. W., and Rozanski, A. (2005). The clinical impact of negative psychological states: Expanding the spectrum of risk for coronary artery disease. Psychosomatic Medicine, 67, S10-S14. Kubzansky, L. D., and Kawachi, I. (2000). Going to the heart of the matter. Do negative emotions cause coronary heart disease. Journal of Psychosomatic Research, 48, 323-327. Kubzansky, L. D., Kawachi, I., Spiro, A., Weiss, S. T., Vokonas, P. S., and Sparrow, D. (1997). Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation, 95, 818-824. Kubzansky, L. D., Kawachi, I., Weiss, S. T., and Sparrow, D. (1998). Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence. Annals of Behavioral Medicine, 20, 47-58. Kuiper, N. A., and Borowicz-Sibenik, M. (2005). A good sense of humor doesn't always help: Agency and communion as moderators of psychological well-being. Personality and Individual Differences, 38, 365-377. Kuiper, N. A., Grimshaw, M., Leite, C., and Kirsh, G. (2004). Humor is not always the best medicine: Specific components of sense of humor and psychological well-being. Humor, 17, 135-168. Kuiper, N., and Martin, R. (1998). Laughter and stress in daily life: Relation to positive and negative affect. Motivation and Emotion, 22, 133-153. Kuiper, N. A., Martin, R. A., and Olinger, L. J. (1993). Coping humor, stress, and cognitive appraisals. Canadian Journal of Behavioral Sciences, 25, 81-96. LaFrance, M., and Hecht, M. A. (1995). Why smiles generate leniency. Personality and Social Psychology Bulletin, 21, 207-214. Lazarus, R. S. and Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
66 Ilona Papousek and Günter Schulter Lederer, F. (2007). Heiterkeitstraining als Methode der betrieblichen Gesundheitsförderung [Cheerfulness training as a method of workplace health promotion]. Unpublished master's thesis, Interuniversitary College for Health and Development, Graz / Seggau. Lefcourt, H. M., Davidson, K., Prkachin, K. M., and Mills, D. E. (1997). Humor as a stress moderator in the prediction of blood pressure obtained during five stressful tasks. Journal of Research in Personality, 31, 523-542. Lefcourt, H. M., Davidson, K., Shepherd, R., Phillips, M., Prkachin, K., and Mills, D. E. (1995). Perspective-taking humor: Accounting for stress moderation. Journal of Social and Clinical Psychology, 14, 373-391. Levenson, R. W., Ekman, P., and Friesen, W. V. (1983). Autonomic nervous system activity distinguishes among emotions. Science, 221, 1208-1210. Levenson, R. W., Ekman, P., and Friesen, W. V. (1990). Voluntary facial action generates emotion-specific autonomic nervous system activity. Psychophysiology, 27, 363-384. Leibbrand, R., Cuntz, U., and Hiller, W. (2002). Assessment of functional gastrointestinal disorders using the Gastro-Questionnaire. International Journal of Behavioral Medicine, 9, 155-172. Lesperance, F., Frasure-Smith, N., Talajic, M., and Bourassa, M. G. (2002). Five-year risk of cardiac mortality in relation to initial severity and one-year chances in depression symptoms after myocardial infarction. Circulation, 105, 1049-1053. Levi, L. (1965). The urinary output of adrenalin and noradrenalin during pleasant and unpleasant emotional states: A preliminary report. Psychosomatic Medicine, 27, 80-85. Levine, J. D., and Gordon, N. C. (1984). Influence of the method of drug administration on analgesic response. Nature, 312, 755-756. Liangas, G., Yates, D. H., Wu, D., Henry, R. L., and Thomas, P. S. (2004). Laughter- associated asthma. Journal of Asthma, 41, 217-221. Libby, P. (2003). Vascular biology of atherosclerosis: Overview and state of the art. American Journal of Cardiology, 91, 3A-6A. Lovallo, W. R. (1997). Stress and Health. Biological and Psychological Interactions. Thousand Oaks: Sage. Mahony, D. L., Burroughs, W. J., and Lippman, L. G. (2002): Perceived attributes of health- promoting laughter: A cross-generational comparison. Journal of Psychology, 136, 171- 181. Martin, R. A. (2001): Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127, 504-519. Martin, L. R., Friedman, H. S., Tucker, J. S., Tomlinson-Keasey, C. Criqui, M. H., and Schwartz, J. E. (2002). A life course perspective on childhood cheerfulness and its relation to mortality risk. Personality and Social Psychology Bulletin, 28, 1155-1165. Martin, R. A., and Kuiper, N. A. (1999). Daily occurrence of laughter: Relationships with age, gender, and Type A personality. Humor: International Journal of Humor Research, 12, 355-384. Martin, R. A., and Lefcourt, H. M. (1983). Sense of humor as a moderator of the relation between stressors and moods. Journal of Personality and Social Psychology, 45, 1313- 1324. Matthews, K. A., Owens, J. F., Edmundowicz, D., Lee, L., and Kuller, L. H. (2006). Positive and negative attributes and risk for coronary and aortic calcification in healthy women. Psychosomatic Medicine, 68, 355-361.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 67 Matthews, K. A., Raikkonen, K., Sutton-Tyrrell, K., Kuller, L. H. (2004). Optimistic attitudes protect against progression of carotid atherosclerosis in healthy middle-aged women. Psychosomatic Medicine, 66, 640-644. Mayer, E. A. (1999). Emerging disease model for functional gastrointestinal disorders. American Journal of Medicine, 107(5A), 12-19. Mayer, E. A. (2000). The neurobiology of stress and gastrointestinal disease. Gut, 47, 861- 869. Mayer, E. A., Munakata, J., and Chang, L. (1997). Does mind-body medicine have a role in gastroenterology. Current Opinion in Gastroenterology, 13, 1-4. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171-179. McLaughlin, K. A., Borkovec, T. D., and Sibrava, N. J. (2005). The effects of worry and rumination on affect states and cognitive activity. Behavioral Therapy, 38, 23-38. McMahon, C., Mahmud, A., and Feely J. (2005): Taking blood pressure - no laughing matter. Blood Pressure Monitor, 10, 109-10. Meyer, M., Zysset, S., vonCramon, D. Y., and Alter, K. (2005). Distinct fMRI responses to laughter, speech, and sounds along the human peri-sylvian cortex. Cognitive Brain Research, 24, 291-306. Middleton, R. A., and Byrd, E.K. (1996). Psychosocial factors and hospital readmission status of older persons with cardiovascular disease. Journal of Applied Rehabilitation Counseling, 27, 3-10. Miller, G. E., and Blackwell, E. (2006). Turning up the heat. Inflammation as a mechanism linking chronic stress, depression, and heart disease. Current Directions in Psychological Science, 15, 269-272. Miller, G. E., Chen, E., and Zhou, E. S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin, 133, 25-45. Miron, D., Duncan, G. H., and Bushnell, M. C. (1989). Effects of attention on the intensity and unpleasantness of thermal pain. Pain, 39, 345-352. Mobbs, D., Greicius, M. D., Abdel-Azim, E., Menon, V., and Reiss, A. L. (2003). Humor modulates the mesolimbic reward centers. Neuron, 40, 1041-1048. Moller, J., Hallqvist, J., Diderichsen, F., Theorell, T., Reuterwall, C., and Ahlbom, A. (1999). Do episodes of anger trigger myocardial infarction? A case-crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosomatic Medicine, 61, 842- 849. Mori, H., Yamamoto, H., Kuwashima, M., Saito, S., Ukai, H., Hirao, K., et al. (2005). How does deep breathing affect office blood pressure and pulse rate. Hypertension Research, 28, 499-504. Moser, D. K., Riegel, B., McKinley, S., Doering, L. V., An, K., and Sheahan, S. (2007). Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction. Psychosomatic Medicine, 69, 10-16. Moskowitz, J. T. (2003). Positive affect predicts lower risk of AIDS mortality. Psychosomatic Medicine, 65, 620-626. Murphy, R., Hirsch, C. R., Mathews, A., Smith, K., and Clark, D. M. (2007). Facilitating a benign interpretation bias in a high socially anxious population. Behavior Research and Therapy, 45, 1517-1529.
