Program Coordinator and Associate professor of Human Services, Dr. David Greene, shares his personal experience as person with diabetes and the role humor can play as a potential healing element.

My name is David Green and I'm the program coordinator and associate professor of human services here at UNC.

I have type one diabetes and I have for 52 years, 10 months, two weeks, and three days. And yes, I keep track. Mostly for bragging rights, but it's been an interest of mine personally long before it became an interest of mine professionally and in research. So it led me in as I went to college, undergraduate and graduate school, I focused a lot of my research on the field of diabetes. Along the way, it occurred to me when I was doing counseling with people with diabetes that, just anecdotally, I just happened to observe that as they resolved the psychological issues in their lives, they seem to become more able to joke about and kid and have a sense of humor about their diabetes and about their lives in general. I kind of stored those ideas away.

Years later, it came back to me as I was doing some research around the history of humor and humor as a healing element. And so I jumped back and thought it might be an interesting research topic to see what is the relationship or the association of diabetes and humor, and is that an area that could potentially be explored for helping this enormous group of people in the United States who have diabetes?

Where did you come to that crossroads of the psychological issues and humor? Where did humor come in from all of that?

Well, mostly in, in reading research and realizing that humor has been associated with or correlated with improvements, such as lessened depression, less anxiety, uh, fewer heart attacks, better immune system. All sorts of medically oriented and psychologically oriented connections. And as I looked at that, I continued on and looked at, well, how did this impact people with diabetes specifically? The humor research was really linked to just the general population and came out of a long history of anecdotal research people all the way back to the Bible where in Proverbs it says, "a merry heart doeth good like a medicine, but a broken spirit dryth the bones." And then throughout history we've had people commenting on the benefits of humor all the way from the 17th century surgical expert, Robert Burton, and he recommended laughter as a cure for melancholy.

Josh billings quipped, "There ain't much fun in medicine, but there's a heck of a lot of medicine and fun." And Tom Sawyer wrote, "the old man laughed loud and joyously. Shook up the details of his anatomy from head to foot and ended by saying that such a laugh was money in a man's pocket because it cut down on the doctor's bills like everything." And my background in psychology, I would be negligent to not even mention that old curmudgeon, Sigmund Freud who said, "like wit and the comic, humor has in it a liberating element." So this has been noted throughout history, but it wasn't until Norman Cousins wrote a bestselling book, anatomy of an illness, and really brought to the public's attention. This was in 1979, he brought to the public's attention his use of humor in curing what at that point was considered an incurable disease. Now that's totally anecdotal. I mean we can't say that it cured his, there might've been other factors, but, but he brought a lot of attention to this and the research since has been quite prolific about both psychological and physical benefits of humor.

So having diabetes and working with people with diabetes, it just hit me that what's the relationship here? And what might be going on that might be a potential benefit to people with diabetes that's relatively low cost, easily instituted and could be quite beneficial to this epidemic of diabetes in this country today?

How do you measure and look at humor since it's so subjective looking at one person to the next?

That's a, that's a great question. And it took me some time to kind of look at this and there are a couple of people in the field of humor research who have really struggled with that. And the most current belief on that is that humor is multi-dimensional. So a researcher named Dr. Rod Martin developed a humor questionnaire and it divides into four different types of humor. Two are considered positive humors and two are considered negative humors. The positive humors are affiliative sense of humor and our self-enhancing sense of humor. On the negative side, we have an aggressive humor. So some people manifest their humor by kind of lashing out and being hurtful and self-defeating. Humor is when folks really use their humor in a self deprecating way and allow other people to do that as well. Now when I say humor, the other part is, people think of laughter and humor and indeed they are different aspects, but laughter is a subheading of a sense of humor. So some research is specific on laughter, but a lot ison humor.

What I try to do is look at the overall sense of humor divided by those four categories. And there's a pretty easy survey that has been copywritten by Rod Martin but he's been very kind in letting researchers use that. So I administered that to people with diabetes and that was our measure and that was normed against a group of people without diabetes so that I have a comparison of the people with diabetes who have taken the survey and comparing it to the norms of people that aren't as a group, people with diabetes. There might be people with diabetes in that group, but there were over 1,100 people in the norming of it so it's not significantly people with diabetes.

So when, when you sent out this survey, you looked for anyone with diabetes...


Versus anyone that without diabetes. Did it matter what type of diabetes?

Basically I sent out and tried to advertise as broadly as possible. So we sent out over 7,000 emails. That included to a random sampling from UNC and another university where I used to teach in the Kansas city area, the University of St. Mary. Andwe sent those out. I also advertised on a couple of websites, Take Control of Your Diabetes has a huge web presence and do newsletters to, I think their mailing list might be in the 20 thousands, and then Diabetes Daily. So I sent these out to as many people as I could. What I experienced and what a lot of other researchers or experience is a factor of what's called survey fatigue, which means we are so over surveyed now. You know, you call your insurance company for something and then they send a survey, "how did we do?" it's just overwhelming.

Data. Data. Data.

Exactly. And, and so after all this, I ended up with a final sample and we tried to solicit to people with diabetes for about an 11 month time period and ended up with 249 subjects in this study.

Out of the thousands of emails?

