Medical Clowning in a Physical Therapy Setting

Such creative approaches to therapy can empower patients

In the last decade, there has been significant growth of medical clowns in hospitals internationally. The Theodora Foundation provides funding for clowns in Europe, Africa, and Asia.1, while in the United States, Big Apple Clown Care Unit (CCU) consists of 80 clown doctors, some of whom visit inpatient and outpatient physical therapy settings.2 Numerous volunteer caring clowns also serve in the United States and Canada, in particular.1 Clowning has been shown to provide many benefits for a variety of ages and conditions including children,3 older adults with dementia,4 and women after in vitro fertilization and embryo transfer.5 Medical clowns are a means to increase collaboration, innovation, and consumer-centricity as called for by the American Physical Therapy Association's (APTA) guiding principles to achieve the Vision Statement for the Physical Therapy Profession.6

An Integrated Team: Increasing Collaboration
In accordance with the guiding principle of collaboration, physical therapists ought to seek more interaction with community organizations. The integration of the Quad-City Clown Troupe clowns into healthcare and rehabilitation facilities in Davenport, Iowa and the surrounding Quad City area, for instance, has led to many positive results.  Therapeutic clowns are integrated members of professional healthcare teams, as they provide targeted empathetic care to compliment the work of other medical personnel.3 A study in England showed a majority of pediatricians believed clown doctors have a positive impact on children; this same study showed that even though many members of the healthcare staff personally did not like clowns, they still perceived they were having a positive impact.7

Likewise, a study in Hamburg, Germany found that almost 91% of the hospital staff found the presence of hospital clowns enriching to daily routine, but the clowns themselves thought that interdisciplinary collaboration could be better.8 I would echo the satisfaction of healthcare staff with medical clowns to be true based upon my own clowning experiences in Davenport, IA this semester. In one case, a nurse at a nursing home came up to us and said, "You know, I typically don't like clowns, but you aren't scary clowns. You're nice clowns, and I like you!" The integration of clowns into a physical therapy setting has a lot of potential and is having a positive result in many locations. In order for the physical therapy profession to fully live up to the guiding principle ideal of collaborating with community organizations, medical clowning must be considered and pursued as a valid means for improving health.

 Positive Psychology: Increasing Innovation in Healthcare Delivery
As healthcare becomes increasingly focused on a holistic approach, the need to use creative and artistic approaches becomes all the more crucial; creative and artistic thought and behavior has an overarching influence on the daily lives of people.9 Medical clowning is obviously an innovative approach to healthcare that provides room for creative expression with techniques which include music, storytelling, and magic tricks.3 The importance of medical clowning is in part highlighted by research findings about the benefits of humor and laughter. This research largely comes out of the recent positive psychology movement to increase the study of the factors that lead to increased psychological well-being and human strength.10 Research has shown laughter can increase immune function,11 lower blood pressure,12 and produce weight loss.13 Medical clowning, or simply the increased use of humor by physical therapists themselves, could clearly have many positive effects on health.

Empowerment: Increasing Consumer-Centricity
The heart of medical clowning is trying to empower patients. This is different from circus clowning, in which the goal of the clowns is to perform and attract attention to themselves. One way therapeutic clowns detract attention from themselves is by wearing minimal make-up, which also works to decrease the fears of those who may have coulrophobia or ballatrophobia, the fear of clowns.3 Research suggests an increased sense of perceived control can have positive health effects.14 There are many techniques clowns can use to specifically empower the patient and give them more perceived control:15 first, the clowns can empower patients by requesting permission to enter the room or approach them, something patients rarely get a choice in.
Another method is for the clown to construct a "problem." The problems of clowns are limitless, from not being able to get their hat on, to perhaps losing their dinosaur in the hallway. Clowns tend to take a long time to solve their problems, but they take all of the patient's suggestions to heart, because he or she is the expert. In addition, being fully present is key to empowering the patient. The patient must be central to the clown in the present moment; all of the distractions of the larger world disappear. Physical therapists may practice medical clowning techniques in their day-to-day by giving patients control in less fantastical ways and being present; by asking patients if they are ready to start, giving them a choice of activity, and giving them full attention, presence can go a long way.

