LOL

The physician must have at his command a certain ready wit, as dourness is repulsive both to the healthy and the sick.
—Hippocrates

Medicine is a serious business; when clinical conversations are scrutinized doctors can be seen to laugh less often than patients. But they do laugh—linguistic analysis suggests that physician laughter performs important interpersonal and therapeutic work. When patients laugh, it’s to make a show of alignment or affiliation with the doctor, signal a problem, or demonstrate superiority to their complaint. Anatole Broyard, in a 1990 essay written while he was being treated for prostate cancer (“Good Books about Being Sick”), wrote of one cheerful doctor:

Bernie Siegel, a doctor who says “call me Bernie,” is a sort of Donald Trump of critical illness. He sounds like a proprietor or landlord of mortality…. Yet, for better or worse, he introduces an element of camaraderie into the medical process.

For Broyard, camaraderie can be overdone: Bernie reminds him of a doctor he once knew who wore such outlandish-looking suits that “I couldn’t help wondering about his medical judgment.” I work in family and emergency medicine; this year I conducted an anonymous survey asking all of my primary care patients, over the course of a week, what they thought of my medical care. One of the responses read, “Dr. Francis can be good for a laugh”—I’m still puzzling over what that patient meant.

In Studies of Laughter in Interaction the linguists Phillip Glenn and Elizabeth Holt have brought together twelve scholarly articles, each illuminating an aspect of the work laughter accomplishes across a range of human interactions. Two of its chapters are related to laughter in the clinical consultation. Others explore a comprehensive range of situations: between teachers and students in class, joking between friends, by job interviewees, between a mother and her autistic son, high-stakes political interviews, and so on.

Laughter is pervasive in human life, across cultures. There is more variety in the laughs generated by one individual in different situations than there is between separate individuals in similar situations. It has

physical, psychological, spiritual, and relational benefits. It is the cost-free medicine that can release endorphins helping us feel good, exercise our muscles and breathing like yoga, help us lighten moods and cope with problems more readily, and strengthen social bonds.

This book could be read as a manual for those who find complex nonverbal communication bewildering, illuminating the startling complexity of everyday social interactions.

The distinction between laughing with and being laughed at is an ancient one: of around thirty references in the Bible to laughter, most involve derision or scorn and only a handful refer to laughter that is in any way connected to joy (do a digital search for “laugh” in the Bible, and you’ll find it far more often as part of “slaughter”). Aristotle thought there was virtue in being quick to laugh: his eutrapelia is sometimes translated as “wittiness,” but a literal translation would be “able to turn well,” the skill of twisting with agility through the shifting demands of dynamic social interaction. In the seventeenth century, Thomas Hobbes described laughter as a “passion” related solely to scorn, “nothing else but sudden glory arising from a sudden conception of some eminency in ourselves, by comparison with the infirmity of others.”

In the later eighteenth and into the nineteenth century, Hobbes’s theory of superiority was overtaken by one in which laughter was believed to discharge pent-up energies—an idea nourished by old humoral theories of the body (we still speak of someone as having “good humor”). If nerves and arteries were simply hydraulic channels for fluids, then those channels might come under pressure that would need to be “discharged.” Freud was among the famous proponents of this idea, and to explain it he repeated a joke by Mark Twain. Twain’s brother (the joke goes) was working on a railroad when dynamite blew too early—he was thrown high in the air and crash-landed some way off. When the unfortunate man struggled back to the railroad, his pay was docked, as he’d been “absent from his place of employment.” According to Freud the energy of pity that we’ve built up through the story is “discharged” into laughter by the ludicrous and unfair treatment of Twain’s brother.

Charles Darwin noted in The Expression of Emotions in Man and Animals that most theories of laughter ignore the fact that children laugh with enthusiasm long before they have the intellectual sophistication to appreciate hierarchies of meaning, or even pity. He considered laughter to be a powerful social signal of high spirits, visible in different forms across the animal kingdom. “Laughter seems primarily to be the expression of mere joy or happiness,” he wrote. “We clearly see this in children at play, who are almost incessantly laughing.” Darwin followed up his observation with a quotation from Homer, who described the laughter of the gods as “the exuberance of their celestial joy after their daily banquet.”