68 Ilona Papousek and Günter Schulter Naliboff, B. D., Chang, L., Munakata, J., and Mayer, E. A. (2000). Towards an integrative model of irritable bowel syndrome. Progress in Brain Research, 122, 413-423. Neumann, R., and Strack, F. (2000). 'Mood contagion': The automatic transfer of mood between persons. Journal of Personality and Social Psychology, 79, 211-223. Neumann, S. A., and Waldstein, S. R. (2001): Similar patterns of cardiovascular response during emotional activation as a function of affective valence and arousal and gender. Journal of Psychosomatic Research, 50, 245-253. Newman, M. G., and Stone, A. A. (1996). Does humor moderate the effects of experimentally-induced stress. Annals of Behavioral Medicine, 18, 101-109. Nezu, A. M., Nezu, C. M., and Blisset, S. E. (1988). Sense of humor as a moderator of the relation between stressful events and psychological distress: A prospective analysis. Journal of Personality and Social Psychology, 54, 520-525. Nograsek, J. (2006). Positive Intervention in der psychiatrischen Rehabilitation [Positive intervention in psychiatric rehabilitation]. Unpublished master's thesis, Karl-Franzens University, Graz. Nouwen, A., Cloutier, C., Kappas, A., Warbrick, T., and Sheffield, D. (2006). Effects of focusing and distraction on cold pressor-induced pain in chronic back pain patients and control subjects. Journal of Pain, 7, 62-71. Ochsner, K. N., Ludlow, D. H., Knierim, K., Hanelin, J., Ramachandran, T., Glover, G. C., et al. (2006). Neural correlates of individual differences in pain-related fear and anxiety. Pain, 120, 69-77. Okun, M. A., Stock, W. A., Haring, M. H., and Winter, R. A. (1984). Health and subjective well-being: A meta-analysis. International Journal of Aging and Human Development, 19, 111-132. Okun, M. S., Bowers, D., Springer, U., Shapira, N. A., Malone, D., Rezai, A. R., et al. (2004). What's in a smile. Intra-operative observations of contralateral smiles induced by deep brain stimulation. Neurocase, 10, 271-279. Olden, K. W. (1998). Stress and the gastrointestinal tract. In J. R. Hubbard, and E. A. Workman (Eds.), Handbook of stress medicine. An organ system approach. Boca Raton: CRC Press. Olds, J., and Milner, P. (1954). Positive reinforcement produced by electrical stimulation of septal area and other regions of rat brain. Journal of Comparative Physiological Psychology, 47, 419-427. Ong, A. D., Bergeman, C. S., Bisconti, T. L., and Wallace, K. A. (2006). Psychological resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91, 730-749. Orth-Gomer, K., Rosengren, A., and Wilhelmsen, L. (1993). Lack of social support and incidence of coronary heart disease in middle-aged Swedish men. Psychosomatic Medicine, 55, 37-43. Ostir, G. V., Goodwin, J. S., Markides, K. S., Ottenbacher, K. J., Balfour, J., and Guralnik, J. M. (2002). Differential effects of premorbid physical and emotional health on recovery from acute events. Journal of the American Geriatrics Society, 50, 713-718. Ostir, G. V., Markides, K. S., Black, S. A., and Goodwin, J. S. (2000). Emotional well-being predicts subsequent functional independence and survival. Journal of the American Geriatrics Society, 48, 473-478.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 69 Ostir, G. V., Markides, K. S., Peek, M. K., and Goodwin, J. S. (2001). The association between emotional well-being and the incidence of stroke in older adults. Psychosomatic Medicine, 210-215. Oswald, L. M., Zandi, P., Nestadt, G., Potash, J. B., Kalaydjian, A. E., and Wand, G. S. (2006). Relationship between cortisol responses to stress and personality. Neuropsychopharmacology, 31, 1583-1591. Otta, E., Abrosio, F. F. E., and Hoshino, R .L. (1996). Reading a smiling face: Messages conveyed by various forms of smiling. Perceptual and Motor Skills, 82, 1111-1121. Overeem, S., Lammers, G. J., and van Dijk, J. G. (1999). Weak with laughter. Lancet, 354, 838. Overeem, S., Taal, W., Ocal, G. E., Lammers, G. J., and van Dijk, J. G. (2004): Is motor inhibition during laughter due to emotional or respiratory influences. Psychophysiology, 41, 254-258. Papanicolaou, D. A., Wilder, R. L., Manolagas, S. C., and Chrousos, G. P. (1989). The pathophysiologic roles of interleukin-6 in human disease. Annals of Internal Medicine, 128, 127-137. Papousek, I. (2008). Heiterkeit und Gelassenheit trainieren mit Lachen [Training cheerfulness and serenity with laughter]. In H. Effinger (Ed.), Die Wahrheit zum Lachen bringen - Humor als Medium in der Sozialen Arbeit [To make the truth laugh - use of humor in social work]. Weinheim: Juventa. Papousek, I., Lang, S., Zitzenbacher, A., and Kogler, E. (2004). Entwicklung und Evaluation eines wissenschaftlich fundierten Heiterkeitstrainings [Development and evaluation of a scientifically founded cheerfulness training]. Research report, Karl-Franzens-University, Graz, Austria. Papousek, I., Nauschnegg, K., Paechter, M., Lackner, H. K., Goswami, N., and Schulter, G. (2010). Trait and state positive affect and cardiovascular recovery from experimental academic stress. Biological Psychology, 83, 108-115. Papousek, I., Ruch, W., Freudenthaler, H. H., Kogler, E., Lang, B., and Schulter, G. (2009). Gelotophobia, emotion-related skills and responses to the affective states of others. Personality and Individual Differences, 47, 58-63. Papousek, I., and Schulter, G. (2001). Associations between EEG asymmetries and electrodermal lability in low versus high depressive and anxious normal individuals. International Journal of Psychophysiology, 41, 105-117. Papousek, I., and Schulter, G. (2002). Brain asymmetry and stress: New perspectives in psychophysiologically oriented psychosomatic research. Psychology Science Quarterly, 44, 535-544. Papousek, I., and Schulter, G. (2006). Heiterkeit trainieren: Subjektive und psychophysiologische Wirkungen [Cheerfulness training: Subjective and psychophysiological effects]. Paper, presented at the 7th Scientific Conference of the Austrian Psychological Society, Klagenfurt, Austria. Papousek, I., and Schulter, G. (2008). Effects of a mood enhancing intervention on subjective well-being and cardiovascular parameters. International Journal of Behavioral Medicine, 15, 293-302. Papousek, I., and Schulter, G. (In preparation). Alterations in EEG laterality produced by a mood enhancing intervention.
