Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2017 Send in the clowns? : emotional reactions to hospital clown interventions Auerbach, Sarah Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-140339 Dissertation Published Version Originally published at: Auerbach, Sarah. Send in the clowns? : emotional reactions to hospital clown interventions. 2017, University of Zurich, Faculty of Arts. Send in the clowns? Emotional reactions to hospital clown interventions Thesis (cumulative thesis) presented to the Faculty of Arts and Social Sciences of the University of Zurich for the degree of Doctor of Philosophy by Sarah Auerbach Accepted in the spring semester 2016 on the recommendation of the doctoral committee: Prof. Dr. Willibald Ruch (main advisor) Prof. Dr. Carl-Walter Kohlmann Zurich, 2017 Heiterkeit Heiterkeit ist weder Tändelei, noch Selbstgefälligkeit, sie ist höchste Erkenntnis und Liebe, ist Bejahen aller Wirklichkeit, Wachsein am Rande aller Tiefen und Abgründe. Sie ist das Geheimnis des Schönen und die eigentliche Substanz jeder Kunst. Hermann Hesse Acknowledgments Many thanks to ... … Prof. Dr. Willibald Ruch for entrusting me with this research, supporting me to realize and improve my ideas and teaching me to see patterns in seemingly random heaps of numbers … Prof. Dr. Carl-Walter Kohlmann for agreeing to be my second supervisor and to reviewing this dissertation thesis … The RedNoses Clowndoctors International for generously supporting this research … Christina Matuella, Helga Jud, Manfred Unterluggauer and Marcel Briand, all wonderful clowns and curious researchers at heart … Prof. Dr. Wilhelm Strubreither, staff members and patients of the Rehazentrum Bad Häring for helping to realize the research … Annette Fehling, the bravest of all master students, without whom I could have never carried out the experiment so successfully (and with so much fun) … Dr. Tracey Platt, Dr. Jennifer Hofmann and PD Dr. René Proyer for their valuable feedback on ideas and manuscripts … The current and former doctoral students of the chair for their ongoing support … Dr. Jessica Milner Davis for sharing her knowledge concerning the clown persona with me … Vivian Ogden for providing very helpful feedback on my writing in English … Sarah Shephard, I am deeply grateful! … all my friends and family, especially my brother and my parents who always believed in me and supported me no matter what … Finally, to Garvin, for all your unconditional love and support (and for being a very reliable supplier of chocolate around the clock) I Abstract This thesis focuses on the identification and assessment of emotional states elicited in individuals in response to hospital clown interventions. Research showed that hospital clown interventions can have a beneficial effect for patients in need of care, but the empirical evidence is thin, inconsistent and methodologically not free of criticism (Dionigi, Flangini & Gremigni, 2012). There is a lack of research that investigates the fine-grained changes in the emotional states of recipients of hospital clown interventions in comparison to other types of interventions. This thesis aimed at identifying the uniqueness of hospital clown interventions in their effects on individuals using a sound empirical methodology (subjective and objective assessment instruments, controlled experimental design). It comprises three empirical parts. In Part One, an assessment instrument sensitive to the induction of clown-specific emotional states was developed (the 29 Clown Emotion List, CLEM-29). Two studies were conducted to examine the usefulness of the instrument in the evaluation of hospital clown interventions. Study 1 hypothesized that the CLEM-29 represents state ratings sufficiently different from existing instruments for the assessment of emotional states and is more specific in predicting the total amount of positive affect in response to clowns than existing state scales. For the study, 119 adults watched two videos of clown interventions (a circus clown and a hospital clown), and rated their emotional state on the CLEM-29 as well as on two broader mood scales. Results showed some empirical overlap of the CLEM-29 ratings with general scales of mood, but many CLEM-29 ratings specific to hospital clowns (e.g., feeling connected to the clown, feeling touched) did not strongly relate to exiting scales. Furthermore, ratings from the CLEM-29 outperformed the existing scales in the prediction of the total amount of positive affect. Study 2 in Part One (N = 183 adult observers) aimed at identifying the unique effects of hospital clowns on the emotional state of observers, and therefore investigated the II differences in elicited emotional states in response to hospital clowns, circus clowns and nurses. Four factors were found (amusement, transcendence, arousal and unease), which successfully distinguished between emotional states elicited by hospital clowns, circus clowns and nurses. Transcendence (which describes the recipients being uplifted and surpassing the ordinary) emerged as a core component of hospital clowning in that hospital clowns elicit a combination of amusement and feeling state that go beyond the typical humor response. Both samples used in Part One consisted of individuals observing hospital clown interventions. To replicate and extend the results, in the following parts the effects on the emotional state were investigated with a sample of adult hospitalized patients. In Part Two, the CLEM-29 was presented to a group of 42 adult hospitalized patients involved in a hospital clown intervention to investigate whether the emotional states identified by experts and laypersons actually exist during a real clown-patient interaction. The study used a controlled experimental design within a natural hospital setting to examine the degree of similarity of emotions elicited when observing the intervention and when being involved in the intervention. Additionally, the experiment was designed to gain more insight into the unique effects of hospital clown interventions on patients in comparison to other types of intervention typically used in hospitals (e.g., a nurse assessment). Results showed that the hospital clown intervention elicited higher levels of self-reported amusement than a nurse intervention (while no difference was found for transcendence and unease). No differences were found between the emotional state of patients observing the intervention and patients involved in the intervention. Again a combination of transcendence and humor (here: the level of perceived funniness) best predicted the total amount of positive affect after the hospital clown intervention, supporting the notion that a hospital clown intervention replicates and exceeds the results from previous research. Importantly, the experiment had a higher internal validity than previous studies; however, external validity was limited, as only one III clown pair was used and thus no effects of different humor types were investigated, and results were valid only for the adult sample of patients in a rehabilitation center. Furthermore, no objective assessment of emotions was used, and no effects of individual differences in the emotional reaction of patients were investigated, which was done in Part Three. Part Three only took into consideration the emotional reaction to the hospital clown intervention, and studied the facial display of enjoyment (Duchenne smile; Ekman, 2003) elicited by hospital clowns compared to false smiles (Non-Duchenne smile; N = 26). It aimed at validating the subjective emotional experiences of patients with an objective assessment method. The study furthermore examined individual differences of patients in their habitual susceptibility to smiling and laughing. Trait cheerfulness has been identified to predict the emotional experience and observable behavior of individuals in several humor studies (Ruch & Hofmann, 2012), and was therefore defined as a potential factor in influencing the emotional state of patients during an interaction with a hospital clown. Results identified the Duchenne smile as the predominant facial display of patients during the intervention (76% of all smiles were smiles of enjoyment). Additionally, patients with a higher frequency of Duchenne smiles also reported higher levels of perceived funniness of the clown visit, global positive feelings, transcendence and enjoyment of participating in the study, which demonstrated a high convergence of subjectively and objectively assessed emotional states. Individual differences in trait cheerfulness influenced the frequency of Duchenne smiles (high trait cheerful individuals had higher frequencies of Duchenne smiles than low trait cheerful individuals, and reported higher levels of positive emotions), indicating that the success of a hospital clown intervention depends, among other factors, on the general susceptibility of individuals to humor. The thesis made an important contribution to the understanding of the elicited emotional states in observers and participants of hospital clown intervention, and provided a IV suitable self-report instrument, which can be of use for future studies. The use of the standardized experimental design in Part Two and Three enhanced the internal validity as it reduced the likelihood for systematic errors. Results presented in the thesis are of use to clown organizations training clowns,