Not Just Clowning Around

The use of humour in health care dates back to the time of Hippocrates, when musicians, jugglers and clowns were considered part of the healing process, Dr. Bernie Warren tells his audience of health-care professionals, clowns, artists, caregivers and volunteers.

Warren, aka “Dr. Haven’t-a-Clue” a Professor of Drama at the University of Windsor, is the founder of Fools for Health, which runs clown doctor programs for all ages in hospitals and health-care facilities across Southwestern Ontario. He and Dr. Peter Spitzer, aka Dr. Fruit-Loop, a family physician, Australia’s first medical Clown Doctor, and the co-founder of the Humour Foundation charity, a non-profit organization which promotes the health benefits of humour, presented a full day workshop at Baycrest on the use of medical clowning with seniors in health care settings as part of the International Week of Clowning, Laughter and Health Care.

In modern times, most clown doctor work has been with children in large urban centre hospitals. Around 2000, Magdalena Schamberger, with the Hearts and Minds program in Edinburgh, Scotland, initiated clown work with seniors, and other programs followed suit. While both Warren and Spitzer admit that hard data may be lagging, they believe that the benefits of using therapeutic clowning with seniors are clearly visible. In 2007, in one hospital, Fools for Health even garnered a standard of care for Long Term Care recommendation from the Canadian Council on Health Services Accreditation.

Warren explains that clown doctors are usually paid professional clowns who have received additional training about various medical procedures, listening skills, empathy and how to interact with people with dementia. Unlike circus clowns, therapeutic clowns wear subtle makeup and costumes, which helps decrease the risk of frightening people. Clown activities can include parodying medical procedures, storytelling, gentle singing and dancing and engaging in discussions about news or events on television. Staff provide notes at the beginning of each clown visit about what is happening in the seniors’ lives, including night-time agitation or visits from the family.

Warren, who, as a clown, wears a red nose and multi-coloured jester’s hat, recalls later on the telephone, of a time when he was quietly singing an old Irish folk song to a patient with dementia, looking into her eyes and holding her hand. At the end, she said “thank you.” He later found out from the staff that she had not spoken in six weeks.

Spitzer, who presents at the conference in a bright yellow shirt splashed with red and blue flowers and a clown tie, says he is able to garner more information from his patients in his clown doctor role than he normally would. “I’m learning stuff through play. I’m learning about the person; I’m learning about the history of their lives, how their family interacts with them and I add that to my knowledge of that person,” he says. This helps him to deliver care in a cooperative and connected manner.

Over the years, a multitude of physiological and psychological benefits have been attributed to laughter as “the best medicine.” One study frequently cited seems to indicate that cortisol, the stress hormone, was reduced among participants in a humour program. However, its small sample size of young healthy adult subjects makes it difficult to generalize the results, particularly to pediatric and senior populations.

Warren says there are challenges to researching the effects of the clown doctor program because no two patients, hospitals, clowns or clown activities are ever the same. Still, one study he conducted showed that the clown visits lightened the mood of both patients and staff, helped patients to relax, eased symptoms of pain and discomfort and enabled staff to more easily administer medical treatments. Warren also found that even among patients with significant dementia, they seemed to remember which clowns visited the previous week, what they did and even seemed to make some connections to the past that they had not done before. He has two pending research grants to look at clown activities, the changes they elicit, and whether the activities are replicable, which he can then integrate into future clown doctor training.

Spitzer is currently in the second year of the Sydney Multi-site Intervention of LaughterBosses and ElderClowns (SMILE) study, in collaboration with the Dementia Collaborative Research Centres. About 400 residents from 36 residential facilities will be randomly assigned to receive the SMILE treatment or usual care. The SMILE treatment involves ElderClowns visiting weekly for 12 weeks and staff volunteers trained to be “LaughterBosses” bringing humour to daily care routines. The study, funded by Australia’s National Health and Medical Research Council, will evaluate the residents’ mood and behaviour, quality of life, impact on staff and the costs and benefits.

One criticism that sometimes arises is whether using clowns in care infantilizes seniors, particularly those with dementia. Jan Stirling, a psychosocial consultant with Dr. Clown, a company founded in Montreal that has recently started offering professional therapeutic clown services in Toronto, disagrees. She says that access to play for older adults can help honour their life experience and enables them to serve as “teacher, advisor, mentor, counsellor.” She cites one example where the senior was able to provide wonderful advice to two clowns acting as a rather competitive couple.

Stirling sees humour and laughter as by-products of play, for which the true purpose is to build a relationship where “there’s a respect for the person, there’s a genuine affection and warmth towards them; there’s an attitude of joy and curiosity and possibility.”

Bianca Stern, the director of Culture and Heritage at Baycrest, who helped organize the event, agrees. She says that with the boomers growing older, many people are living with chronic conditions. She says health professionals know they have to give compassionate care, “but where does play fit in, where does joy and spontaneity fit in, and why should it not fit in at this age?”