Out of the thousands of emails, right.


Interestingly, that had an impact on the people that responded as they were a relatively biased sample based on their ability to control their diabetes. So, people who control their diabetes well were much more willing to participate. But I just want to jump back because you asked about type one and type two. In the population right now, about 92% of the population of people with diabetes or type two. Interestingly, our statistics of our sample were, were almost the, the exact opposite. We had far more type one and the only thing that we could speculate was that people with type one were more engaged with the area of diabetes, more willing to participate, more interested in research on diabetes. Whereas type two folks tend to be not quite as connected with it. And an article that just recently had accepted for publication, one of the reviewers said, "I really wish you could have had a better blending of type one and type two," to which I responded "me too!" I really wished that we had had a better representation of that. But you have to go with what you have.

So if you're wanting to continue down this road with this sort of research, say you were to do this again with the same survey, what would be the best route to maybe reach to that other population that was hard to reach?

Well that's exactly what I'm doing. From the results that we have, what we really wanted to examine was the relationship between sense of humor and control of diabetes. Now just real quickly, control of diabetes is the gold standard to measure that is a blood test that's called a hemoglobin A1c (HB A1C) and that's a three month average of blood sugars. And even though there's some current thought about, we ought to be moving a little bit away from that and more into time in range. So not what's your HB A1C score, but how much of a day, how much over a month are you in the range of blood sugars. But that's a much more difficult thing to measure. So we still use the A1C, and the average A1C for the subjects in this pool was a 7.1 which is a phenomenally well controlled group. So we were trying to see was there a correlation between the different types of sense of humor, either overall or one by one or pairing them, we ran analysis on all of those, as compared to their A1C with the hypothesis that the better control, the lower the A1C, the higher the two positive humor scales, the self enhancing and the affiliative would be higher, while the aggressive sense of humor and the self-defeating sense of humor would be lower.

As a matter of fact, when I submitted this article, I heard that from a couple of journals who said, "you really didn't find anything significant. Let us know when you do." And it's like, but this is the foundation. This is the stuff that we need to be able to publish so people are aware and then we can build on that. But I think that that this is important and it is relevant and it does lay some foundation to say that people with diabetes can live with a chronic life altering day to day problematic disease and still maintain a sense of humor, because that's what we were able to show with the exception of self-defeating. And the self-defeating group with diabetes was actually higher than the norm.

But there's some evidence that self-defeating scale also measures psychiatric, physical, and psychological manifestations of living. So since we know that those are impacted by diabetes, it does stand to reason that people with diabetes might display a little bit more of that, but that's very preliminary at that point. But because the sample was so closely controlled, it kind of washed out the results. What we were able to do then is look at the results and compare our sample to the norms of the humor survey questionnaire. And that's the study that is just recently been published.

In the meantime, I am out trying to expand my, my subject pool. So rather than going to places where people who are kind of invested in diabetes, like websites where they're interested in and they take good control of their diabetes and that's part of how they do that, I'm going to local community health organizations and trying to get a wider range now of A1C scores and add those to the subjects I already have and see then if there is a correlation between the types of sense of humor and their ability to control. So that's ongoing now and then ultimately what I'd like to do is actually get a small group of people with diabetes, measure their sense of humor and their A1C at the beginning, administer a humor improvement program and there are a number of them that are available (interestingly enough, we can improve our sense of humor), and then measure them after a period of time, same measures - has their sense of humor improved and has their A1C improved? Which would then allow us to do a little bit more experimental in the sense of being able to say that there is a direct relationship between these, these two variables. And that's, and that's coming. But that's down the road a little bit.

You mentioned that there's a way to, what's the best word, better your humor? Edify your humor? What is it?

Increase your sense of humor. You can learn ways to look at the world differently. In this case, look at your diabetes differently. You can use humor as a stress release. You can use humor as a way to deal and cope with depression and anxiety and those kinds of things. So, these programs are really set up to teach people how to view life differently and how to incorporate humor in their day to day living. And, just important to note that this is a very, very early research project. I mean we were unable as we did our background research on this, to find really much of anything comparing humor and a chronic illness, any kind, let alone diabetes, and how those might fit together. There's a lot of research on specific things, like that humor has been shown to decrease depression and they can measure depression. I mean, you can do a Beck depression inventory and those kinds of things. So very, very specific agendas. But no kind of overall of how does humor help somebody with a chronic illness deal with it on a day to day basis. So very preliminary. And so we have to be very cautious. We can't just say yes, humor improves your diabetes control. I mean, that's a long way down the road, but I hope we can get there. Honestly.

You sound like the academic patch Adams patch.

Patch Adams really followed Norman Cousins in his work and he's probably a little bit better known today just because of the movie and some of those things. But yeah, there are some interesting dynamics of the use of humor in everyday functioning.

Human services is a very interesting program and we really provide people with a bachelor's degree that opens up doors in such a huge range of helping professions. So you think of mental health centers, drug and alcohol rehab programs, homelessness, aging... Anything that has people that are, that have basic needs that they're at risk about and our students are going out and working in that. So, I'd just like as many people to know that we exist. So if people listening (or reading) have an interest in helping and in being out there, then let me know, give me a call and I'll be happy to talk with you about our program.


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