The “emotional labour” of living with heart disease

by Carolyn Thomas  ♥  @HeartSisters

♥ “My hubby is stuck with me for another 15 years as long as I keep following doctor’s orders.”

♥ “I told my family that I now had a pig valve in my heart – but I was disappointed when the doctor told me I couldn’t keep the bacon.”

♥ “I am determined to outlive my husband – because I want to clean out his garage!”

Heart patients often use humour* like this to distract themselves from the high levels of stress and fear often associated with a life-altering diagnosis like heart disease – such as distressing symptoms, upcoming surgery, diagnostic tests, or even the ongoing awareness of a significantly increased risk of future cardiac events.  So reports Nicholas Lockwood, whose research focused on how heart patients use humour to help them cope with their condition – but ended up showing some surprising results. 

Nicholas is not just your average garden-variety researcher. Here’s how he explained his personal experience to me recently:

”  My mother’s own heart attack a few years ago was the primary attraction to this study’s focus. Aside from the prescribed medical treatments, my mother’s use of humour about her condition has comforted family members, fellow patients, her cardiologist, and most importantly, herself.

Nicholas was intrigued when he discovered that this phenomenon was not unique to his mother.  After her cardiac event, his observations of other heart patients he met at the Montana chapter of the organization called Mended Hearts led him to choose humour in enhancing recovery for his University of Montana graduate thesis.

He knew that research already suggests humour has a wide range of known health benefits.

For example, humour may increase the pain tolerance of a patient (physiological), which then in turn can influence the attitude of the patient (psychological).

But other-oriented humour (used to distance the patient from companions – e.g. “After I die, you’ll be glad to have the remote control all to yourself!”) seem to negatively predict health outcomes.

The first kind – that self-oriented antidotal function of self-oriented humour – allows the patient to escape the role of the patient (Scholl & Ragan, 2003), so that person – if even for a short while – no longer identifies as a victim of a disease, but instead identifies as a “normal” healthy individual.  It functions as a coping mechanism, associated with reducing stress, tension, and instilling relief to an overwhelming situation.   (See also: “To Just Be a Person, and Not a Patient Anymore”)

But when humour disturbs the relationship between the patient and their companions, the patient can suffer a psychological and social health decline.

This response is known as emotional labour – and in this thesis, it’s particularly compelling.

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

This is widely experienced by heart patients who tell me they often feel compelled to put on their best ‘game face’ so as not to worry their families or friends.  (See also: “Smile, Though Your Heart is Aching”: Is Fake Smiling Unhealthy?)

When patients exhibit this emotional labour, explains Nicholas, the outward expression of emotion is not always genuinely felt – even though this outward expression serves to make other people feel more comfortable.  And when they feel one way, but act another, this can result in more stress, frustration, and even impaired health.

And it’s not limited only to patients.

For example, previous research has found that cardiac rehabilitation nurses can exhibit emotional labour when speaking to their heart patients (Barrett et al, 2005). Nurses note that they outwardly express care and compassion even as they are internally focused on the more instrumental tasks at hand. This emotional dissonance can evoke psychological stress.

Heart patients may feel the need to put on a happy face when in fact they actually feel psychologically distressed about their cardiac condition. 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.”

Hiding this psychological distress can have far-reaching negative outcomes, he adds.  For example, heart patients who perceive poor health can experience grief and depression much like those suffering from bereavement. In fact, grieving widows and heart patients have been found to share similar negative psychological impacts including fear, anxiety, loneliness, and anger (The American Heart Association, 2010).  See also: The “loss of self” in chronic illness is what really hurts

“The most surprising finding is that not all humour is created equal.

“The effects of negative humour appear to be more potent than positive humour. As such, it could take five positive humorous messages to counteract the health effects of one negative humour message.

“So humour can possibly harm you more than help you if not used in a positive manner.”

Nicholas also found that the introduction of taboo topics through humour might be one possible explanation as to why pro-social humour in heart patients can negatively predict relationship satisfaction.

Other researchers had previously found that topics become taboo when partners perceive they can harm the relationship, and are typically avoided because they are seen as risky, inefficient, or futile for the relationship.

But a cardiovascular event is a compelling reason to introduce conversations with loved ones about taboo topics such as fears, death, and the state of the relationship itself.  Humour can be seen as inappropriate when it involves discussion about medical diagnoses, treatment procedures, and illness outcomes.

So humour can function as a social lubricant to introduce taboo topics, which Nicholas explains are, by their very presence, negative weights upon relationship satisfaction. Humour can serve to introduce difficult topics, but re-introducing topics that have become more serious may not be related to positive relationship outcomes.

Heart patients clearly use humour to fulfill multiple functions, he adds – not all of which are necessarily positive.

For instance, a patient joking about funeral arrangements, the medical procedure, or his/her companion’s future lifestyle following the patient’s death, negatively predicted relationship satisfaction – which also negatively predicted health.

While recovering following a serious cardiac diagnosis, for example, patients can use humour:

• to cope with the medical event
• to socialize with their companion
• to distance themselves from their companion

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* Dear American readers: the spelling of humour reflects how we spell your word “humor” here in Canada – and in all other Commonwealth countries!

Q:  How has using humour helped or hurt your experience living with chronic illness?

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NOTE FROM CAROLYN:  I wrote more about how women use humour to help cope with a serious diagnosis in my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press).  You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (and if you use their code HTWN , you can save 30% off the list price).

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See also:

It’s Hard to Feel Like a Victim When You’re Laughing 

“Smile, Though Your Heart is Aching”: Is Fake Smiling Unhealthy?

I Don’t Want to Talk About It…

Do You Want the Truth, or Do You Want “Fine, thank you”?

Women Laugh Their Way to Better Heart Health

When We Don’t Look as Sick as we Feel

Find out more about the organizations Mended Hearts and WomenHeart: The National Coalition for Women With Heart Disease.

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