Learning from the paediatric literature
Numerous studies, including randomised control trials, support the use of therapeutic clowning in paediatric practice, including clowning on children’s wards, emergency departments (Wolyniez 2013, Meiri 2017), intensive care units (Mortamet), rehabilitation units (Kingsnorth2011), outpatient departments and hospices, with studies also demonstrating their value in improving adjustment in disaster areas and refugee camps (Ilan 2018).
Clown interventions have been shown to reduce pain and anxiety in children undergoing procedures as an alternative to sedation (Dvory 2016, Fernandes 2010, Ofir 2015, Meiri 2008, Zhang 2017) and is benficial during the induction of anaesthesia (Vagnoli 2005, 2010, Yip 2009, Golan 2009). Clowns promote cooperation via therapy and diversion (Nuttman, Schwartz 2010) and clowning has been shown to be beneficial during minor surgery (Canto 2008, Meisel 2009), during uncomfortable procedures, for example, intra-articular injections, botulinum toxin injections (Ben-Pazi 2017), and allergy prick skin testing (Weintraub 2014, Goldberg 2014) or sexual abuse examinations (Tener 2010, 2012). More recently it has been shown that clowns may benefit children hospitalised for respiratory disorders (Bertini 2011) and may improve the performance of spirometry among preschool children (Nir 2018).
For children in hospital clowns create ‘joy without demands’ (Linge 2011), providing a magical safe area with the lighter side of life taking precedence (Linge 2013). Although opportunities for play may be limited in hospital settings, clowns may help overcome this (Finlay 2017). Children report that clowns help make their hospital stay fun and parents say that clowns help children focus on something other than their illness (Glasper 2007). Clowns have also been shown to reduce parental anxiety levels (Fernandes 2010, Goldberg 2014, Gilboa-Negari 2017).
A study in the community has shown that clowns may help children with ASD interact with their normally developing peers, improving their ability to communicate and form personal connections and handle sensory overload (Arutz Sheva 2017). Ankan (2018) conducted a study to determine the effect of therapeutic clowning on hand washing technique and microbial colonization in preschool children. The microbial growth was ≤103 in 68.9% and >103 in 31.1% of the subjects in the experimental group, compared to ≤103 in 34.3% and >103 in 65.7% of the control group, the difference being statistically significant. The authors conclude that paediatric healthcare professionals could use entertaining methods such as those involving clowns to teach children hygienic hand washing techniques.
Although most children find clowns funny, some are scared of clowns – refered to as coulrophobia or ballatrophobia. This may be due to a previous traumatic encounter or because circus clowns often wear loud clothing and make up, but therapeutic clowns generally wear minimal make up with a red nose. A recent study looking at the prevalence of fear of clowns in the general paediatric hospitalized population, found it was 1.2%, with a significant predominance of girls - 85.7% (Meiri 2017).
Studies involving staff and teams
Studies have also been conducted to examine the clown’s role within the medical team and their impact on staff as well as patients and their families (Scheyer 2008). Clowns have been found to improve communication between parents and clinicians and within clinical teams. Amongst staff, humour can cultivate teamwork, improve morale and motivation, increase productivity, enhance problem solving, ease distress in difficult situations, reduce negative moods, and create a positive work culture with more enthusiasm and greater job satisfaction (Warren 2011, Blain 2012, Chenoweth 2014). Clowns may help to improve staff morale and motivation, and enable staff members to ‘let off steam’ (Nuttman-Schwartz 2010), with their playful, improvisational and light-hearted approach (Warren 2011, Dionigi 2016).
Learning from the elderly literature
Research has shown that some older people may live longer, experience a better quality of life and be more satisfied with their physical health if they use humour as a way of coping with the challenges of aging (Warren 2011). Elder-clown programmes have been developed to work specifically with older people and may address some of these needs, especially for those with dementia (Warren, 2011). Elder clown programmes include the Hearts and Minds Elderflower program in Scotland, Fools for Health and the Jovia Foundation in Canada, MiMakkus in the Netherlands and the Big Apple Vaudeville Caravan in USA.