In 1984 the linguist Gail Jefferson emphasized the distinction between laughter that floods out at the appraisal of something as funny or joyful, and laughter put in between words in order to accomplish interactional work.^* Glenn and Holt think the distinction is less clear-cut than Jefferson suggested: they point out that the laughter we put into conversation can be as authentic as that which floods out, and is often a response to humorous cues (known to linguists as “referents” and “laughables”). Laughter in conversation signals something—often something awkward or troublesome—but at the same time it seeks in subtle or covert ways to resolve that problem.

Hobbes may have been onto something: laughter is undoubtedly a signifier of hierarchies. Glenn and Holt note that the phenomenon of the unsmiling doctor is widespread among other professional groups as well, in part because solemnity is considered part of the professional manner, but also because of the human tendency to perceive hierarchies in every interaction and modulate behavior accordingly. People who imagine themselves to be of lower status than the professionals with whom they are interacting will tend to laugh more, as if seeking alignment and affiliation with someone higher up a chain of prestige.

One of the main themes of the book, the subject of one of its four parts but relevant to them all, is how laughter mediates and expresses temporary identities. For the purposes of Glenn and Holt, personal identities like gender, ethnicity, and nationality are of less interest than briefly assumed, more pliable identities such as “complaint-maker,” “troubles-teller,” or even “doctor” and “patient.” The way we use laughter depends upon which of those identities we occupy at any particular moment. In the case of “complaint-maker” they observe that complaining is never one-sided, it’s always a negotiation, and that carefully chosen laughter may have a crucial part in advancing a complaint toward a desired outcome. Many of the chapters explore the ways in which laughter assists the expression of such temporary identities.

To examine the function of laughter in the clinical consultation, Glenn and Holt have included video analyses of a couple of medical situations. One looks at the laughter and smiles employed between a patient, a doctor, and a nurse to navigate the interpersonal tensions that arise during a visit to a gynecology clinic in Italy. The authors, Marilena Fatigante and Franca Orletti of Rome, observe that in medical consultations patients laugh at delicate, difficult moments in the clinical interaction. Unlike laughter between friends, a laugh from a patient doesn’t represent an invitation to shared laughter with the doctor. This may be one of the reasons doctors laugh infrequently: when they hear laughter from a patient it is almost invariably flagging a problem. In Fatigante and Orletti’s chosen consultation the patient smiles as she indicates, early in the consultation, that she appears to have been incorrectly coded on her record as having had two abortions. Her partner had noticed, and had become angry with her as if she was keeping something from him.

“Questioning the expertise and authority of the doctor,” Fatigante and Orletti write, “is a delicate task for the patients, who, on their part, can claim accuracy of knowledge when the objects of medical description are part of their own experience.” Even to articulate the problem threatens “disaffiliation” with the doctor and the nurse, and the patient’s smiles and laughter seek to sustain a positive connection, while issuing criticism. The coding of her record “points to a possible medical misdoing, [but] her facial displays convey an impression of a nonhostile stance.” In fact, both she and her partner had misunderstood the record, and the figure “2” related to the number of children she has had, rather than the number of abortions.

Over the subsequent couple of minutes of the consultation, which require four pages of textual analysis, Fatigante and Orletti break down the myriad subtleties of the interaction between doctor, patient, and nurse, all while the three women are engaged in the practical requirements of the gynecological examination. The doctor

instructs her to confront her partner and attribute to him responsibility for the misunderstanding. The patient joins in laughing at the end of the doctor’s turn, once the problematic quality of the narrative has been converted into a critique toward the third absent party, who is cast (and somehow “scolded”) as someone who did not understand.

At one point the doctor and nurse laugh together, then hurriedly seek to align themselves with the patient, so that she in no way feels that she is being laughed “at.”

Body language figures in the ways we mitigate and emphasize the meaning of our words—Fatigante and Orletti focus on how the doctor uses her “postural configuration” to demonstrate simultaneous engagement with her audience at different levels of interaction. Her use of “body torque” signals her awareness that both patient and nurse have claims on her attention, and simultaneously conveys the sequence in which she will respond. Throughout the gynecological visit laughter marked trouble, but could be both affiliative (between the three women present) or disaffiliative (laughing at the absent partner for his exaggerated reaction to a medical coding misunderstanding). Though patients laugh more often than doctors, Fatigante and Orletti also showed how the patient muted her laughter, for fear that it implied an unwarranted level of intimacy with the doctor and nurse.