70 Ilona Papousek and Günter Schulter Papousek, I., Schulter, G., and Premsberger, E. (2002). Dissociated autonomic regulation during stress, and physical complaints. Journal of Psychosomatic Research, 52, 257-266. Paterniti, S., Zureik, M., Ducimetiere, P., Touboul, P. J., Feve, J. M., and Alperovitch, A. (2001). Sustained anxiety and 4-year progression of carotid atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology, 21, 136-141. Patton, G. C., Hibbert, M., Rosier, M. J., Carlin, J. B., Caust, J., and Bowes, G. (1996). Is smoking associated with depression and anxiety in teenagers. American Journal of Public Health, 86, 225-230. Peeters, F., Nicholson, N. A., and Berkhof, J. (2003). Cortisol responses to daily events in major depressive disorder. Psychosomatic Medicine, 65, 836-841. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer. Petrie, K. J., Moss-Morris, R., Grey, C., and Shaw, M. (2004). The relationship of negative affect and perceived sensitivity to symptom reporting following vaccination. British Journal of Health Psychology, 9, 101-111. Pettit, J. W., Kline, J. P., Gencoz, T., Gencoz, F., and Joiner, T. E. (2001). Are happy people healthier? The specific role of positive affect in predicting self-reported health symptoms. Journal of Research in Personality, 35, 521-536. Petrovic, P., Kalso, E., Pettersson, K. M., and Ingvar, M. (2002). Placebo and opioid analgesia. Imaging a shared neuronal network. Science, 295, 1737-1740. Petrovic, P., Petterson, K. M., Ghatan, P. H., Sone-Elander, S., and Ingvar, M. (2000). Pain- related cerebral activation is altered by a distracting cognitive task. Pain, 85, 19-30. Pfaus, J. G., Damsma, G., Nomikos, G. G., Wenstern, D. G., Blaha, C. D., Phillips, A. G., et al. (1990). Sexual behavior enhances central dopamine transmission in the male rat. Brain Research, 530, 345-348. Picavet, H. S. and Schouten, J. S. (2003). Musculoskeletal pain in the Netherlands: Prevalences, consequences and risk groups, the DMC(3) study. Pain, 102, 167-178. Pitsavos, C., Panagiotakos, D. B., Papageorgiou, C., Tsetsekou, E., Soldatos, C., and Stefanadis, C. (2006). Anxiety in relation to inflammation and coagulation markers among healthy adults: The ATTICA study. Atherosclerosis, 185, 320-326. Plotsky, P. M., Owens, M. J., and Nemeroff, C. B. (1998). Psychoneuroendocrinology of depression. Hypothalamic-pituitary-adrenal axis. Psychiatric Clinics of North America, 21, 293-307. Porterfield, A. (1987). Does sense of humor moderate the impact of life stress on psychological well-being. Journal of Research in Personality, 21, 306-317. Pressman, S. D., and Cohen, S. (2005). Does positive affect influence health. Psychological Bulletin, 131, 925-971. Provine, R. R. (1992). Contagious laughter: Laughter is a sufficient stimulus for laughs and smiles. Bulletin of the Psychonomic Society, 30, 1-4. Provine, R. R. (2000). Laughter: A scientific investigation. New York: Viking Putnam. Raikkonen, K., Matthews, K. A., Sutton-Tyrrell, K., and Kuller, L. H. (2004). Trait anger and the metabolic syndrome predict progression of carotid atherosclerosis in healthy middle- aged women. Psychosomatic Medicine, 66, 903-908. Reis, H. T., Wilson, I. M., Monestere, C., Bernstein, S., Clark, K., Seidl, E., et al., (1990). What is smiling is beautiful and good. European Journal of Social Psychology, 20, 259- 267.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 71 Ring, C., Harrison, L. K., Winzer, A., Carroll, D., Drayson, M., and Kendall, M. (2000): Secretory immunoglobulin A and cardiovascular reactions to mental arithmetic, cold pressor, and exercise: Effects of alpha-adrenergic blockade. Psychophysiology, 37, 634- 43. Ringel, Y., and Drossman, D.A. (1999). From gut to brain and back - a new perspective into functional gastrointestinal disorders. Journal of Psychosomatic Research, 47, 205-210. Ritz, T., George, C., and Dahme, B. (2000): Respiratory resistance during emotional stimulation: Evidence for a nonspecific effect of experienced arousal. Biological Psychology, 52, 143-160. Ritz, T., and Steptoe, A. (2000): Emotion and pulmonary function in asthma: Reactivity in the field and relationship with laboratory induction of emotion. Psychosomatic Medicine, 62, 808-815. Ross, R. (1999). Atherosclerosis. An inflammatory disease. New England Journal of Medicine, 340, 115-126. Rotton, J., and Shats, M. (1996). Effects of state humor, expectancies, and choice on postsurgical mood and self-medication: A field experiment. Journal of Applied Social Psychology, 26, 1775-1794. Rowe, G., Hirsh, J. B., and Anderson, A. K. (2007). Positive affect increases the breadth of attentional selection. Proceedings of the National Academy of Sciences, 104, 383-388. Rozanski A., and Kubzansky, L. D. (2005). Psychologic functioning and physical health: A paradigm of flexibility. Psychosomatic Medicine, 67, 47-53. Ruch, W. (1993a). Exhilaration and humor. In M. Lewis and J. M. Haviland (Eds.), The handbook of emotion (pp. 605-616). New York: Guilford Press. Ruch, W. (1993b): Die Emotion Erheiterung: Eine Übersicht über den Forschungsbestand [The emotion exhilaration: Overview over the scientific evidence]. In Montada, L. (Ed.), Proceedings of the 38th Congress of the German Psychological Society (pp. 277-285). Göttingen, Hogrefe. Ruch, W. (1997). State and trait cheerfulness and the induction of exhilaration. A FACS study. European Psychologist, 2, 328-341. Ruch, W., and Ekman, P. (2001). The expressive pattern of laughter. In A. W. Kaszniak (Ed.), Emotion, qualia, and consciousness (pp. 246-443). Tokyo: World Scientific Publisher. Ruch, W., and Köhler, G. (1999). The measurement of state and trait cheerfulness. In I. Mervielde, I. Deary, F. De Fruyt, and F. Ostendorf (Eds.), Personality psychology in Europe: Theoretical and empirical developments, Vol. 7 (pp. 67-83). Tilburg: University Press. Ruch, W., Köhler, G., and vanThriel, C. (1997). To be in good or bad humor: Construction of the state form of the State-Trait-Cheerfulness-Inventory STCI. Personality and Individual Differences, 22, 477-491. Ruch, W., and Proyer, R. T. (2008). The fear of being laughed at: Individual and group differences in Gelotophobia. Humor: International Journal of Humor Research, 21, 47- 67. Ruch, W., and Zweyer, K. (2001). Heiterkeit und Humor: Ergebnisse der Forschung [Cheerfulness and humor: Scientific findings]. In R. D. Hirsch, J. Bruder, and H. Radebold (Eds.), Heiterkeit und Humor im Alter. Schriftenreihe der Deutschen Gesellschaft für Gerontopsychiatrie und -psychotherapie, Band 2 [Cheerfulness and
