From Laughter to Medicine, from Clowning to Therapy

Introduction

Laughter has been the fastest way to cure any form of disturbance, especially psychological. It acts like a catalyst to unburden people from stress, pain, anxiety, anger, etc. simultaneously enhance relationships, maintains the balance between body and mind and above all keeps an individual grounded and focused [1]. Similarly, play that is contrasted with work is also an essential ingredient to keep oneself, healthy and happy. Even though, considered as unimportant and associated only with children, it is interesting to understand how play, acts like the softener to one’s stress in life [2]. It has been established in many studies that laughter and play goes hand-in-hand. These two are also the main components of clowning, which could be defined as act by comic performers, characterized by colored wigs, makeup, outlandish costumes and usually oversized shoes whose purpose is to induce hearty laughter [3]. Clowning, has not limited itself on stages, or circuses, but has entered serious stations, like the hospitals and other medical care units. An age-old proverb says, “Laughter is the best medicine”. Even though used in casual comments, it has unraveled important facets of laughter that takes form of healing. The new age concept of medical clowning has maintained the value and meaning of this saying.

History of Clowning

The history of clowns begins from court jesters found in Egypt and Chinese kingdoms. They performed to make rulers laugh in the middle ages. In line, the next form of clowns that rose to existence were the Harlequin clowns from Italian theatre, who brought in a change in the clothing patterns by incorporating bright colored masks and collars. Followed by Harlequin, the Pierrot clowns were the ones who carried big pompoms, wore pointed hats and used white make up. Some of the popular clowns who rose to perfecting the art of entertaining the audience by filling the circus with roars of laughter were Joseph Grimaldi in 18th century, Dan Rice from America, etc.

Clowns became one of the main glue that held different performances together during circus shows. They were called fillers, as they would come and do their business between acts when performers required time to prepare and dress up. Where on one side the audience focused more on the performances, clowns were left with no acknowledgment, on the other side, something known as Clown Alleys started to develop. These spaces were exclusively meant for clowns for their dresses, quick entry and exists, storing larger props, etc. Although it was just another green room, the clowns owned it and gave it a special position. It was also said that younger clowns learnt the art of clowning from elder clowns in Clown Alley [4].

Early understanding of medicine propagated health to be a by-product of the interplay amongst four humors: sanguine, melancholic, choleric, and phlegmatic. It was believed that the imbalance between these humors resulted in distinctive emotional states. Clowns being the props of entertainment and laughter were bestowed with the job to rebalance the humors. Therefore, clowning was always seen as a medicine that healed the disturbed emotional states of people around. Other evidences for this relationship between clowning and medicine are:

• In ancient times where the Dervishes of Turkey used their performances to feed, the soul after medicine was fed to patient’s body.
• The cover page of Le Petit Journal, the September issue of 1908, displayed clowning in children’s ward in a hospital in London.
• Patch Adams, a young doctor reignited medical clowning in 1970s for hospital patients in Virginia, USA.
• The Big Apple Circus took medical clowning from an individual level to a community level. They launched the very first structured clowning program in the name of Clown Care Unit in 1980s.
• Clowning related initiatives for hospital patients, like Theodora Foundation, Le Rire Médecin functional in France, Die Clown Doktoren in Germany, Doctors of Joy in Brazil, Fools for Health in Canada, Humor Foundation in Australia, etc.

The Association for Applied and Therapeutic Humor, founded in 1988, defines therapeutic humor as “any intervention that promotes health and wellness by stimulating a playful discovery, expression, or appreciation of the absurdity or incongruity of life’s situations” [5].

Even though the concept of medical clowning is fairly new, there has been some amount of empirical research being conducted on it that stands as an evidence for its effectiveness in maintaining people’s well-being. Of the many articles searched and reviewed using the databases, Jstor, Ebsco, ProQuest, and Google Scholar, the researcher here has selected 27 articles. These 27 articles have been thematically arranged to present a comprehensive understanding about the effects of medical clowning across contexts and populations.

Medical Clowning in Pediatric Practice, in Patient Wards

With the association established between humor and well-being, “clown doctors” have been increasingly employed in hospitals, to facilitate the traumatic environment with creativity, humor and spontaneity so that an open and empathetic emotional space for the interaction of sick children could be built [6]. There have been many studies conducted to analyze the effect of a medical clown present in different circumstances within the hospital boundaries. Mostly these researches have shown significant results on the pain, anxiety and distress level of patients and their caregivers.

