Joy without demands: Hospital clowns in the world of ailing children.

The aim of the present study was to achieve, using an affect theory approach (Tomkins, 1962; 1963; 1991), a deeper theoretical understanding of the psychological significance of hospital clowns' work in caring for ailing children viewed from a care-giver perspective. The methodological approach was qualitative and based on 20 interviews with healthcare staff: 3 men and 17 women. The result showed how the staff emphasized a psychological quality of care alongside the physical quality of care. The hospital clowns' "unexpected possibility" provided a safe area for recovery, for both the children and the staff. The theoretical interpretation showed the presence of the affects surprise/startle, interest/excitement, and enjoyment/joy as well as specifically how "joy without demands" often had a lingering effect in the form of vitality. Joy without demands is discussed in relation to psychological theory with emphasis on: a confirmation of the body's possibilities, a magical attachment, a chance to transcend boundaries, and a non-demanding situation.

Introduction

During the past 20 years in Sweden, as well as in other countries, hospital clowns have come to work with children in the context of healthcare (Duffin, 2009; Gibson, 2004; Linge, 2007). Gryski (2003) described enterprises in the USA (Big Apple Circus) and in Canada where hospital clowns work at various children's hospitals. Duffin (2009) discussed the Big Apple Circus and its clown program in the USA, and pointed out the value of clowns' ability to increase healthcare staff members' feeling for and sensitivity to the emotional climate created with the children. Several European countries have established clown programs, including Le Rire Medicin in France. In her research, Linge (2008) has focused on the various working methods of hospital clowns active in different university hospitals in southern and central Sweden.

Gryski (2003) described the importance of encounters with hospital clowns in building up children's ability to overcome difficult situations through games that reinforce their hope of recovery and their competence in a positive spirit of community with tolerant adults. Klein (2003) emphasized the work of hospital clowns pointing out their play and clowning, which promote the development of children's creative thought and social skills. With regard to children's physical health and well-being, one study (Linge, 2007) showed how play constitutes the point of departure and how curiosity is stimulated in encounters with hospital clowns. In particular, the hospital clowns' and the child's synchronized body movements become an encounter characterized by affinity, with the child leading and the clowns following. The child is the one who controls the activity in a communication with or without words.

With respect to healthcare, Duffin (2009) described different ways of finding new approaches to increasing salutary interactions between staff and child patients. The reason for involving hospital clowns in training healthcare staff is to achieve a feeling of ease and cheerfulness within the hospital walls. Through play training, staff members can test being more conscious of various emotional states and in this way increase their competence as regards helping ailing children deal with their problems in an enjoyable manner. In this connection, Duffin mentioned a certain initial skepticism among the staff, as well as how this skepticism gradually diminished with their increased awareness and greater emotional accessibility in encounters with the children. For instance, Vagnoli, Caprilli, Robiglio, and Messeri (2005) showed how the presence of hospital clowns, together with the child's parents, when anesthesia is given constitutes an effective intervention for managing the child's and parents' anxiety during pre-operative preparations. The study reveals the importance of the hospital clowns' presence in the pre-operative room though, of course, not in the operating room.

Examinations and treatments often put great strain on the children and their parents and negative affects such as sadness and fear are present. But if the negative affects can be reduced making room for more positive affects, the child will probably be able to actively overcome his/her hospital stay instead of just passively experiencing it. Using Tomkins's (1962; 1963; 1991) affect theory as our reference, we can elucidate an affect climate that includes the positive affects interest/excitement and enjoyment/joy; the neutral affect surprise/startle; and the negative affects anger/rage, fear/terror, distress/anguish, shame/humiliation, disgust, and dissmell. Linge (2008) showed how it is the hospital clowns' duty to “infect” the children with the positive affects. Bauer (2005) referenced Italian brain scientist Giacomo Rizzolatti, who has shown how various neurons in the brain are set in resonance and how this “infectiousness” allows the affect of enjoyment/joy to spread to many people involved in a common activity. Sonnby-Borgström (2005, p. 131) wrote:

Current neuropsychological research can add a additional link to the explanation of the tendency for us to imitate and for our emotions to be contagious. Special neurons called “mirror neurons” are thought to play a role in the tendency to imitate other living creatures.