72 Ilona Papousek and Günter Schulter humor in old age. Series of the German Society of Gerontopsychiatry and - psychotherapy, Vol. 2] (pp. 9-43). Bornheim-Sechtem: Chudeck-Druck. Rugulies, R. (2002). Depression as a predictor for coronary heart disease. A review and meta- analysis. American Journal of Preventive Medicine, 23, 51-61. Salaffi, F., Cavalieri, F., Nolli, M., and Ferraccioli, G. (1991). Analysis of disability in known osteoarthritis: Relationship with age and psychological variables but not with radiographic score. Journal of Rheumatology, 18, 1581-1586. Salovey, P., Rothman, A. J., Detweiler, J. B., and Steward, W. T. (2000). Emotional states and physical health. American Psychologist, 55, 110-121. Sauro, M. D., and Greenberg, R. P. (2005). Endogenous opiates and the placebo effect. A meta-analytic review. Journal of Psychosomatic Research, 58, 115-120. Schimmack, U., Oishi, S., Furr, R. M., and Funder, D. C. (2004). Personality and life satisfaction: A facet-level analysis. Personality and Social Psychology Bulletin, 30, 1062- 1075. Segerstrom, S. C. (2005). Optimism and immunity: Do positive thoughts always lead to positive effects. Brain, Behavior and Immunity, 19, 195-200. Segerstrom, S. C. and Miller, G. E. (2004). Psychological stress and the immune system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130, 601-630. Severeijns, R., Vlaeyen, J. W., Van den Hout, M. A., and Weber, W. E. (2001). Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clinical Journal of Pain, 17, 165–172. Sharp, T. J. (2001). Chronic pain: A reformulation of the cognitive-behavioural model. Behaviour Research and Therapy, 39, 787-800. Sheffield, D., Krittayaphong, R., Cascio, W. E., Light, K. C., Golden, R. N., Finkel, J. B., et al. (1998). Heart rate variability at rest and during mental stress in patients with coronary artery disease: Differences in patients with high and low depression scores. International Journal of Behavioral Medicine, 5, 31-47. Sobel, D. S. (2000). The cost-effectiveness of mind-body medicine interventions. Progress in Brain Research, 122, 393-412. Soussignan, R. (2002). Duchenne smile, emotional experience, and autonomic reactivity. Emotion, 2, 52-74 Staud, R. (2006). Biology and therapy of fibromyalgia: Pain in fibromyalgia syndrome. Arthritis Research and Therapy, 8, 208-214. Stein, M., Miller, A. H., and Trostman, R. I. (1991). Depression, the immune system, and health and illness. Archives of General Psychiatry, 48, 171-177. Steptoe, A., O'Donnell, K., Marmot, M., and Wardle, J. (2008). Positive affect and psychosocial processes related to health. British Journal of Psychology, 99, 211-227. Steptoe, A. and Wardle, J. (2005). Positive affect and biological function in everyday life. Neurobiology of Ageing, 26, 108-112. Stiles, D. P., and Terr, A. I. (1991). Basic and clinical immunology. San Mateo: Appleton and Lange. Strack, F., Martin, L. L., and Stepper, S. (1988). Inhibiting and facilitating conditions of the human smile: A nonobtrusive test of the facial feedback hypothesis. Journal of Personality and Social Psychology, 54, 768-777.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 73 Strand, E. B., Zautra, A. J., Thoresen, M., Odegard, S., Uhlig, T., and Finset, A. (2006). Positive affect as a factor of resilience in the pain-negative affect relationship in patients with rheumatoid arthritis. Journal of Psychosomatic Research, 60, 477-484. Svebak, S., Martin, R. A., and Holmen, J. (2004). The prevalence of sense of humor in a large, unselected county population in Norway: Relations with age, sex, and some health indicators. Humor: International Journal of Humor Research, 17, 121-134. Szameitat, D. P., Alter, K., Szameitat, A. J., Darwin, C. J., Wildgruber, D., Dietrich, S., et al. (2009). Differentiation of emotions in laughter at the behavioral level. Emotion, 9, 397- 405. Thayer, J. F., Friedman, B. H., and Borkovec, T. D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255-266. Thomsen, D. K., Mehlsen, M. Y., Olesen, F., Hokland, M., Vidik, A., Avlund, K., et al. (2004). Is there an association between rumination and self-reported physical health. A one year follow-up in a young and an elderly sample. Journal of Behavioral Medicine, 27, 215-231. Tracey, I. Ploghaus, A., Gati, J. S., Clare, S., Smith, S., Menon, R. S., et al. (2002). Imaging attentional modulation of pain in the periaqueductal gray in humans. Journal of Neuroscience, 22, 2748-2752. Troisi, A., and Moles, A. (1999). Gender differences in depression. An ethological study of nonverbal behavior during interviews. Journal of Psychiatric Research, 33, 243-250. Tugade, M. M., and Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology, 86, 320-333. Tugade, M. M., Fredrickson, B. L., and Barrett, L. F. (2004). Psychological resilience and positive emotional granularity: Examining the benefits of positive emotions on coping and health. Journal of Personality, 72, 1161-1190. Tveito, T. H., Passchier, J., Duivenvoorden, H. J., and Eriksen, H. R. (2004). Subjective health complaints and health related quality of life in a population of health care workers. Psychology and Health, 19, 247-259. Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377-387. Uchino, B. N., Holt-Lunstad, J., Uno, D., Betancourt, R., and Garvey, T. S. (1999). Social support and age-related differences in cardiovascular function: An examination of potential mediators. Annals of Behavioral Medicine, 21, 135-142. Vagnoli, L., Caprilli, S., Robiglio, A., and Messeri, A. (2005). Clown doctors as a treatment for preoperative anxiety in children: A randomized, prospective study. Pediatrics, 116, 563-567. Van Hooff, J. A. (1972). A comparative approach to the phylogeny of laughter and smiling. In R. A. Hinde (Ed.), Nonverbal communication (pp. 209-237). Cambridge: Cambridge University Press. Ventis, W. L., Higbee, G., and Murdock, S. A. (2001). Using humor in systematic desensitization to reduce fear. Journal of General Psychology, 128, 241-253. Villemure, C. and Bushnell, M. C. (2002). Cognitive modulation of pain: How do attention and emotion influence pain processing. Pain, 95, 195-199.
