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Essay: Hospital clowns—modern-day court jesters at work

2006; Elsevier BV; Volume: 368; Linguagem: Inglês

10.1016/s0140-6736(06)69919-4

1474-547X

Peter Spitzer,

Historical Psychiatry and Medical Practices

Clowning has a long history as an art form that invites play, interaction, and above all laughter. The court jester or fool was a particular type of clown in the Middle Ages, someone thought of as a special individual whom God had touched with a childlike madness. They wore bright, motley-patterned costumes and floppy, three-pointed cloth hats with a jingle bell dangling from each point. They also carried a mock sceptre. Mediaeval medicine considered health to be largely governed by four humours: sanguine, melancholic, choleric, and phlegmatic; imbalance of the humours produced distinctive emotional states. The court jester was specifically employed by the court to help rebalance the humours. For example, the court jester would be summoned to lift the monarch out of an angry or melancholic mood. Primarily, the court jester used humour and improvisation. Other skills included music, poetry, and acrobatics. The tradition of court jesters lasted about 400 years in the royal courts of Europe, the Middle East, and Asia. Clowning in hospitals is not a new development. Several centuries ago in Turkey the Dervishes, who were responsible for the well being of patients, first fed the body then used their performance skills to feed the soul. The September 1908, issue of Le Petit Journal had on its cover a drawing of two clowns at work in a children's hospital ward in London. More recently, Patch Adams, as a young doctor in the 1970s, began clowning for hospital patients in Virginia, USA. Big Apple Circus established the Clown Care Unit in New York City in 1987 as the first structured hospital clown programme, with frequent and regular visits to host hospitals. There are now many hospital clowning programmes around the world—Theodora Foundation (Europe, South Africa, Hong Kong, and Belarus), Le Rire Médecin (France), Die Clown Doktoren (Germany), Payasospital (Spain), Soccorso Clown (Italy), CliniClowns (Europe), Doctors of Joy (Brazil), Fools for Health (Canada), and Humour Foundation (Australia). The study of humour and its effect on the human body is called gelotology. The Association for Applied and Therapeutic Humor, founded in 1988, defines therapeutic humour 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". Much has been written about the healing power of humour and laughter, and there are many studies on the effects of laughter, which the philosopher Bertrand Russell described as a universal medicine. The role of the hospital clown is to bring play, humour, and laughter into the facility for the benefit of the patient, family members, and staff. This role originates from the philosophy that laughter is the best medicine. Sharing a smile and a laugh not only activates healing elements but also creates an atmosphere of positivity and warmth. In 1997, Jean-Paul Bell, a professional performer, and I, a medical practitioner, founded the Humour Foundation, an Australian charity. It is dedicated to promoting the health benefits of humour to patients, their families, and health-care professionals through its core project, the Clown Doctor Program. The creative concept was the possibility of marrying medicine and the arts. There was no previous programme of its kind in Australia, so a new model had to be created to answer the questions (of what, how, who, why, where, and when) surrounding the art of medicine. Organisational structure underpins the delivery of the programme to the host hospital, supports the performers, and sources funding. This administrative section is staffed by professionals, with support from volunteers to help contain and reduce operating costs. Hospital clowns are professional performers. They come from a variety of backgrounds—clowning, acting, physical theatre, mime, music, close-up magic. Many different people want to be hospital clowns. Most continue to work in their original type of performing, which helps maintain a good balance. Hospital clowning is intense work and is not sustainable on a full-time basis. The maximum work load is 3 days a week. Selection is via an audition process. The applicant is screened to assess his or her ability to deal with the hospital experience. They must be able to work with a partner, have strong improvisation skills to use interactively, and be comfortable with taking instructions from hospital staff. After selection, there is a 3-month trial period working in hospitals with a senior clown. Each clown takes on a Clown Doctor name, such as Dr Doctor, Dr Achoo, Dr B Bubbly, Dr Phil Betta. All attend regular monthly team meetings, performance-related workshops every 3 months, and an annual conference. What is a typical day in the life of a Clown Doctor? He or she meets their partner in a designated "dressing-room" space, at which time they will catch up to review messages and any patients' or staff referrals. Next begins the transformation into character. The silly clothes, the oversized shoes, the white coat with too many pockets, the outrageous props and musical instruments are all checked; as well as the hat. Little or no make-up is used. In this close-up work, the traditional clown make-up can be scary for some children. Finally, the schnoz goes on. Clown noses come in a huge variety of colours, shapes, and sizes. This is a defining moment in the day. The Clown Doctor is in and on duty. A couple of songs, some musical tuning, testing a couple of props, and some jokes are all part of the warm-up. The relationship between Clown Doctor and medical staff is crucially important. We acknowledge each other and maintain a professional working partnership. Meeting with staff is the first point of contact when coming into a ward. They give us up-to-date relevant information about the patients. They tell us about the state of play in the ward. In exchange they get a story, a serenade, the latest gag or prop, or even a massage; all part of a 1 minute tropical holiday routine. Doctors conduct ward rounds; Clown Doctors conduct clown rounds. Permission is needed to enter the patient's space. Here, we look for what is right with the patient and the emphasis is on interaction. Often the family and staff are drawn into the play. Most often, gentle parody of the hospital routine works to reduce stress and anxiety for the patient. Laughter prescriptions are given, funny-bones are checked, red-nose transplants are done without anaesthesia, and cat scans are enjoyed. There is no fixed routine, and improvisation ranks highly. Areas visited include medical and surgical wards, intensive-care units, outpatient areas, emergency, dialysis and oncology areas, and preoperative and postoperative wards. In some hospitals there are specific protocols to accompany the child into the operating room. We are paged for specific situations, such as activating a distraction technique during a difficult procedure. Staff in procedural areas have learnt of the benefits that Clown Doctors bring, especially in burns units and for bone-marrow procedures. The child is more relaxed, as are the staff, and the procedure proceeds more smoothly. And the child is left with a more positive memory. I recall the time we were asked to see a 12-year-old patient in a major city burns unit. He had received the maximum dose of narcotics, and we were invited to see whether we could help him feel more settled. We improvised by using a thumb stall with a built-in red light as a "hot-spot remover"—the latest thing in Clown Doctor technology—which was passed magically in the air between Clown Doctors until it finished up in a magic bag, only to disappear into thin air. A pleasant surprise replaced the dreaded, painful "hot-spot". The screaming stopped. In this situation, professionals whose work was known and who acted as trusted partners with health professionals, were briefed on a situation. Action was taken that proved both inspiring and therapeutic. Clown Doctors weave their magic to change the balance, feeling, and atmosphere in a hospital setting and move on. Procedural staff would like us to visit daily! At the end of the day it is time to change. Take off the schnoz; reflect on the day; record stories and events; provide follow-up for the next team visit. Debrief. Clown Doctors remind us of so many things: to take our work seriously but ourselves lightly; the value of a smile and a laugh; that it is OK to take a minute to play. As medical practitioners, we can, beneficially, incorporate appropriate laughter and play as brief interventions in our clinical practice. I do. Take the risk and enjoy letting your inner clown emerge. Peter Spitzer has worked in general practice for 25 years. He is also the Chairman, Medical Director, and co-founder of the Humour Foundation charity. In hospitals, he works as Dr Fruit-Loop with the aim of dispensing mirth, infecting the ward with laughter, and leaving his patients in stitches. Peter Spitzer has worked in general practice for 25 years. He is also the Chairman, Medical Director, and co-founder of the Humour Foundation charity. In hospitals, he works as Dr Fruit-Loop with the aim of dispensing mirth, infecting the ward with laughter, and leaving his patients in stitches.