One of the most traumatic event that any patient could undergo is surgery or operation. The presence of medical clowns in such an atmosphere proves to be a socio-emotional resource for the diseased, the medical staff and the parents. The results of the study that aimed to assess the preoperative pain of pediatric patients clearly indicate that clowning intervention acts like anxiety and distress management that eases the medical procedures to be conducted. Additionally, it was also found that parents even though were not the focus of this intervention, if participated experienced some amount of calmness and peace [6]. Supporting these conclusions, Fernandes and Arriaga found out that, these clowns also help in uplifting the mood of the patients, regulating their emotional responses. The levels of perceived positive affect was also a contribution made by the clowns not only to the patients, but also to their caregivers. Being a strong predictor for positive emotional states and managing the anxiety and worries attached to operations, clowning was seen to have future implications especially in clinical practice [7]. The positive atmosphere created not only manages, but also empowers children to distract themselves and remain happier. It is clear by now, that medical clowns have been a useful addition to the hospital staff. The integration of preoperative clowning intervention has even shown lasting effects on the postoperative problems of children and parents. Presence of clowns, provided therapy before and during surgeries, and with Yun’s research interpretations, it has been established that they effectively use the humor and play to maintain the open and creative space for emotional expression up until the side effects of operations last [8].

The process of hospitalization is traumatic for every member in a family. Clown doctors who use their street- theatre experience along with non-verbal techniques, music, games, acting, etc. to create a space that mediates humor and interaction, have shown to lighten this stressful situation. These elements bring about a change in the quality of life of the patients who are constantly under the influence of life-threatening diseases [9]. There have been studies that focus other aspects of a patient’s life, except responses to operations. The injection of medical clowns on the face of stressful, shameful and difficult circumstances like sexual abuse, transform the traumatic hospitalization into a calm and pleasant expression of emotions. Acting as a social support inside the hospital, they help in enhancing the ability of coping from disturbing experiences. Teaming with the sick or abused thus empowers them with some control inside the examination room [10]. In this manner, they offer to be a pain reliever [11], not only to combat physiological pain, but also to improve the mental well-being by providing therapy to their unexpressed emotions.

Work of a hospital clown has been extensively studied in various studies. The use of humor in clinical practice, has gained respectability and visibility with the help of frequent clowning interventions in the invasive examinations of pediatric patients. Bringing in “hugs and happiness”, they are a symbol of fun and entertainment [12]. The way a clown and child pair up to work towards coping from the trauma, effectively, shows that they allow the child to take control of the situation which gives them hope, trust, and belief in their own strength and abilities. The remarks made by the clown, encourages the child to cognitively process the humor and reciprocate [13]. Not only the child that clowns are friends to, but also it is a well-known fact that family undergoes stress while they have one member hospitalized. Therefore, facilitating the creation of sharing and positive emotional interplay, they also enhance the existing familial bonds. Vigorously assessing the therapeutic essence behind clowning is difficult, but studies have contributed to the healthy and positive impact that medical clowns have brought to patients, families and healthcare teams [12]. Therefore, with these evidences of how clowning works like a therapy, it can be established that employing them inside the hospital is a need and would allow for better treatment results. The integration of medical clowning additionally improves the functioning of the entire medical staff, aiding them in difficult situations and the emotional challenges they face with people [9].

Medical Clowning Perspective of Adults

As understood by now, medical clowning has given therapeutic results pertaining to reduction of anxiety and maintaining emotional stability in children. In the background of these evidences, there has been a study that uses the same intervention with adults. Supporting results have been identified in researches, where clown-insertion to hospitalization of adults, have shown inverse relationship with anxiety levels. Additionally, their presence has also made the experience of medical examination of adults pleasant and fruitful. Facilitation of verbal and nonverbal communication mediated with laughter and joy, makes this intervention a valuable complementary therapy for adults also [14]. Humor and play, which are crucial components of therapeutic clowning has been researched to show physiological improvements in patients like, improving circulation, enhancing the production of natural painkillers, and strengthening immune system. Hypothesized by a group of researchers, the acts and tricks of the medical clowns acting as a therapy for the caregivers too, who are equally distressed and anxious, were studied. Realizing the role of parents as the only support system on whom sick children rely to in hospitals, literature states how the presence of this attachment figure brings differences in the child’s ill state. Linking parental presence to reduction of children’s anxiety, this study focused on alleviated parental psychological well- being, which may indeed be helpful for children. The results exhibited drastic reduction in maternal anxiety levels and possibilities of showing less somatization tendencies [15]. As mentioned before, humor has been researched upon to understand its effects on health, both physical and mental [16]. Just as wisdom is told to have come with age and experience, there is some amount of difference between humors across ages. When McMahan, visited the old age home, to use clowning activities and tricks with elderly people, there were some interesting insightful observations that were made. Even when songs and tasks were same, the humorous response of adults contained depth and childlike delight changed to appreciation to the joke made [17]. The present-centeredness and creative spontaneity of the clowns [18] proved to be beneficial in highlighting the little life present among the death-related thoughts. These experiences stand as proof for the effectiveness of clowning intervention with adults, and how these games are more than just mimics to create laughter, but facilitate their imagination making it more personal and powerful [17].