74 Ilona Papousek and Günter Schulter Vinton, K. L. (1989). Humor in the work place: Is it more than telling jokes. Small Group Behavior, 20, 151-166. Visser, M. R., Smets, E. M., Oort, F. J., and De Haes, H. C. (2003). Stress, satisfaction and burnout among Dutch medical specialists. Canadian Medial Association Journal, 168, 271-275. Wadlinger, H. A., and Isaacowitz, D. M. (2006). Positive mood broadens visual attention to positive stimuli. Motivation and Emotion, 30, 89-101. Watkins, L. L., Grossman, P., Krishnan, R., and Sherwood, A. (1998). Anxiety and vagal control of heart rate. Psychosomatic Medicine, 60, 498-502. Watson, D., Clark, L. A., McIntyre, C. W., and Hamaker, S. (1992). Affect, personality, and social activity. Journal of Personality and Social Psychology, 63, 1011-1025. Watson, D., and Pennebaker, J. W. (1989). Health complaints, stress, and distress: Exploring the central role of negative affectivity. Psychological Reviews, 96, 234-254. Weisenberg, M., Raz, T., and Tener, T. (1998). The influence of film-induced mood on pain perception. Pain, 76, 365-375. Weisenberg, M., Tepper, I., and Schwarzwald, J. (1995). Humor as a cognitive technique for increasing pain tolerance. Pain, 63, 207-212. Weisse, C. S. (1992). Depression and immunocompetence: A review of the literature. Psychological Bulletin, 111, 475-489. White, P. D. and Moorey, S. (1997). Psychosomatic illnesses are not 'all in the mind'. Journal of Psychosomatic Research, 42, 329-332. Wicker, B., Keysers, C., Plailly, J., Royet, J. P., Gallese, V., and Rizzolatti, G. (2003). Both of us disgusted in my insula: The common neural basis of seeing and feeling disgust. Neuron, 40, 655-664. Wild, B., Erb, M., and Bartels, M. (2001). Are emotions contagious? Evoked emotions while viewing emotionally expressive faces: Quality, quantity, time course and gender differences. Psychiatry Research, 102, 109-124. Wild, B., Rodden, F. A., Rapp, A., Erb, M., Grodd, W., and Ruch, W. (2006). Humor and smiling: Cortical regions selective for cognitive, affective, and volitional components. Neurology, 66, 887-893. Wilhelmsen, I. (2000). Brain-gut axis as an example of the bio-psycho-social model. Gut, 47, 5-7. Williams, J. E., Paton, C. C., Siegler, I. C., Eigenbrodt, M. L., Nieto, F. J., and Tyroler, H. A. (2000). Anger proneness predicts coronary heart disease risk: Prospective analysis from the atherosclerosis risk in communities (ARIC) study. Circulation, 101, 2034-2039. Williams, R. B., Barefoot, J. C., Califf, R. M., Haney, T. L., Saunders, W. B., Pryor, D. B., et al. (1992). Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. Journal of the American Medical Association, 267, 520-524. Wood, J. D., Alpers, D. H., and Andrews, P .L. R. (1999). Fundamentals of Neurogastroenterology. Gut, 45, II6-II16. Zautra, A. J., Fasman, R., Reich, J. W., Harakas, P., Johnson, L. M., Olmsted, M. E., et al. (2005). Fibromyalgia: Evidence for deficits in positive affect regulation. Psychosomatic Medicine, 67, 147-155.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 75 Zautra, A. J., Johnson, L. M., and Davis, M. C. (2005). Positive affect as a source of resilience for women in chronic pain. Journal of Consulting and Clinical Psychology, 73, 212-220. Zautra, A. J., Smith, B., Affleck, G., and Tennen, H. (2001). Examinations of chronic pain and affect relationships: Applications of a dynamic model of affect. Journal of Consulting and Clinical Psychology, 69, 786-795. Zillmann, D., Rockwell, S., Schweitzer, K., and Sundar, S. S. (1993). Does humor facilitate coping with physical discomfort. Motivation and Emotion, 17, 1-21. Zweyer, K., Velker, B., and Ruch, W. (2004). Do cheerfulness, exhilaration, and humor production moderate pain tolerance? A FACS study. Humor: International Journal of Humor Research, 17, 67-84.
In: Psychological Well-Being ISBN 978-1-61668-180-7 Editor: Ingrid E. Wells, pp. 77-113 © 2010 Nova Science Publishers, Inc. Chapter 2 PSYCHOLOGICAL WELL-BEING, ASSESSMENT TOOLS AND RELATED FACTORS Jesús López-Torres Hidalgo1,2, Beatriz Navarro Bravo1,2, Ignacio Párraga Martínez1, Fernando Andrés Pretel1, José Miguel Latorre Postigo2 and Francisco Escobar Rabadán1,2 1.Health Care Service of Castilla-La Mancha (SESCAM). 2. University of Castilla-La Mancha. 1. ABSTRACT The positive psychological functioning has received several approaches along the history. We must distinguish between the hedonic approach, which speaks of the ―subjective well-being‖ relating it to happiness, and the eudaemonic approach, which relates the ―psychological well-being‖ to human potential development. In this second thinking trend we find authors like Maslow and Rogers. These authors focused on self- actualization and on the view of the fully functioning person respectively, as ways to achieve well-being and personal fulfillment. More recently, Carol Ryff has divided this construct in 6 dimensions: Self- acceptance, Positive relations with others, Autonomy, Environmental Mastery, Purpose in Life and Personal Growth. In order to asses the 6 dimensions mentioned, Ryff created the ―Psychological well-being scales‖, with 20 items each. After that, shorter versions have been proposed, due to the 120 items of the original ones. Psychological well-being positively correlates to factors as satisfaction with life, self-esteem or internal control, and negatively to depression or the powerful others. Likewise, the health levels positively correlates to the 6 factors of the psychological well-being above. When we speak about psychological well-being by sex, women have higher scores in ―relations with others‖ and in ―personal growth‖, even though men get better scores in self-esteem and self-concept. As for differences by ages, literature speaks about higher scores in the group of aged people on some factors, like ―autonomy‖ and ―environmental mastery‖. In other factors like, ―personal growth‖ and ―purpose in life‖, young people have higher scores.
78 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Regarding the differences by education and occupation level, the psychological well- being positively relates to a higher educational and occupational level. Maintaining a good psychological well-being level can be an important protective factor when it comes to suffer several physical or psychological problems, and it is interesting to investigate the extent to which influences the development and evolution of certain health problems. 2. INTRODUCTION 2.1. Historic Introduction to Positive Psychological Functioning Throughout history, psychologists have offered different descriptions of positive psychological functioning, or well-being, in the context of the different branches of psychology, such as developmental or clinical psychology. From the perspective of developmental psychology, Erikson [1950] presented the concept of a ―healthy personality‖ in the context of Freudian theory. Erikson perceives development of the personality as a process in which each personality factor is related with the others, in such a way that the personality as a whole depends on the correct development of each of its components. In his analysis of the growth process, this author talks about how the components of mental health develop over the following series of sequential stages: a sense of basic trust, a sense of autonomy, a sense of initiative, a sense of industry, a sense of ego identity, geniality, generativity and integrity. During each of these stages a conflict takes place, and the person‘s development will be more or less healthy, depending on how this conflict is resolved. According to Erikson‘s vision, development of the ego is a continuous growth process, which progresses, throughout a person‘s lifespan, towards a superior capacity. This same perspective of continuous growth throughout the lifespan can be found in Bühler‘s theory [1935], which speaks of the so-called ―curve of life‖. Buhler concluded that, in spite of individual differences, there is a regular sequence in which events, experiences and achievements appear in peoples‘ lives, and that improvement or deterioration in psychological well-being does not necessarily occur at the same rate as changes in physical well-being. From the perspective of clinical psychology, authors such as Maslow, Allport and Rogers have offered other descriptions of well-being. In his well-known pyramid, Maslow [1958] includes 5 basic needs that a person must fulfill to become fully-functioning. A person begins by satisfying the most basic needs and after fulfilling the first one, then moves on to the next, on the level immediately above. Firstly, the most basic needs for an organism are considered to be physiological ones. These are, undoubtedly, the most important in the pyramid, in that when a person loses everything in life, his strongest desire is to satisfy this type of need. The most important goal in a person without food, love or safety, will most certainly be to find food before anything else. When none of the needs are satisfied and the organism is dominated by physiological requirements, the other needs cease to exist or become less important.
