Clowning and Posive Instuons

Alberto Dionigi1,2, Willibald Ruch3, Tracey Platt3, & Jennifer Hofmann3

[email protected] Los Angeles, June 28, 2013

1University of Macerata 2Federazione Nazionale 3University of Zurich Clown Dottori

1 Positive Institutions

2

¨ Positive psychology has put forward the concept of “positive institutions” which are ones that support positive emotions and focus on character strengths (Seligman & Csikszentmihalyi, 2000)

¨ In healthcare settings patients primarily come to reduce suffering (see also Harris & Thoresen, 2006), anxiety, stress, and other negative emotions that are more prevalent than positive ones

¨ How can institutions such healthcare settings become positive institutions?

Positive interventions (including humor and clowning) Clowning as Humor Intervention

3

¨ Clowning within health settings can be seen as the application of humor intervention within an institution (Linge, 2011; Ruch et al., 2010)

¨ Humor is not the only strength linked to clowning in health settings ¤ Clowning may activate strengths ¤ i.e. creativity, curiosity, and open mindedness are present in clowns and promoted in patients ¤ i.e. patients and relatives might experience hope and gratitude after clown interventions

Clowning in Health Settings (Dionigi et al., 2012) 4

¨ Professional clowns started working in hospitals in 1986

¨ Karen Ridd (Robo the Clown), a child life specialist, founded the first Canadian therapeutic clown program at Winnipeg Children’s Hospital (Canada)

¨ Michael Christensen along with Jeff Gordon, two famous clowns of the Big Apple Circus in New York, founded the Big Apple Circus Clown Care Unit (USA)

¨ The programs are still alive and well and they gave the basis to two different kinds of approach: ¤ the solo therapeutic clown (Karen Ridd’s model) ¤ clown doctors working in pairs (Christensen and Gordon’s model) Research around the world

Italy = 5 UK = 4 USA = 3 Spain = 2 Portugal = 1 Israel = 5 Sweden = 4 Denmark = 1 Australia = 4 Brazil = 1 Germany = 1 Netherlands = 1

Our studies

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¨ Aims ¤ Focus on positive emotions ¤ Provide evidence that the presence of clowns has the potential to change institutions into positive ones

¨ Overview ¤ Clinic Clown Interventions in Elderly with Dementia n Measuring facial expressions ¤ Emotions Elicited in Patients and Observers by a Clown and a Nurse Intervention ¤ Positive Emotions in Clinic Clowns Clinic Clown Interventions in Elderly with Dementia* 7

¨ Research Questions: Do clinic clowns elicit positive emotions? How can we measure this in people that lost verbal communication skills?

¨ Sample: 23 residents of two nursery homes with slight to severe

dementia (Age M1 = 90.58; SD1 = 5.70; M2 = 86.55; SD2 = 3.98) ¨ Methods and Procedure: Filming of clown sessions and analysis of spontaneous facial expressions with the Facial Action Coding System (FACS; Ekman, Friesen, & Hager, 2002) à searching for “Duchenne Smiles” and peer-reported affect and behavior (nurse ratings)

*A collaboration of the University of Zurich, the APH Moosmatt, Clown Wieni, and Seniorenzentrum Gritt Neutral Face

Polite Smile

Duchenne Smiles

AU 6

AU 12 Results

¨ Duchenne smiling and laughter appeared to different frequencies for different clown strategies (music and clumsy behavior elicit most smiles and laughs)

¨ Duchenne Displays correlated with the dementia severity (r = .70, p < .01)

¨ Negative Affect decreased from pre to post clown sessions (p < .05)

¨ Communication behavior improved (p < .05)

¨ Residents felt less pain (p < .05)

¨ Positive feedback from staff and relatives Emotions Elicited in Patients and Observers by a Clown and a Nurse Intervention (Auerbach, Ruch, & Fehling, 2013)

¨ Aim: Study the effect of a hospital clown intervention on the emotional experience of N = 42 adult patients of a rehabilitation center