On one hand, where a clown’s ability to create open emotional space by giving the sick child the control enhances their well-being and chances of improving their health, a clown’s traits of performing with his soul and body to act out life stories facilitating transformation and perspective taking is considered more essential for adults. Brito and his colleagues hypothesized this by experimenting the presence of a medical clown amongst distorted families. His venture brought him answers stating that medical clowns facilitate the development of resilience in members and by making imaginative and intelligent interpretations of their present conditions, they were encouraging the resolution of conflictual thoughts and emotions that were left unexpressed. Being the “friend”, they had the advantage of using the freedom and flexibility to question the mechanical and automated lives, defined by social norms and beliefs. Compassionate care was seen to be provided which entailed laughter that unraveled the convenient masks being worn [19]. Clowns tend to look at the problem holistically, taking the perspective of the victim, their issues and how it can be resolved. They also take into consideration the affective presence of others around the sick individual [20]. These studies could be collectively used as a resource to claim the competence of therapeutic clowning to be an alternative and complementary strategy for maintaining well-being.

The reach of therapeutic clowning to the adult population in need, is still limited, and one of the reasons could be the lack of definition of their roles and responsibilities inside the context they are put into. Most of the studies focus on their work with children, there is some amount of dearth in literature speaking about the effectiveness of clown therapy on adults, be it diseased or disabled. Medical clowning is still in its formative stages, because of which it has still not established its name as a profession. This ambiguity in the functions of a medical clown across different contexts raises question on the authenticity and applicability of such alternative and complementary therapies. It is also interesting to note that, with the advent of such new and contemporary medical or psychological strategies for enhancement of well- being, the approach towards health would become holistic and multi-disciplinary in nature [9].

Therapeutic Clowning for Treating Psychiatric Patients

Humor has important significance in emotional, cognitive and social rehabilitation of patients. It has been utilized constructively in individual as well as supportive group therapies. Especially in psychiatric settings, humor and laughter play the role of social monitor of enhancing social skills as most of the treatment take place in a group format. The therapeutic use of humor, play and interaction by medical clowns, have shown results of reduced destructive behavior and transforming perceived attitude about their presence [21]. Existing literature base has extensively studied the effects on clowning across different patients, with physiological ailments undergoing hospitalization. Even though the impact of clowning activities is psychological in nature, its application to psychiatric illnesses is limited. Clowns have earned their reputation based on the emotional stability and crisis intervention they provide to individuals under stress [16]. All these strategies are mostly in a social context that is amongst people. As clowning heavily employs principles of play and social interaction, studies have shown that its effort to develop and strengthen the social skills during play of children suffering from attention deficit hyperactivity disorder (ADHD) are positive. Techniques of self-modelling by clowns and the therapist-peer interaction were highlighted to be the most useful to enhance the socio- emotional development of these children [22]. Some of the strengths of a medical clown is to facilitate communication, fantasy, imagination and bring to deep-seated unexpressed and unacknowledged emotions to the surface in an acceptable manner. These traits make a clown, an asset in psychiatry wards with patients suffering from psychological issues. One of the study that focused on the work a medical clown with in-patients of psychiatric wards using psycho- dramatic techniques in the form of group therapy have stated that these measures contribute to the patient’s chances of better prognosis. Integrating their acting skills to psycho- drama, they are not only tools of laughter, but have the ability to encourage patients to push their boundaries of reality, yet stay grounded to it [23]. Drama therapy, as a contribution and extension of psychodrama has also been integrated with clowning to bring about results for mentally ill patient to ensure better prognosis. One such case study, facilitated the understanding of how becoming a clown, opens ground for expression of not only emotions, but also struggles that patients face in their lives. As understood by now, clowning intervention is largely relief and recovery-oriented, because it offers hope and empowerment to individuals. Thus, when combined with drama therapy, it has shown progress in the improvement of mentally ill patients [24]. Therefore, in the field of mental health, it could be stated based on the existing evidence that medical clowning is therapeutic in nature.

Much said there still exists the paradox of the knowledge of the effectiveness of therapeutic clowning and the scientific evidence supporting it [21]. In order to decrease this discrepancy in literature, further exploration and empirical evidence on the effects and applicability of clowning intervention, on psychiatric patients, or individuals with psychological issues is required.

Medical Clowning Becomes Therapeutic Clowning

Based on the review of researches so far, medical clowning could be an asset to all the individuals involved in service to humankind. Clowning if done with the intention of maintaining holistic well-being of people in the society, then clowns not only act as entertainers to allow expression by humor and play, but also mediate as therapists. This is because they should be aware of the psychological implications of their actions based on the environment that the patients are from and what they need [6]. Using the humor and tricks that they specialize in, clowns accelerate the healing process at a psychological and spiritual level by allowing the patients to connect with their inner selves that they have subdued because of the present pain and anxiety associated with life circumstances. It also provides the opportunity to resume contact with oneself, by deriving from the positive energy spread around by the clown [25].

