“Smile, Though Your Heart is Aching”: is fake smiling unhealthy?

by Carolyn Thomas  @HeartSisters

The classic song called Smile was originally written as an instrumental by the legendary Charlie Chaplin for his 1936 movie Modern Times; lyrics were later added, and the song was recorded by Nat King Cole in 1954. Sing along with me now, my heart sisters, as we revisit these famous lines:

“Smile, though your heart is aching
Smile, even though it’s breaking
When there are clouds in the sky, you’ll get by
If you smile through your fear and sorrow
Smile and there’ll be tomorrow
You’ll see the sun come shining through
If you’ll just . . . smile.”

It turns out that Nat’s advice about faking smiles, however, may be exactly the wrong thing to do for your own mental health.

This warning is particularly important for those living with a chronic diagnosis like heart disease, who often report feeling obliged to paste on a happy face around other people – even when feeling alarmed about their symptoms. 

According to a study published in the Journal of Personality and Social Psychology:(1)

”      Positive emotional behavior that does not accurately signal a person’s experience – such as a smile that is not felt – may impede social connectedness and, in turn, psychological functioning.”

The study authors suggest that smiling when you don’t feel like smiling is a form of dissociation that can actually predict poor psychological functioning. Dissociation is defined in Abugel & Simeon’s book Feeling Unreal as:

“…the human psyche’s way of coping with intolerable circumstances – a means of escape to assure survival, no matter what the price.”

A Michigan State University study on this phenomenon tracked bus drivers, whose jobs require them to be courteous and endure frequent interactions with many other people all day long, day after day.(2)    Researchers examined what happened when the drivers engaged in fake smiling, known as “surface acting” and its opposite, “deep acting” where they generated authentic smiles through focusing on positive thoughts.

The study found that on days when the smiles were forced, the drivers’ moods deteriorated and they tended to withdraw from work, emotionally exhausted. Trying to suppress negative thoughts, the researchers observed, may have made those thoughts even more persistent.

According to Dr. Brent Scott, the study’s lead author:

“     Women were harmed more by surface acting, meaning their mood worsened even more than the men and they withdrew more from work. But they were helped more by deep acting, meaning their mood improved more and they withdrew less.”

Deep acting – affecting one’s mood through conscious focus on positive things – is also demonstrated in the work of social psychologist Dr. Martin Seligman, author of Learned Optimism. This focus can indeed help – especially for those who tend to ruminate (“…things are bad now, and they’re only going to get worse!”)

While Dr. Scott’s study didn’t explore the reasons behind these differences, he said that previous research suggests women are both expected to and do show greater emotional intensity and emotional expressiveness than men.

So faking a smile while still feeling negative emotion conflicts with this cultural norm, and can cause even more harmful feelings in women compared to their male counterparts.

Similarly, I wrote here about the interesting concept called emotional labour.

Originally identified by researchers in 1983, emotional labour is described as the suppression of feelings to provide a welcoming outward appearance.  (Sound familiar, heart patients?)

This is widely experienced by patients who tell me they often feel compelled to pretend to be “fine, just fine” so as not to worry their families or friends – even when they are quite clearly not feeling fine.

When patients exhibit emotional labour, explains Nicholas Lockwood (who has studied how heart patients’ use of humour can help – or hurt – their recovery), it means that their outward expression of emotion is not genuinely felt.

For example, although this outward expression serves to make other people around us feel comfortable, when this expression isn’t a genuine representation of how we really feel inside, it can actually hurt us.

And this concept is not limited only to patients. Previous research has found that cardiac rehabilitation nurses can exhibit emotional labour when dealing with their heart patients (Barrett et al, 2005). Nurses report, for example, that they outwardly express care and compassion even while they are internally focused only on the more instrumental tasks at hand.

This emotional dissonance evokes psychological stress.

And when patients exhibit this emotional labour on an ongoing basis  (meaning that they feel one way, but act another so as to hide how they’re feeling around others), this can eventually result in stress, frustration, and even impaired physical health.

Heart patients may feel the need to put on that happy face even when they are in fact experiencing severe cardiac symptoms. Nicholas explains:

“    This masking of genuine emotions not only increases psychological stress, but it can decrease relationship satisfaction. Whether a person uses humour to entertain their companion, start a conversation, or even enhance their likability, heart patients can be attempting to express a positive, pro-social emotion which is not genuinely felt.”


(1)  Source: “Don’t Hide Your Happiness! Positive Emotion Dissociation, Social Connectedness, and Psychological Functioning”. Journal of Personality and Social Psychology April 2011; 100(4): 738–748. doi:  10.1037/a0022410
(2) Source: Academy of Management Journal. February 2011; Brent Scott, Christopher Barnes.


Q: Do you tend to paste on a happy face – no matter what?


NOTE FROM CAROLYN:   I wrote much more about My book, A Woman’s Guide to Living With Heart Disease, was published by Johns Hopkins University Press. You can find this book:

  • at your nearest library branch
  • at all bookstores (please support your local independent bookshops while they still exist)
  • order it online (paperback, hardcover or e-book) at Amazon
  • order it directly from Johns Hopkins University Press (and use their code HTWN to save 30% off the list price when you order)


See also:

A heart patient’s positive attitude: a “crazy, crazy idea”?

How humour can help – or hurt – your heart disease recovery

The heart patient’s chronic lament: “Excuse me. I’m sorry. I don’t mean to be a bother”

Do you think too much? How ruminating hurts your heart

4 thoughts on ““Smile, Though Your Heart is Aching”: is fake smiling unhealthy?

  1. Pingback: 02XL
  2. I too thought it was just me feeling this way.THANK YOU THANK YOU. The emotional labor concept is interesting and makes sense. It helps to explain why just having visitors when you’re ill is so exhausting, keeping that ‘happy face’ in place is so tiring. Note to self – from now on, when visiting ANY sick person or somebody recuperating from any procedure, keep visits BRIEF. Don’t take your coat off or even sit down. Deliver the flowers or card or casserole and then get the hell out so the patient can rest.


  3. Hello Caroline. My girlfriend in cardiac rehab just sent me this article, it’s exactly how I’ve been feeling since double bypass surgery. My family was so worried about me during my heart attack & surgery experience, I had many complications afterwards & the doctors actually thought at 1 point that I wouldn’t make it.

    To think that I put my family through this nightmare was very upsetting to me once I got home & started recuperating & I became determined to act as if I’m fine now no matter how I’m feeling really. When they walk in the door, I paste on my HAPPY FACE smile, everything is FINE JUST FINE no matter what. It’s been EXHAUSTING & until I read this article I thought I was the only one feeling this way. THANK YOU for this.


    1. Thanks for sharing your perspective here. I’m glad you’re in cardiac rehab now – make sure you stick it out until the very last program session (most women drop out!) Maybe this topic would be a good one to share with all your cardiac rehab participants – you’re NOT the only person feeling like this!


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