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Laughing to longevity—the work of elder clowns

2011; Elsevier BV; Volume: 378; Issue: 9791 Linguagem: Inglês

10.1016/s0140-6736(11)61280-4

1474-547X

Bernie Warren, Peter Spitzer,

Aging and Gerontology Research

In 1969, at the age of 15, I (BW) accompanied my best friend and his mother to the Chiltern Cheshire Home nearest our house. Ostensibly I was going to help prepare a Sunday tea for the residents of the home, many of whom had lost their mobility, hearing, and sight, during World War 1 and some were also living with dementia. As I helped deliver the tea I sang to, and with, the residents. I told jokes and stories, and listened to their jokes and stories. What I didn't know then was that I had started a journey that would become a lifetime of work and research in the arts and health care. Many years later, in 2002, I met Peter on a very rainy evening in a cafe in Paris. It was a meeting that very nearly didn't happen. I had been in Spain doing research on the role of clowns in hospitals, while Peter was on a Churchill Fellowship undertaking an exhaustive and exhausting study on the international effect of hospital clown units on the health-care system. Luckily, despite the weather and our schedules, the meeting did take place. Since that time we've engaged in collaborative research on many aspects of clown work in health-care settings. Our most recent work has involved examining the practice of elder clowns working with older people in residential care and health-care settings. For nearly three decades professional performers have worked as hospital clowns to help improve the mood of patients in a therapeutic context. Clowns work under many names—for example, clown-doctor, therapeutic clown, medical clown, or hospital clown. These various names in part emphasise whether clowns regard their work primarily as "clown therapy" with an aim to help deliver interventions for patients, or as "artistic" in its intent with a more performance-based role in which they parody the work of doctors and nurses, which can provide benefits for patients in and of itself. However, many hospital clowns view their work as a balance between both approaches—a blend of artist and health-care worker. Initially, the work of hospital clowns developed in paediatric wards with clowns working primarily in large urban centres. But during the past decade this work has evolved and, today, it is delivered across the lifespan in a wide range of health-care settings. Professionally trained hospital clowns now work with patients undergoing dialysis or in palliative care settings, as well as patients in oncology wards, burn units, paediatric wards, and emergency medicine units. In these settings clown-doctors work with health-care staff to help reduce patients' stress, as well as supporting patients and their families to develop positive attitudes, coping mechanisms, and resilience in the face of illness, tragedy, and catastrophic health events. Another relatively new area that clowns have begun to work in is with older people both in geriatric wards and in residential care homes. My (BW) first experience of the value of clown work with older people came in 2001. I encountered an Italian woman in her 80s who sat silently in her wheelchair in the same place every time we visited. She looked sad and distant, in her own world and space. In my role as "Dr Haven't-a-clue" I walked over to her, instinctively I gently held her hand in mine and began to sing She moves through the fair. As I softly sang the first words, her eyes opened and she looked directly at me. As I sang she held my gaze and smiled, and at the end of the song she said, "thank you, thank you very much for coming". I later learnt these were the first words she had spoken in almost a week. The residents of care facilities for older people are often afforded few choices about their lives. Many do not have a key to their front door, they cannot choose their home furnishings or what colour to paint their walls. This loss of control and independence tends to exacerbate negative feelings that may already be present as a result of the loss of old friends and a diminution in physical abilities and, for some, mental acuity. Recent research has suggested that some older people who use humour as a way of coping with the challenges of ageing might be more likely to live longer, age well, and be more satisfied with their physical health and experience a better quality of life. However, opportunities to experience humour and laughter can be hard to come by for residents of residential care facilities. The recent development of elder-clown programmes with distinctive models of delivery, practice, and goals may go some way to meet the needs of these seniors, especially those with dementia. An elder clown is a professional performer who works with older people living in various residential care facilities, such as nursing homes, long-term care facilities, and closed dementia units. Elder-clown programmes operate around the world: for example, Hearts&Minds, based in Edinburgh, UK, uses clown-based techniques to encourage communication, interaction, and laughter in hospice, residential, or respite care, while in the Netherlands, the MiMakkus Foundation uses clowns for sensory work and non-verbal communication with patients with dementia in health-care settings. In Chicago, USA, the Big Apple Circus, Vaudeville Caravan works in residential nursing care facilities and uses a repertoire of recognisable songs, puppetry, dance, and magic to help empower older people to take part in the action and express positive emotions. Our own involvement with elder clowns is through Fools for Health in Canada and the Australian Humour Foundation. Both these charitable organisations work with a range of patients in hospitals but also have dedicated programmes for elder clowns. Fools for Health works with seniors living in residential care facilities and uses elder clowns to promote wellness and to improve quality of life through the use of humour, music, and improvised play. By contrast, the Australian Humour Foundation's Elder Clown Programme primarily visits people with dementia or depression in aged care and dementia facilities. These visits take place on a regular basis; however, the frequency and duration of visits varies for each programme and can range from three times a week to once a month, with each visit usually lasting 2 to 4 hours. The intention of elder clowns is to help positively change the atmosphere of the facility. While hospital clowns mostly visit patients in their hospital rooms, elder clowns go to a place that seniors call home. This home may be the last one they will know. Unlike in the hospital setting, most residents are not bed-ridden and elder clowns treat the resident's living space with respect. Elder clowns are not circus or birthday clowns who "play big". They do not wear garish make-up, oversized clothes, and large floppy shoes in order to be identified as clowns. Since elder clowns often perform in a more personal and private space than a hospital ward, they must perform in softer, subtler ways than their circus clown counterparts. They rely on character-based idiosyncrasies to create humorous moments and relationships in their interactions with other people. They use techniques, such as telling jokes and stories, magic, music, and song, to help stimulate memory and cognitive functioning. This is important since many older people in residential care facilities experience cognitive difficulties either from the natural processes of ageing or more profoundly as a result of dementia. The primary aim of the elder-clown visit is to engage with each resident on a personal level. Elder clowns also work with the health-care team. Before each shift they meet and interact with staff and receive notes about each resident's psychosocial and medical condition. Elder clowns keep notes after the visit and share their observations with the health-care team. Elder clowns are improvisers who use staff information about a resident's abilities, previous history, and interests combined with their own experience and intuition to create tailored interactions, or "plays", with each resident. Strategies used by elder clowns include such approaches as asking residents stimulating questions to engage them in conversation. By asking the resident to tell them a story about a picture on their wall, or asking them if they have one piece of life advice, for example, elder clowns may encourage residents to take the lead in interactions. Often through the clown's misunderstanding of instructions and "acting foolish", residents have the opportunity to tell the clowns what to do. All of these strategies may return a sense of autonomy to individuals who have very little control over their lives. This engagement is especially important for residents who do not receive many visitors. Some of our recent research in Canada as part of the "Down Memory Lane" project suggests that elder clowns may help some seniors improve communication skills, mood, and quality of life. Elder clowns may also help some older people with dementia connect to their immediate surroundings and remember some past events. We have also found that the presence of elder clowns can have a positive effect on the feelings of staff members caring for older people. Recent and ongoing research points to the value that this type of clowning may have for older people and staff in residential facilities. This work has led to an increasing interest in the development of similar programmes in facilities not currently receiving elder-clown visits. Although more research is needed, our first decade of work as elder clowns suggests that a playful, improvisational, and light-hearted approach to psychosocial health may have beneficial effects on the lives of elderly residents, their families, and the staff who care for them. For older people who have experienced so many losses, the work of elder clowns can return humour, playfulness, music, and joy to their lives. BW is founder of Fools for Health and PS is co-founder and Medical Director of the Humour Foundation; both organisations are charities.