Anna Claudia Ticca of the University of Lyon analyzes a different sort of medical interaction. Across a series of field trips to Mexico she video-recorded ninety medical consultations, exploring the laughs uttered by indigenous Mexican villagers who speak only Yucatec Maya when subjected to criticism by a Spanish-speaking doctor of their parenting skills. The consultations are mediated through an interpreter. The villagers believe that ill children should not be allowed to get wet, and the doctor expresses disgust that the child is unwashed: “Why is your baby so dirty?” she demands. “Don’t you bathe him?” The mother laughs, shakes her head, and keeps on laughing through her response: “He has a cough.” Later in the conversation the doctor threatens the mother: “Your child is badly cared-for—if she continues [to be dirty] I won’t see her again.” Again the mother simply laughs, adding to the doctor’s bewilderment. She questions the skill of the interpreter: “It makes you laugh or you didn’t understand me.”

Ticca points out that laughing under such a barrage of criticism is an effective interactional strategy—the mother’s laughter “mark[s] an interactional problem, displaying resistance, while simultaneously continuing the interaction.” She wants the doctor to get on with assessing her sick baby, but in terms of her status relative to the doctor, the only way she can resist the questions about hygiene is to mark the trouble and wait. Laughter is often used in this way, Ticca observes, “when doctors call on patients to change or account for their everyday practices, which include nursing practices, child care, and eating and cooking habits.” I can’t think of an example when I’ve ever harangued a patient the way Ticca’s doctor does. But at least once a day in clinic, when I raise the connection between my patients’ poor health and their lifestyle choices (bad diet, lack of exercise, smoking, drug-taking), the awkwardness of the moment will be broken by a laugh.

Ticca quotes Christian Heath’s work on embarrassment in human interaction, in particular his suggestion that laughter—just as much as shifts in gaze, gesture, and body movement—can be a response to shame. The laughter of the patients Ticca describes is analogous in some ways to the “nervous laughter” by job applicants during interviews. Phillip Glenn’s “Interviewees Volunteered Laughter in Employment Interviews” reveals the intricacies of nervous laughter and makes a plea for it not to be dismissed as something trivial, but recognized as a potentially sophisticated and sensitive response to stress. Interviews demand that each interviewee be immodest about their achievements but at the same time express appropriate humility. In an intensely competitive situation, they nonetheless have to strive to convey ease and confidence.

Glenn brings in Freud’s interpretation of laughter as a cathartic response to the emotional tension this interaction produces. But laughing too much is high-risk: he also refers to Stanley Milgram’s infamous Yale studies in obedience, in which subjects were instructed by authority figures to inflict pain on others. Milgram’s subjects often laughed inappropriately as they heard the screams of their victims, and according to Glenn, job applicants who are less skillful at gauging when to laugh (whose laughter is deemed “inappropriate” by interviewers) are less likely to be successful. When adept interviewees say something boastful or self-deprecating, they laugh at the end of their turn to show they’re aware of how conceited or meek they might sound. When they feel they’ve oversold their abilities, they laugh to roll their claims back:

Thus the term “nervous laughter” may be to some extent a layperson’s gloss of exactly the kinds of laughs described [in an interview setting]: laughs that work on one’s own actions in delicate environments and that are unlikely to be reciprocated.

Politicians in broadcast interviews are in an analogous situation to job interviewees, but the risks and power dynamics are very much greater, and laughter performs a different function. In 2009 Senator Charles Schumer was interviewed on MSNBC about the electoral prospects of Sarah Palin. The interviewer, David Gregory, asked, “Is Sarah Palin the future of the Republican Party?” Schumer laughed, and continued laughing all the way through his response, eventually managing to say, “I guess I shouldn’t judge and let them fight among themselves.” In lexical terms his response was evasive, but his laugh was eloquent: it delegitimized the question, and enabled him to take the moral high ground, implying that he chose to disqualify himself from comment. His laughter alone indicated that his response to the question, if he had given one, would have been negative.

This was a television interview in which a politician was questioned about a third, absent party; when the politician present is the subject of critical questioning, laughter plays a different part. When Rudolph Giuliani was interviewed on Meet the Press in December 2007 he was asked about his law firm’s connections with Venezuela and North Korea. Speech is conventionally taken in turns—speaking over an interviewer risks appearing rude—but there’s no such restriction on laughter. Giuliani began laughing even as Tim Russert first mentioned Venezuela, and laughed throughout the subsequent accusations, as well as all the way through his own response (“Tim, that’s a stretch”). He laughed so much that the clip on YouTube has the mocking title “Rudy Giggliani.”