Psychological Well-Being, Assessment Tools and Related Factors 79 In second place, when the physiological needs are satisfied the need for safety takes over. When a person is in this stage, safety becomes more important than anything else, even than the physiological needs that are already covered. Maslow‘s third need concerns the requirement to belong to a group, and for affection and love, which comes into play when the previous two needs have been satisfied. The person is now interested in forming relationships with others and becoming part of a group, and will work hard to achieve this. The person is now more interested in doing this than in anything else and forgets the little importance he attributed to this when he was hungry. Maslow‘s fourth need corresponds to a person‘s self-esteem. This author considers that everyone (with the exception of some mental illnesses) needs a positive opinion of himself, self-respect and self-esteem and also to be valued by others. These needs can be classified into two sub-groups: on the one hand, a desire for fortitude, achievements, independence and freedom and, on the other hand, a desire to earn a good reputation or prestige, defined as having gained the respect or esteem of others. Finally, we come to the need for self-actualization, defined as a person realizing his full potential, which comes into play when all the other needs are satisfied. According to Maslow ―what a man can be, he must be‖, and he calls this need, self- actualization. If a person has the talent to do something, he will be unsatisfied or unhappy if he cannot fully develop this part of himself, in other words, a musician must make music and a poet must write poems. This need refers to the desire for a person to develop his full potential, to seek personal growth and to become everything he is capable of being. Clearly, these desires vary greatly from one person to the next. Some people may feel self-fulfilled by becoming top sportsmen, while others will acquire a feeling of self-fulfillment by being good parents. Allport [1952] described a mature personality as a form of positive functioning. In his study on maturity, this is partly achieved through marriage, during which the need for affiliation reaches adulthood. A mature person would be defined as having ―an extended ego, a self-objectification related to a sense of humor and some sort of integrative philosophy of life‖. This maturity would be acquired through a series of stages of emotional maturation. Rogers [1963] introduces the concept of ―the fully functioning person‖ to refer to people who can live fully with all of their own feelings and reactions. These people trust their own organism and its functioning, not because this is infallible, but because they can accept the consequences of their own actions and can correct them if they consider them to be unsatisfactory. They can experience all their feelings and are not afraid of them. They are open to evidence and are fully implicated in the process of being themselves. These people live life to the full and are aware of themselves through their own experiences. To summarize, the integration of studies on mental health, clinical aspects and life-span theories have many converging aspects of positive psychological functioning. Historically, research into mental health has tended to focus on psychological dysfunction, instead of studying more positive aspects of human functioning. This perspective is rather limiting, since definitions of mental health as an absence of illness ignore the human capacities, needs to prosper and the protective traits associated with their well-being [Ryff and Singer, 1996].
80 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. When we refer to psychological well-being, we are talking about a construct associated with the optimum or positive functioning of a person [Ryan and Deci, 2001]. For more than 20 years, the study of psychological well-being has been guided by two essential concepts. We can find the first of these in the work of Bradburn [1969], which distinguishes between positive affect and negative affect, and defines happiness as achieving a balance between the two. The second formulation, which has acquired importance among sociologists, regards satisfaction with life as being a key indicator of well-being. Considered as a cognitive component, satisfaction with life was interpreted as a complement to happiness, the most affective dimension of positive functioning [Andrews and McKennel, 1980; Andrews and Withey, 1976]. Waterman [1993] distinguishes between the hedonic and the eudemonic facets of well- being. The hedonic facet mainly focuses on happiness and defines well-being as an indicator of quality-of-life, based on the relationship between environmental characteristics and a person‘s level of satisfaction [Campbell, Converse and Rodgers, 1976]. This perspective focuses on achieving pleasure and avoiding pain [Ryan and Deci, 2001]. The eudemonic approach is orientated towards life having a meaning and a person‘s degree of self- fulfillment. It defines well-being as the extent to which someone becomes a fully functioning person, [Ryan and Deci, 2001]. On the basis of this previous classification, some authors [Keyes, Shmotkin and Ryff, 2002] have used the construct of subjective well-being (SWB) as the main representative of hedonic tradition, taking special interest in studies of affections and satisfaction with life [Diaz, Rodriguez-Carvajal, Blanco et al., 2006]. The construct of psychological well-being (PWB) is taken to represent eudemonic tradition, focusing on the development of skills and personal growth, both conceived as key indicators of positive functioning [Diaz, Rodriguez- Carvajal, Blanco et al., 2006]. If we consider the construct of subjective well-being as happiness, Wilson [1967] concluded that a happy person would be ―young, healthy, well-educated, well-paid, extrovert, optimistic, free from worries, religious, married with a high self-esteem, job morale, with modest aspirations, of either sex and within a broad interval of intelligence‖. Michalos [1985] explains in his multiple discrepancy theory of satisfaction that an individual compares himself with many standards; these include other people, past conditions, ambitions and ideal levels of satisfaction and his own needs or goals. The conclusions he reaches about his level of satisfaction will be based on the differences between current conditions and these standards. Wilson reached this definition some time ago, and since then research into subjective well-being has advanced significantly. Wilson believed that a happy person would be well- paid, young, educated, religious and married, among other factors [Wilson, 1967]. Now, three decades later, Diener, Suh, Lucas et al., [1999] consider that a happy person is someone with a positive temperament, who tends to see the good side of things and does not ponder over negative events, he lives in an economically-developed society, has social confidants, and has sufficient resources to advance towards his most important goals. According to Diener‘s [1984] so-called telic theories, a person‘s behavior can be best understood by studying his goals: what a person tries to do in life [Austin and Vancouver, 1996] and the extent to which he achieves these goals. The types of goals one has, the structure of these, the extent to which one is successful in attaining them, and the speed of progress towards them, can all potentially affect one‘s emotions and degree of satisfaction. According to this model, overall, a person reacts positively when he progresses towards his
Psychological Well-Being, Assessment Tools and Related Factors 81 goals, and negatively when he fails to attain them. The basic concept is that goals serve as an important standard of reference for the system of affects. Other authors such as Cantor and Sanderson [1999] also emphasize the importance of having goals, and explain that the commitment of trying to attain these gives a person a sense of personal agency and a structure and meaning to daily life. When different philosophical and scientific lines of thinking are compared, they are found to converge in their descriptions of a good and healthy life as one that encompasses processes of setting and then pursuing goals, which are used to try to develop a person‘s potential of experiencing significant connections with other people, managing demands and opportunities, practicing self-management and having a positive self-regard. Studies on life events/experiences have found these life experiences and individual interpretations of these experiences to be essential factors of psychological well-being [Heidrich and Ryff, 1993a; Heidrich and Ryff, 1993b; Ryff and Essex, 1992]. Collectively, these studies showed that life experiences and how these are interpreted can help to understand human variations in well-being [Ryff and Singer, 1996]. Happiness cannot be guaranteed by simply having goals or having the resources to attain them. These goals can act as standards or as aspirations and, according to this perspective, subjective well-being is a criterion or a rule that measures the proximity of a person to the goals he is striving to reach. Carver and Scheier [1998] suggested that the difference between a person‘s goals and current life situation affects the amount of positive or negative affect that a person feels. Hsee and Abelson [1991] found that the speed of progress towards these goals, rather than attainment of the goals itself, had a greater influence on the differences in affect. Moreover, Emmons [1986] found that having valued goals, regardless of past success, was associated with a greater satisfaction with life. Also, happy people would tend to choose goals for which they already had the appropriate resources [Diener and Fujita, 1995]. The achievement of these goals would, therefore, be the result, rather than the cause, of a high subjective well-being. 2.2. Multidimensional Model of Psychological Well-Being In relation to the concept of psychological well-being, Ryff [1989a] proposes a multidimensional model composed of 6 different dimensions: Self-acceptance, Positive relations with others, Autonomy, Environmental mastery, Purpose in life and Personal growth. These 6 dimensions of psychological well-being can be defined as follows: Self-acceptance: This is a key part of well-being and concerns the positive opinion a person has of himself. It does not refer to narcissistic self love or superficial self- esteem, but instead to a constructed self-regard that includes both positive and negative aspects [Ryff and Singer, 2003]. Other authors spoke about this previously, [Jung 1933; Von Franz, 1964] emphasizing that only a fully-individuated person can accept his own failures. The concept of ego integrity introduced by Erikson [1959], also refers to a person coming to terms with his own triumphs and failures in past life. This acceptance of self is constructed with an honest self-assessment; the person
