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Advance Access Publication 17 May 2007 eCAM 2008;5(1)17–25 doi:10.1093/ecam/nem033 Review The Life Threatened Child and the Life Enhancing Clown: Towards a Model of Therapeutic Clowning Donna Koller1 and Camilla Gryski2 1Academic and Clinical Specialist, Department of Child Life, Hospital for Sick Children and 2Therapeutic Clown, Therapeutic Clown Services, Toronto, Ontario, Canada In the last decade, there has been a rapid growth in the presence of clowns in hospitals, particularly in pediatric settings. The proliferation of clowns in health care settings has resulted in varying levels of professionalism and accountability. For this reason, there is a need to examine various forms of clowning, in particular therapeutic clowning in pediatric settings. The purpose of this article is to address what therapeutic clowning is and to describe the extent to which it can provide a complementary form of health care. In an attempt to apply theory to practice, the article will draw upon the experiences of a therapeutic clown within a pediatric setting while providing a historical and theoretical account of how clowns came to be in hospitals. Toward this end, a proposed model of therapeutic clowning will be offered which can be adapted for a variety of settings where children require specialized forms of play in order to enhance their coping, development and adjustment to life changes. Finally, current research on clowning in children’s hospitals will be reviewed including a summary of findings from surveys administered at the Hospital for Sick Children. Keywords: child life – clowning – complementary care – hospitalized child – pediatric psychosocial care – therapeutic play Introduction bedside visits yearly. Australia has the Humour Foundation Clown Doctor Programs, South America its In the last decade, there has been a rapid growth in the Doutores da Alegria (Doctors of Happiness) and France, presence of clowns in hospitals, particularly in pediatric Le Rire Me´decin (Laughing Doctors). In addition, settings. Many thousands of children are exposed to volunteer caring clowns visit countless hospitals and clowns during their hospitalization. For example, six nursing homes, particularly in the United States and clowns from the Therapeutic Clown Program at the Canada. Hospital for Sick Children (Sick Kids) in Toronto, This rapid expansion of clowns in health care settings Ontario, Canada, see an average of 20 children 2 days has resulted in varying levels of professionalism and per week, for a total of over 10 000 visits a year. Patients accountability. At their most professional, therapeutic can range in age from infancy to adolescence. clowns are respected complementary care providers who The Theodora Foundation sponsors clowns in are able to articulate their role in the care of the patients 82 hospitals on three continents, Europe, Africa and as integral members of the health care team. At the other Asia. In the United States, 90 clown doctors from the Big end of the spectrum, volunteer clowns, though well- Apple Circus Clown Care Units (CCU) provide 250 000 intentioned, may be simply dressed-up people with little training and less understanding of the role and potential For reprints and all correspondence: Donna Koller, Child Life of the therapeutic clown. Therapeutic clowns in pediatric Department, Hospital for Sick Children, 555 University Avenue, settings use gentle play and laughter to provide ill Toronto, ON M5G 1X8. Tel: 416-813-8211; Fax: 416-813-5364; E-mail: [email protected] children with another avenue for emotional expression, ß 2007 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original workis properly cited. 18 Life threatened child and life enhancing clown control and social interaction during their hospitalization. ‘ ‘‘Clowns don’t belong in hospitals.’’ I told him, ‘‘Neither The goal of therapeutic clowning is to minimize stress for do children.’’ ’ (8, p. 37). ‘Clowns here are you joking?’ patients and their families during hospitalization and (9, p. 9) was the apparent response of a physician to treatment (1–3). Caroline Simonds, Artistic Director of France’s Le Rire Since clowning in pediatric settings continues to grow, Me´decin, upon hearing her request to provide clown there is an urgent need to define the role of the doctor services to children in his hospital with life- therapeutic clown, particularly because this form of threatening illnesses. Yet the relationship between clowns clowning can involve interactions with seriously ill or and those in need of healing should not be so surprising. dying children. The purpose of this article is to address Historically and culturally, clowns have been associated what therapeutic clowning is and to describe the extent to with the well-being of society and the healing arts. It is which