Tanya Romaniuk, an assistant professor in the Department of Communication at Portland State University in Oregon, wrote the chapter on political interviews. She shows why politicians laugh on TV: to seek alignment with interviewers and with viewers, make a show of good humor, and suggest that any criticisms being voiced are laughable. But she also shows how laughter in a political interview can be a risky strategy, seemingly less tolerated among women than among men. In 2007 Joan Vennochi of The Boston Globe wrote of Hillary Clinton: “HENS CACKLE. So do witches. And, so does the front-runner in the Democratic presidential contest.”

In a 1989 article on the social significance of laughter, Viveka Adelswärd wrote, “We use laughter to signal that we are aware of a tension between what we say, how this could be interpreted by others and what we mean.” People with autistic spectrum disorders are often thought to have diminished capacity for recognizing conflicting levels of interpretation, as a result of what Timothy Auburn and Christanne Pollock call a “deficit in social awareness.” In their chapter “Laughter and Competence,” Auburn and Pollock analyze an interaction between Alfie, a nonverbal boy with autism, and his mother. They quote research led by the British psychologist Vasudeva Reddy that children with autism laugh just as often, and in the same way, as children with Down syndrome, though children with autism are less likely to heed the laughter of others.

Auburn and Pollock describe Alfie teasing his mother, inviting laughter and projecting affiliation as he attempts to persuade her to give him an extra cookie. Citing earlier research published by Reddy in 1991, Auburn and Pollock assert that this teasing involves “the rapid alternation of metasignals, which create then remove doubt”—something Alfie accomplishes with ease. Laughter is a cultural modifier for those with autism as much as it is for anyone “neurotypical”: “Alfie displays a clear orientation to sharing and gaining affiliation in his attempts to initiate laughable moments,” they conclude, “countering a view that laughter in those with autism is simply the outward manifestation of an inner state.”

The place of laughter in complex social interaction is explored through a handful of other situations: how laughter signals readiness to take a conversational turn (since laughter, unlike speech, is something everyone in a group can do together at once); how issuing a “last laugh” can modulate the effect as well as the meaning of any conversational contribution; how laughter among a group of English as a Second Language students can act as a challenge and a resource for a tutor; how laughter can give nuance to the delicate negotiation immigrants perform when questioned about their national identity.

The stated aim of Studies of Laughter in Interaction is to present a comprehensive overview of how laughter operates in social interactions, but it’s difficult to see how such a study could ever be comprehensive. The book repeatedly makes the point that human social interactions are immeasurably complex, that laughter is as plural, as richly variegated as human interaction itself. It goes a long way toward explaining how we make use of many different kinds of laughs: invitations to share a laugh, invited laughs, volunteered laughs, second laughs; equivocal laughs, “free-standing” or “embedded”; “hearty” and “prolonged,” or “small, scarcely-noticed particles.” One of the book’s triumphs is to show just how ambiguous laughter can be—a vocal signal we cast out into a delicate interaction, which could potentially be perceived as either friendly and encouraging (“affiliative”) or hostile and disapproving (“non-affiliative”) in order to more clearly divine the nature of a particular exchange and plan an appropriate response. Though laughter has traditionally been thought of as a response to humor, Glenn and Holt make the point that its work is often anticipatory—it modulates the direction of speech yet to come.

When I was judged by a patient as “good for a laugh,” I became anxious that perhaps I wasn’t taking my job seriously enough. But if I’m lucky, that patient was referring to eutrapelia, the virtue of being “able to turn well” so valued by Aristotle and, it appears, by Glenn and Holt. Laughter is endlessly versatile, they write, “moving between polarities of serious and not serious, hostile and affiliative, self- and other-referential.” As an activity it’s central to the negotiations that occur moment to moment whenever human beings communicate with other human beings:

Broadly speaking, laughter shows up time and time again in two kinds of environments: celebrations and trouble. In moments of celebration, it allows people to laugh together, appreciate, affiliate, and even claim a kind of intimacy. In moments of trouble, it provides a resource for aligning, modifying actions, and mitigating meanings.

Laughter is the lubricant that makes language slippery, brings malleability to meaning, expresses inner emotion, and at the same time acts as a device that can be deployed strategically. We are only beginning to understand how vocalized agitation of breathing, so often thought of as solely reactive to humor, is in truth a universal language, capable of fine interactional work.