82 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. is aware of his personal failings and limitations, but has the love to accept and embrace himself as he is. High scores in this factor are indicators of people with a positive attitude, who recognize and accept the multiple aspect of the self, including their good and bad qualities, and can look at the past with positive feelings [Ryff and Keyes, 1995]. Low scores in this factor appear in people who are largely unsatisfied with themselves; they are uncomfortable with what has happened in their past life, are concerned about some of their personal qualities and want to change [Ryff and Keyes, 1995]. Positive relationships with others: These include the fortitude, pleasures and human delights that come from close contact with others, from intimacy and love [Ryff and Singer, 2003]. Theories about the stages of adult development also emphasize close relationships with others (intimacy) and the guidance and care of others (generativity). The importance of having positive relationships with other people is repeatedly emphasized in definitions of psychological well-being [Ryff and Singer, 1996]. High scores appear in people who have warm, satisfactory and trusting relationships with others, who are concerned about the well-being of others and have the capacity to feel empathy, affect and intimacy and understand the give and take in human relationships [Ryff and Keyes, 1995]. Low scores indicate that a person has few close and trusting relationships with other people, finds it difficult to be warm, open and to feel concern for the well- being of others. They feel isolated and frustrated with social relationships. These people do not want an important commitment with others [Ryff and Keyes, 1995]. Autonomy: This refers to a person‘s ability to march to his own drum and to pursue personal convictions and beliefs, even if these go against accepted dogma or conventional wisdom. It also refers to the ability to be alone if necessary and to live autonomously [Ryff and Singer, 2003]. Also, in theories about self-actualization, the self-actualizers are described as functioning autonomously and as being resistant to enculturation. In studies into the concept of a fully functioning person, this person is someone with an internal frame of assessment, who is mainly uninterested in what others think of him, but will evaluate himself according to his own personal standards [Ryff and Singer, 1996]. High scores in this factor show people who are self-determined and independent, capable of resisting social pressure and of acting by regulating their behavior from an internal frame of assessment. These people self-evaluate according to personal standards [Ryff and Keyes, 1995]. Low scores indicate people who are concerned about the expectations of others, they depend on other peoples‘ judgments before making important decisions, and
Psychological Well-Being, Assessment Tools and Related Factors 83 their thoughts and actions are influenced by social pressures [Ryff and Keyes, 1995]. Environmental mastery: This is another essential factor in well-being and concerns the challenge of a person mastering the environment around him. This ability requires the skills of creating and sustaining environments that are beneficial to a person [Ryff and Singer, 2003]. The ability of an individual to choose or to create environments appropriate for his mental state is defined as a characteristic of mental health. According to life-span developmental theories, for a person to adequately master his environment, he needs the ability to manage and to control complex surroundings, emphasizing from this perspective the need to move forwards in the world and to change it creatively with physical and mental activities [Ryff and Singer, 1996]. High scores in this factor are obtained by people with a sense of mastery and competence of their surroundings, who can make effective use of opportunities that arise and can choose or create contexts appropriate for their needs and personal values [Ryff and Keyes, 1995]. Low scores indicate a difficulty in managing daily affairs, or changing or improving their environment and making the most of opportunities that arise, and a lack of control about the world around them [Ryff and Keyes, 1995]. Purpose in life: This is a person‘s ability to find a meaning and a direction in his own experiences, and to propose and set goals in his life [Ryff and Singer, 2003]. The definition of maturity also clearly emphasizes an understanding of the purpose of life and the presence of a sense of direction and intentionality. A positively functioning person has goals, intentions and a sense of direction, and all of this helps to give a meaning to life [Ryff and Singer, 1996]. High scores in this factor appear in people who have goals in life and a sense of direction; they feel that both the past and the present of their lives has a meaning, they hold beliefs that give their lives a purpose and have goals and reasons to live [Ryff and Keyes, 1995]. Low scores appear in people who feel their life has no meaning and have no goals or sense of direction; they can‘t see any point in their past experiences [Ryff and Keyes, 1995]. Personal growth: This factor concerns a person‘s ability to realize his own potential and talent and to develop new resources. It also frequently involves encounters with adversity that require one to dig deeply to find one‘s inner strength [Ryff and Singer, 2003]. It is associated with being open to new experiences, which is a key characteristic of the fully functioning person. Life-span theories also explicitly emphasize the importance of continuing to grow and to tackle new tasks or challenges in the different stages of one‘s life [Ryff and Singer, 1996].
84 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. High scores indicate people who want to continue to develop. They regard themselves as growing and expanding, are open to new experiences, feel they are fulfilling their potential, they can see improvements in the self and in their behavior over time, and change towards ways that improve their self-knowledge and effectiveness [Ryff and Keyes, 1995]. Low scores appear in people with a sense of personal stagnation, with no improvement or growth over a period of time, they feel bored and lack interest in life. They feel incapable of developing new attitudes or behaviors [Ryff and Keyes, 1995]. This model was studied in a representative sample of 1108 adults over 25 years old. In the confirmatory analysis of the factors, it was found that the results supported the multidimensional model proposed, and was the model which best fitted the six factors combined together to form a factor of higher order, called psychological well-being [Ryff and Keyes, 1995]. In this same study, it was found that the factors self-acceptance and environmental mastery were highly correlated, so it was proposed to combine these factors to obtain a model with 5 factors. In any case, the authors concluded that well-being is more than simply feeling happy or satisfied with life; nor is it merely an absence of negative emotions or experiences which define the well-lived. Instead it entails having a rich perception of these experiences and successfully managing the challenges and difficulties that may arise [Ryff and Singer, 2003]. 3. MEASURES OF PSYCHOLOGICAL WELL-BEING 3.1. Bradburn Affect Balance Scale One of the first scales that could be used to measure psychological well-being, which later served as a reference to validate subsequent scales is the BABS (Bradburn Affect Balance Scale) [Bradburn, 1969]. This is a ten-item scale divided into two subscales, one that evaluates positive affect and the other that evaluates negative affect. Each of these subscales has 5 items. These items refer to pleasant or unpleasant experiences over the past few weeks which are intentionally treated with a degree of ambiguity [Bartlett and Coles, 1988]. The score is obtained by adding one point for every yes answer and summarizing separately the responses to the positive and negative subscales, respectively. After this, the difference between the scores is calculated and a constant is added to eliminate possible negative results. The test-retest reliability was evaluated by Bradburn [1969], and in a sample of 200 people with an interval of 3 days the reliability calculated for positive affect, negative affect and the affect balance were 0.83, 0.81 and 0.76, respectively.