it can provide a complementary form of health believed that the hospital of Hippocrates kept troupes of care. The aim is to offer an established model of players and clowns in the quadrangle, ‘as the doctors of therapeutic clowning upon which standards of practice the day believed that mood influenced healing’ can be developed and measured. In an attempt to apply (10, p. 202). The 12th century buffoon Rahere or theory to practice, the article will draw upon the Rayer, went on to found St Bartholomew’s Priory and experiences of a therapeutic clown within a pediatric Hospital and Fair. setting while providing a historical and theoretical Clowns appear in the cultures of many First Nations account of how clowns came to be in hospitals. Toward peoples, functioning in ways similar to the saints, this end, a proposed model of therapeutic clowning will prophets and artists of the Western world (11). be offered which can be adapted for a variety of settings The sacred clowns of the Hopi serve as jesters, priests where children require specialized forms of play in order and shamans (12). This latter concept is taken up by Van to enhance their coping, development and adjustment to Blerkom (13) who discusses the role of the Big Apple life changes. Finally, current research on clowning in Circus CCU clowns in the context of shaman healers children’s hospitals will be reviewed including a summary providing complementary therapy. To support her case, of findings from surveys administered at Sick Kids. she cites the clowns’ appearance, use of puppets, music, character and ritual, and their role as order-breakers. Although many clowns have volunteered in hospitals as Clowns as Healers entertainers, and today’s Caring Clowns continue to do Clown historian John Towsen (4) suggests that ‘the so, the advent of the clown doctor and the therapeutic clown’s ability to evoke feelings of superiority in the clown in health care settings can be traced back to 1986, spectator plays a hidden role in all clowning’ (p. 206). when the two models in current hospital clowning Hoyle (5) calls clowns ‘life-enhancing’ and for Henderson originated independently. The following is a brief (6), the clown is ‘the embodiment of hope in the face review of these models and their origins. of hopelessness, and possibility in the face of the impossible’. Clown Doctors However, the journey towards acceptance of therapeu- tic clowns by other health care professionals has not Michael Christensen, one of the founders of the Big always been smooth, reflecting the ambivalent nature of Apple Circus, was asked to perform at an event at New the relationship between the clown and the society of York’s Babies and Children’s Hospital. Christensen, which he or she is a part. Cline (7) offers a useful Dr Stubs, and his colleague Jeff Gordon presented a synthesis of this unsettled relationship. Speaking of the 20-min parody of the realities of hospital life to a essence of the clown he says: delighted audience of patients, parents and staff. For Christensen, this was ‘the most fulfilling twenty He is our scapegoat, ‘‘he who gets slapped,’’ minutes of my professional career, and it was from that suffering every indignity that the human mind experience that the Clown Care Unit plan took root’ (14). can conceive. He is our alter-ego, vicariously All of the CCU clowns are professional artists who acting out the unspoken desires that we could undergo a rigorous training program before working in never hope to act on in reality. He is our critic, the hospital. Their doctor characters evolved from the piercing through our cultural hypocrisies with clown’s natural relationship with authority figures: in the well-aimed barbs. And he is our healer, enabling circus, the ringmaster; in the hospital, the doctor. It has us to laugh at the realities that could too easily also been suggested that the clown doctors’ brightly- make us weep. (p. 8) colored costumes and red noses paired with white coats Recounting a now-famous incident from the early days help to make the ‘institutional garment and the medical of the Big Apple Circus’ Clown Care Unit, founder staff more ‘‘friendly’’ and less intimidating’ (15, p. 1). Michael Christensen tells how his clown character, In addition, clown doctors always work in pairs, to Dr Stubs, once had a doctor come up to him and say, encourage creative performance, to free the child from eCAM 2008;5(1) 19 pressure to participate, and to offer professional and mirrors that of the child, who is also out of place in the emotional support (9). Simonds and Warren also suggest health care environment, and who must ultimately, that a partner can indicate to a colleague the need to put despite the support of family and friends, cope with his on the brakes if a clown scenario is getting out of hand.

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