¨ 2 patients received together a hospital clown and a nurse intervention, one in the role of the participant, one in the role of the observer

¨ At baseline and after each intervention they filled out the CLEM-29

¨ Dimensionality of the CLEM-29: amusement (e.g., hilarity, playfulness), transcendence (feeling uplifted and surpassing the ordinary, e.g., elevated, appreciated, freed), unease (e.g., threatened), arousal (high arousal = overexcited, low arousal = touched) Results

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¤ Amusement and arousal higher at clown intervention than at nurse intervention ¤ No difference in transcendence between clown and nurse ¤ No negative emotions reported, and no differences found ¤ Interaction: At baseline, participants were higher in arousal than observers, at clown intervention observers were higher than participants à witnessing an act of moral kindness leads to a rise in transcendence (e.g., elevation; Algoe & Haidt, 2009) ¤ Transcendence was the most important predictor of a global positive evaluation of the hospital clown intervention The research shows that the variety of positive emotions elicited in patients during hospital clown intervention has been underestimated!

Positive Emotions in Clinic Clowns

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¨ Research Questions: Do clowns experience positive emotions during their activity? Which ones?

¨ Sample: 123 Italian Clinic Clowns (Age M = 37.46, SD = 10.67, Range 17 – 69 years)

¨ Instrument: PEEQ (Hofmann et al., 2012)

¨ 16 enjoyable emotions (Ekman, 2003): Amusement, Excitement, Contentment, Relief, Wonder, Fiero, Naches, Elation, Gratitude, Schadenfreude, Ecstasy, the 5 sensory pleasures

¨ Joy, Interest, Love, Awe, Challenge, Tenderness, Compassion Posive Emoons Experienced 5.99 5.97 5.97 5.97 5.95 5.94 by Clinic Clowns 5.59 5.55 5.49 5.45 during Clown Intervenon* 5.12 5.08 4.89 4.76 4.59 4.43

4.07 4.02

3.26 3.24 3.02

2.38

1.39 Conclusion

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¨ Studies on clowning in health settings suggest that clown interventions have positive effects on patients, observers and staff (short-term)

¨ Clown intervention is a positive intervention linked to different strengths

¨ Clown interventions elicit positive emotions and decrease negative ones both in the recipients and in clinic clowns

¨ The implementation of clowns into a variety of settings has the potential to render these institutions positive institutions Thank You!