Psychological Well-Being, Assessment Tools and Related Factors 85 3.2. The Short Form 36 The Short Form 36 (SF-36) was developed to measure the services provided by different health departments in the United States [Ware, Snow, Kosinski et al. 1993]. It is a self-administered scale comprised of 8 different subscales that contain Likert-type items. The 8 different concepts are each evaluated by their own scale: Physical functioning. Role limitations because of physical health problems. Bodily pain. Social functioning. General mental health (psychological distress and psychological well-being). Role limitations because of emotional problems. Vitality (energy/fatigue). General health perceptions. Both the General mental health and the Vitality subscales have psychological implications. The authors of the SF-36 scale understand mental health (measured by the General mental health scale) as part of a construct of psychological well-being with a positive pole and another negative pole [Bartlett and Coles, 1998]. This scale has received some criticism, such as that from Hunt and McKenna [1993] who question the design of the scale, both in the selection of its items and also its objective. For example, Hunt asks how many British people could answer the question ―Does your health limit you in your ability to do vigorous activities, such as sports, running, lifting heavy objects?” when most of them don‘t even do this kind of activity. Hunt uses another example with the question “Does your health limit you in your ability to walk a mile?”. He considers this question is complicated with the factor of necessity. He explains that some people won‘t walk a mile even if they are in good health, while others, from necessity, because they live in the outskirts or for other reasons, will walk the mile in spite of having poor health. McHorney, Ware and Razcek [1993] provided evidence to support the validity of SF-36, showing that the mental health scale can discriminate between groups by using the mean scores. A group with minor medical conditions has a mean score of 83, a group with a serious medical condition would have a mean score of 78 and a group with a serious medical condition with psychiatric comorbidity would obtain a mean score of around 53. 3.3. Satisfaction with Life Scale (Swls) This is a self-administered scale with 5 items relating to level of satisfaction with life. The possible responses are 1 to 7, where 1 indicates that the person strongly disagrees with the statement and 7 that they strongly agree [Diener, Emmons, Sem et al. 1985]. The score is the total of the responses to these 5 items and can be used to classify the person into one of the following categories: 30-35: extremely satisfied, well above average.
86 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. 25-29: very satisfied, above average. 20-24: quite satisfied, average for adult United States citizens. 15-19: slightly dissatisfied, a little less than average. 10-14: dissatisfied, clearly below the average. 5-9: extremely dissatisfied, far below the average. The test-retest correlation was carried out with 2 months difference and gave a result of 0.82. The alpha coefficient of the scale is 0.87 [Diener, Emmons, Sem et al. 1985]. This is a scale to measure subjective well-being and in its original validation the authors calculate the correlation existing between SWLS and other scales to measure subjective well- being, including the Bradburn scale (BABS) described previously. The coefficient of correlation for Bradburn‘s positive affect subscale is 0.5 and that for the negative affect subscale is -0.37. 3.4. Psychological General Well-Being Index Short (PGWB-S) The PGWBI scale is a 22-item scale that evaluates self-perceived psychological well- being, each item is evaluated on a 6 point scale. The scale assesses 6 dimensions of quality of life relating to health: anxiety, depression, positive well-being, self-control, general health and vitality [Grossi, Groth, Mosconi et al. 2006]. There is a considerable amount of information about the original scale since it was used widely in studies in the United States and worldwide, and has been translated and validated in several languages, for example to Spanish by Badia, Gutierrez, Wiklund et al. [1996]. The short version of the PGWBI aims to reduce the number of items but to maintain the validity and reliability of the scale. In its final version, the PGWB-S has only 6 items that reflect 5 of the 6 items assessed in the original version (except for general health) and reproduces 90% of the variation in the result of the PGWBI. The high Cronbach alpha value (between 0.8 and 0.92) indicates a good reliability when compared with the original scale. 3.5. Psychological aWell-Being Scales (PGWB) One of the most widely used scales to measure psychological well-being is Ryff‘s scale [1989a]. This scale breaks down the construct into 6 different dimensions [Ryff, 1989b] that are analyzed separately, each with their own subscale. The dimensions analyzed are: Self-acceptance, Positive relations with others, Autonomy, Environmental mastery, Purpose in life and Personal growth. Each of these subscales has 20 likert-type items in which the patient self-assesses himself by choosing from the six possible responses, from strongly agree to strongly disagree. This test has a high test-retest reliability and a high internal consistency. Moreover, its convergent and discriminate validity with other measures have also been studied.
Psychological Well-Being, Assessment Tools and Related Factors 87 The test-retest coefficients per subscale (with a retest of 6 weeks) were self-acceptance 0.85, relations with others 0.83, autonomy 0.88, environmental mastery 0.81, purpose in life 0.82 and personal growth 0.81. The alpha coefficients for the subscales were: self-acceptance 0.93, relations with others 0.91, autonomy 0.86, environmental mastery 0.90, purpose in life 0.90 and personal growth 0.87. Ryff‘s article gives an in-depth explanation of convergent validity [1989a]. Here, we indicate the convergent validity values for the different dimensions with Bradburn‘s Affect Balance Scale: self-acceptance 0.55, relations with others 0.30, autonomy 0.36, environmental mastery 0.62, purpose in life 0.42 and personal growth 0.25. The fact that this covers 6 scales (120 items), combined with its good psychometric qualities has given rise to the development of shorter versions, which still maintain good fits and consistency. These versions include the one by van Dierendonck [2004] which, with only 39 items, obtains a goodness of fit indicator (GFI) of 0.88 and Cronbach‘s alpha between 0.84 and 0.70 (depending on the subscale). 4. PSYCHOLOGICAL WELL-BEING RELATED TO SOCIODEMOGRAPHIC FACTORS Psychological well-being is influenced by the nature of one‘s subjective experiences and is related to different aspects of physical, mental and social functioning. We can refer to well- being as the result of the balance between a person‘s expectations and achievements in the different spheres of action of the human being, such as work, the family, health, the material conditions of life, and interpersonal and affective relationships [Garcia-Viniegras and Gonzalez Benitez, 2000]. One of the components of well-being is personal satisfaction with life, which is influenced by an individual‘s relationship with their social environment, together with current and historical elements. It is recommendable to study the context in which a person‘s experiences develop to determine the influence of external circumstances that could affect this well-being (economic development, the existence of friendships and the availability of adequate resources to be able to achieve the goals set) [Diener, Suh, Lucas et al., 1999]. One of the ways to get closer to understanding the concept of psychological well-being is to study the factors associated with it, bearing in mind that these will have some cultural variation. Several authors [Diener and Suh, 2000] suggest that the emotions are good predictors of well-being in so-called individualistic cultures, while in collectivist cultures well-being is more closely associated with behaviors of respect and compliance with the social rules in force. Therefore, taking into consideration the broader concept of culture, well- being should be studied from a sociocultural level (individual level of income, life expectancy, unemployment) and a personal level (beliefs, opinions and attitudes). According to Triandis and Harry [2000], culture is to society what memory is to individuals, and this culture influences each of the six dimensions of psychological well-being. Sociodemographic differences not only produce different levels of well-being and health [Organización Panamericana de la Salud, 1993a], but also different ways of finding psychological well-
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