Talking about counselling, a profession demanding high levels of emotional regulation and stability require counsellors to have expert level skill set to control the implications of what is commonly called as counter- transference. While engrossed in the therapeutic alliance, counsellors might also use their own exercises to enhance self-understanding and awareness [26]. In a much similar way, clowns also require personal traits associated with emotional regulation while dealing with children or adults who are ill. Based on the reverse logic, they transform their pain into smiles on the face of audience and assist them in maintaining their well-being. Thus, it is essential to look at medical clowning as therapeutic in nature.

Scope for Alternative Therapy

Counseling, as a part of mental health services, recently has started integrating different and creative styles of therapies into the mainstream theoretical orientations, which has expanded the scope of psychological research too. Therapeutic clowning has emerged as a psychosocial intervention in the backdrop of alternative healing strategies [27]. Based on the results of the different studies done on therapeutic clowning, it has proven to tap on the emotional, social and psychological gaps that conventional treatment strategies have left. Looked upon as an alternative therapy, especially with children [6], this upcoming contemporary therapy has shown elevated positive moods, along with positive behavioral patterns [27] of those who were once just a passive occupant of beds in hospitals. Their ability to develop a strong and trusting therapeutic alliance has brought clowns under the limelight of being employed inside hospitals as a valuable addition to the medical science. It is important that for their assistance, medical teams also be trained to work with them. Additionally, the work of medical clown and that of a doctor should not be confused and maintained separately, by creating the atmosphere of respecting each other’s work and allowing autonomy and flexibility to maintain the team effort for ensuring suitable treatment provided to patients [28]. The medical staff and caregivers’ utilization of the spillover effects of a clowning intervention would also guarantee that the positive environment developed be handy for adult self-care.

Clowning is considered a multi-model approach towards positive health and well-being. Respecting the individual differences, it is comforting to see how clown doctors tailor- make their techniques to suit the needs of each patient. This one-on-one pairing that clowns do with patients, develop a trusting environment for them to release their piled up emotions and thoughts. However, there are groups of clowns too who conduct clowning intervention, which has shown similar results [29]. Thus, therapeutic clowns have been working for a while, but adoption of an interdisciplinary approach by the medical staff is integral to their sustenance in maintaining positivity in trauma-induced spaces [30]. In the light of these interesting inputs of researchers studying clowning, it could be stated that therapeutic clowning in gradually stepping into the field of complementary and alternative strategies, with a certificate of providing happiness, hope, compassion and care.

Conclusion

This article aimed to review articles on therapeutic clowning and its efficacy in modern day medicine. It is ironical to note that, the clowns who were once employed as court-jesters in ancient era for maintaining the moods of the courtiers eventually were vanished into the glamour and light of entertainment programs. The same people, who were known for creating humor and balanced emotional states with their outlandish costumes and tricks, have entered serious spaces like hospitals and rehabilitation centers, to serve the same old function. Children of this generation are used to placing clowns in a circus, whereas they always belonged to places of treatment and well-being. The varied articles reviewed in this piece, are standing proof for the authenticity and the efficiency of the work of clowns to enhance health of people around. Not only do they eliminate anxiety and pain, but the interaction and value of deep, open and expressive communication that they foster has been appreciated. Their presence facilitates the growth of imagination and fantasy that acts like therapy for individuals to look inside, for their strength and learn to accept their existence in the manner it is. By attaching psychological and spiritual meaning to clowning, it is considered an alternative therapy, technique or strategy for maintaining well-being and life satisfaction. Laughter is the best medicine, once said, still holds value, but is looked at clearly in crisis, with the help of these therapeutic clowns trained to create magic by spreading smiles.

Scope

Medical clowning needs to be accepted as therapeutic clowning after seeing the impacts that it has created in the above-mentioned researches. This piece of study, expands scope for clowning to be established as a profession in psycho-social service industry. By injecting therapeutic clowns in the medical industry, this paper attempts to bring medical practice, mental health, and social service together to make treatment and rehabilitation inter-disciplinary in nature. Knowing the contribution of therapeutic clowns, it would also be interesting to see how the insertion of clown training in our present-day education system, helps children to be more sensitive and grounded in their perspectives about world and relationships. Owing to the therapeutic nature of clowning, more studies need to be conducted to understand how clowns and mental health professionals can work together and how can their joint effort make therapy more effective. Organizations working for the marginalized sections of our society could also help from therapeutic clowning as an intervention model, needs to be studied. Therefore, with the existing literature, this paper accentuates the need of future researches to examine effects of therapeutic clowning in specific conditions and with specific populations.