The elder clown interacts with individuals through improvisation, music, dance and drama which empowers, calms and strengthens the patient while reinforcing the patient’s connection with their surroundings and contributes to an improved quality of life (Raviv, 2014). Clowns encourage interaction, engagement and connection with people and they create humorous moments and use stories to stimulate memory and cognitive functioning, engaging each resident on a personal level, with a positive effect on both verbal and non-verbal social interaction (Warren 2011, Rämgård 2016). They do not infantilise those with dementia but empower, honour and delight them (Symons 2012).
Elder clowns generally work with people in residential homes or nursing homes where the residents are usually up and about rather than being confined to bed like those on many hospital wards. Clowns may visit residents individually in their own rooms, or they may entertain small groups in communal areas, such as a living room or the dining room. These clowns do not wear outlandish clothes or loud make-up and they perform in softer, subtler ways than their circus counterparts (Warren, 2011).
Elder clowns work with the health-care team, obtaining information about individual’s medical and psychosocial condition, their life-history, interests and abilities prior to meeting them. Clowns use this information, along with meaningful objects in the environment and sensory triggers, to tailor their approach and engage individual residents (Warren 2011, Rämgård 2016). Clowns work in culturally responsive ways to strengthen individuals sense of self (Rämgård 2016) and they may help individuals connect with their past stepping into their bygone era by putting together an individual "package" dating back to times the elder person relates to including dress, music, news and relationships. However their work is not about merely reminiscing, it is also about being in the moment and connected to the present (Symons 2012).
Clowns may ask residents to give them one piece of life advice, to tell them a story about a picture on their wall to initiate interaction, and then by ‘acting foolish’ or misunderstanding instructions residents have the opportunity to tell clowns what to do, giving the resident a sense of control and autonomy (Warren, 2011). The efficacy of elder-clown programmes in dementia care has been demonstrated in a number of studies. Low et al (2013) conducted a study in Sydney with 189 residents in 17 nursing homes receiving weekly elder-clown visits over a 9-12 week period, with 209 residents in 18 homes receiving normal care. Levels of agitation were significantly reduced in the intervention group compared with controls over a 26 week period, although levels of depression did not alter significantly. A study by Kontos (2014) found twice weekly visits from a pair of clowns, over a 12 week period, reduced moderate to severe behavioural and psychological symptoms of dementia in nursing home residents.
A pilot study on the work of miMakkus, a special method of clowning for people living with advanced staged dementia, also showed a lasting improvement in the wellbeing in those who received a 45-60 minute intervention (Symons 2012, Hendriks 2012). Guidelines recommend non-pharmacological interventions before medication to control agitation in dementia patients and the use of humour may be an effective complementary and alternative intervention in the treatment of dementia patients (Takeda 2010).
By working with staff the benefits of clowning can be continued and developed in-between clown sessions with care staff incorporating performance principles into their daily work (Symons 2012). Clowns may also relieve visitors of the burden that accompanies prolonged visits with relatives (Nuttman-Schwartz 2010. Although families may initially be sceptical about clowns, they are often won over when they see them interacting with their loved ones (Symons 2012).
Clowns give everyone permission to find the silly in the serious, or the funny in the frightening, introducing a sense of levity into day to day life. While Patch Adams used to clowning in a variety of clinical settings, the majority of research has been undertaken with children and families largely in paediatric healthcare settings (Dionigi 2016). However elderly people, particularly those with dementia, may share many characteristics with children including being dependent on others, fearful of strange environments and lacking the ability to fully participate in complex decision-making. Both children and the elderly may have to undergo invasive examinations, unfamiliar and potentially painful procedures and rehabilitation post injury, and there is therefore potential to undertake further studies in the elderly population. There are however significant differences between the elderly and children including disease profile, comorbidities, metabolism and life experience. Clowning techniques therefore need to be adapted to individuals.