The Future of Medical Clowning and Physical Therapy
Medical clowning has the ability to contribute to the achievement of the APTA's Vision Statement for the Physical Therapy profession, especially through the guiding principles of collaboration, innovation, and consumer-centricity. As medical clowning continues to gain footing in the United States and around the world, physical therapists will be more likely to encounter clowns in their profession. Physical therapists do not have to wait to act, however. One option would be to discover if any local clowning troupes already exist and, if they do, to contact them and see if they have had any experience interacting with patients. Another option would be for physical therapists to embody the values of medical clowning themselves. By increasing the use of humor and empowering patients, physical therapists may improve quality of care and the human experience.



1. Koller, D., & Gryski, C. (2008). The life threatened child and the life enhancing clown: Towards a model of therapeutic clowning. Evidence-Based Complementary and Alternative Medicine, 5(1), 17-25. doi: 10.1093/ecam/nem033
2. Performers collaborate with doctors to fit the needs of each hospital. (2012). Clown care. Retrieved from http://www.bigapplecircus.org/clown-care/
3. Finlay, F., Baverstock, A., & Lenton, S. (2013). Therapeutic Clowning in Paediatric Practice. Clinical Child Psychology and Psychiatry 0(0), 1-10.
4. Stevens, J. (2012). Stand up for dementia: Performance, improvisation and stand up comedy as therapy for people with dementia; a qualitative study. Dementia, 11, 61-73.
5. Friedler, S., Glasser, S., Azani, L., Freedman, L.S., Raziel, A., Strassburger, D., Ron-El, R., & Lergner-Geva, L. (2011). The effect of medical clowning on pregnancy rates after in vitro fertilization and embryo transfer. Fertility and Sterility, 95(6), 2127-2130.
6. Vision statement for the physical therapy profession and guiding principles to achieve the vision. (2014). Vision. Retrieved from https://www.apta.org/Vision/
7. Battrick, C. Glasper, E.A., Prudhoe, G., & Weaver, K. (2007). Clown humour: The perceptions of doctors, nurses, parents and children. Journal of Children's and Young People's Nursing, 1(4), 174-179.
8. Barkmann, C., Siem, A., Wessolowski, N., & Schulte-Markwort, M. (2013). Clowning as a supportive measure in paediatrics-a survey of clowns, parents and nursing staff. BioMed Central, 13(166), 1-10.
9. Christenson, G.A. (2013). Conceptualizing the arts as tools for medicine and public healh. Journal of Applied Arts and Health, 4(3), 247-264.
10. Compton, W.C., & Hoffman, E. (2013). Positive psychology: The science of happiness and flourishing (2nd ed.). Belmont, CA: Wadsworth.
11. Dillon, K., Minchoff, B., & Baker, K. (1985-1986). Positive emotional states and enhancement of the immune system. International Journal of Psychiatry in Medicine, 15, 13-18.
12. du PrĂ©, A. (1998). Humor and the healing arts: A multi-method analysis of humor use in health care. Mahway, NJ: Lawrence Erlbaum Associates Publishers.
13. Buchowski, M., Majchrzak, K., Blomquist, K., Chen, K., Byrne, D., et al. (2007). Energy expenditure of genuine laughter. International Journal of Obesity, 31(1), 131-137.
14. Mallers, M. H., Claver, M., & Lares, L. A. (2014). Perceived Control in the Lives of Older Adults: The Influence of Langer and Rodin's Work on Gerontological Theory, Policy, and Practice. Gerontologist54(1), 67-74.
15. Lindheim, J. (2007). The Art and Joy of Hospital Clowning. Needham, MA: Hearts & Noses Hospital Clown Troupe.

Kristin Upah earned a Bachelor of Science (BS) degree in Behavioral Neuroscience at St. Ambrose University in Davenport, Iowa, where she was enrolled in a Medical Clowning course. Upah started coursework in August 2014 in the Doctor of Physical Therapy (DPT) program at St. Ambrose.

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