15 References

16 Algoe, S. B., & Haidt, J. (2009). Witnessing excellence in action: The ‘other-praising ‘emotions of elevation, gratitude, and admiration. The Journal of Positive Psychology, 4(2), 105-127. Auerbach, S., Hofmann, J., Platt, T., & Ruch, W. (2012). The 29 Clown Emotion List (CLEM-29). Unpublished research instrument, University of Zurich, Switzerland. Dionigi, A., Flangini, R., & Gremigni, P. (2012). Clowns in Hospitals. In P. Gremigni (Ed.), Humor and Health Promotion (pp. 213-228). New York: Nova Science Publisher. Dionigi, A., Sangiorgi D. & Flangini, R. (2013). Clown intervention to reduce preoperative anxiety in children and parents: A randomized controlled trial. Journal of Health Psychology. Published online before printing, DOI 10.1177/1359105312471567 Ekman, P., Friesen, W. V., & Hager, J. C. (2002). Facial action coding system. Salt Lake City: A Human Face. Fernandes, S. C., & Arriaga, P. (2010). The effects of clown intervention on worries and emotional responses in children undergoing surgery. Journal of Health Psychology, 15, (3), 405–415. Golan, G., Tighe, P., Dobija, N., Perel, A., & Keidan, I. (2009). Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial. Pediatric Anesthesia, 19, (3), 262–266. Lee Duckworth, A., Steen, T. A., & Seligman, M. E. (2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629-651. Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and- build theory of positive emotions. The American Psychologist, 56(3), 218. Fredrickson, B. L. (2003). The value of positive emotions: The emerging science of positive psychology is coming to understand why it's good to feel good. American Scientist, 91(4), 330-335. Friedler, Glasser, S., Azani, L., Freedman, L. S., Raziel, A., Strassburger, D., Ron-El, R., & Lerner-Geva, L. (2011). The effect of medical clowning on pregnancy rates after in vitro fertilization and embryo transfer (IVF-ET). Fertility and Sterility, 95, 6, 2127-2130. Gervais, N., Warren, B., Twohig, P. (2006). “Nothing seems funny anymore”: Studying Burnout in Clown-Doctors. In A. D. Litvack (Ed.), Making Sense of Stress, Humour and Healing (pp. 71-82). Oxford, UK: Inter-Disciplinary Press – Publishing Creative Research. Harris, A. H., & Thoresen, C. E. (2006). Extending the influence of positive psychology interventions into health care settings: Lessons from self-efficacy and forgiveness. The Journal of Positive Psychology, 1(1), 27-36. Linge, L. (2011). Joy without demands: Hospital clowns in the world of ailing children. International Journal of Qualitative Studies on Health and Well-being, 6, 5899. Linge, L. (2012). Magical attachment: Children in magical relations with hospital clowns. International Journal of Qualitative Studies on Health and Well- being, 7, 11862. Low, L. F., Brodaty, H., Goodenough, B., Spitzer, P., Bell, J. P., Fleming, R., Casey, A. N., Liu, Z., & Chenoweth, L. (2013). The Sydney Multisite Intervention of Laughter Bosses and Elder Clowns (SMILE) study: cluster randomised trial of humour therapy in nursing homes. British Medical Journal, 8, 3-8. Nuttman-Shwartz, O., Scheyer, R., & Tzioni, H. (2010). Medical clowning: Even adults deserve a dream. Social Work in Health Care, 49(6), 581–598.

17 Ruch, W., & Müller, L. (2009). Wenn Heiterkeit Therapie wird [When cheerfulness becomescheerfulness becomes therapy]. Geriatrie Praxis Österreich, 3, 22-24. Ruch, W., Platt, T., Hofmann, J., Auerbach, S., & Dionigi, A. (2013). Hospital clown research: A positive psychology perspective. Manuscript submitted for publication. Ruch, W., Proyer, R. T., & Weber, M. (2010). Humor as character strength among the elderly: Theoretical considerations. Zeitschrift für Gerontologie und Geriatrie, 43, 8-12. Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice friendly meta- analysis. Journal of Clinical Psychology, 65, 467-487. Tener, D., Lang, N., Ofir, S., & Lev-Wiesel, R. (2011). The Use of Medical ClownsMedical Clowns as a Psychological Distress Buffer during Anogenital ExaminationAnogenital Examination of Sexually Abused Children. Journal of Loss and Trauma. DOI: 10.1080/15325024.2011.578025 Van Blerkom, L. M. (1995). Clown-doctors : Shaman healers of Western medicine. Medical Anthropology Quarterly, 9, 462-475. Warren, B. (2009) “Hi Jean! : how clown-doctors help facilitate infection control and positive health care practice”, in P. Elliot (Ed.), Infection Control : A Practical Approach To Psychosocial Issues (pp. 149-158). Abingdon, Oxon : Radcliffe Publishing.

18 Research: State of Art

19 Theoretical approach (e.g. Dionigi et al., 2012; Ruch et al., 2013; Van Blerkom, 1995; Warren, 2009) Research has focused primarily on the impact of clowns in reducing negative states and emotions: Many studies on children: ¤ Preoperative anxiety (e.g. Dionigi et al., 2013; Fernandes & Arriaga, 2010; Golan et al., 2009) ¤ Distraction during medical procedures (e.g. Tener et al., 2011)

¨ Influence on adults, in fertility treatments (Friedler et al., 2011) or with the aged (Low et al., 2013)

¨ Interaction between clowns, patients, families, and staff (e.g. Nuttman-Shwartz et al., 2010)

¨ Clowns (Gervais et al., 2006; Linge, 2012)