The aim of the present research project is to achieve a deeper psychological understanding of hospital clowns' work in the care of ailing children, seen from a care-giver perspective. The more concrete questions form the basis of the study: How do healthcare staff view hospital clowns' activities in relation to: (a) hospital clowns' working methods, (b) the role of healthcare staff and the collaboration with the hospital clowns, and (c) the children's well-being. The present article will present a theoretical discussion where the findings will be interpreted in an affect theoretical context using Tomkins's (1962; 1963; 1991) affect theory as the theoretical base.

The present study is part of a research project: Hospital clowns—in the care of ailing children—which is a three-stage research project funded by the Swedish Childhood Cancer Foundation.

Method

Research design

The present study in this research project utilizes an interpretive phenomenological analysis (IPA; Eatough & Smith, 2008) method, where data are collected through interviews and interpreted through both descriptive and theoretical analysis. It is also influenced by Gadamer's (1997) hermeneutic approach using language as a guide for understanding and interpreting the individual's inner life-world and experiences in all their diversity and complexity. The IPA focuses on the individual's lived experiences, using interviews as a means of collecting data. A semi-structured interview form (Smith, 2007) has been used as a framework for the interviews including certain predetermined initial questions, which also allowed for the spontaneous and unexpected.

The intimate and detailed aspects of the narrative constituted the starting point, which was later integrated with a deeper and more holistic perspective in the summary of the result. The process of “step-by-step” involved a description of the introductory narratives including the possible links between them. Finally an analytic work has entailed moving back and forth between the various steps in the results, as is done in the hermeneutic tradition (Dahlberg, Drew, & Nyström, 2001). According to Eatough and Smith (2008), the final presentation should ideally move between different levels, from a rich description to a more abstract interpretation of the results. The present theoretical interpretations have been based on the theoretical constructs of Tomkins' (1962; 1963; 1991) affect theory.

Participants

First the selection criteria. The directors of the respective children's hospitals gave their permission for us to contact their staff. At this point, suggestions were made about contacts at the hospitals, who in their turn could provide the names of staff members who had worked with the hospital clowns earlier for various lengths of time. The goal was to include a broad spectrum of healthcare staff, which would reflect everything from director positions and managerial functions on the ward to staff who worked in close contact with the children and the hospital clowns.

Then the selection process proceeded as follows. Twenty care-givers (between 30 and 60 years of age) were contacted. In the present study, the concept of “care-givers” applied to three men, who had positions as senior physician or director, and 17 women, who had the following positions: registered nurse (9), children's nurse (7), and a play therapist (1). The staff members worked on oncology wards, general medical wards, and orthopedics wards at three university hospitals in southern and central Sweden. Finally they all agreed to participate in the interviews. Because the sample was small, the various occupational categories could only represent their workplaces to a certain degree. Only three kinds of wards have been included in the study: oncology, general medicine, and orthopedics. The children (0–18 years) were being treated and cared for on these wards during stays of different duration.

Data collection

An interviewing guide was prepared; five themes, related to the relevance and credibility of having hospital clowns, framed the areas to be explored. The five themes that were presented initially (so as to construct a framework around the interviews) were: the hospital clowns' working methods, each interviewee's own staff role, cooperation, the children's well-being, as well as obstacles and possibilities associated with the hospital clowns' work in the care of ailing children. The semi-structured interview format enabled a free discussion around the various themes, such that the interviewees were able to talk about their experiences of collaborating with the hospital clowns. This format also allowed follow-up questions. The present author was the interviewer in all of the interviews.

Procedure

All of the 20 interviews were conducted at the interviewees' workplaces (coffee rooms, conference rooms, or staff rooms). The interviews lasted between 45 and 60 min. The interviews started with a review of the aims and questions, as well as a presentation of the five themes. Following this was a short description of the ethical principles, and then the staff members were asked whether they were willing to participate in the study. The interviews were audio-recorded and later transcribed in their entirety.

Ethical considerations

The local ethics committee of Halmstad University approved the study design (Dnr: 90-2008-486). The following four ethical considerations have served as guidelines (Brinkman & Kvale, 2008): informed consent, confidentiality, consequences, and researcher responsibility. These were introduced to the care-givers in the first meeting. All gave their consent to participate in the study. In the present article, the different occupational categories (senior physician, registered nurse, children's nurse, play therapist) have not been tied to the interview findings given the small sample and the principle of anonymity.

Qualitative data analysis

The descriptive analysis was then based on several readings of the result of the interview data, the goal being to achieve an initial understanding of the data as a whole. “The hermeneutic circle” (Kvale, 1997) thus constituted the reference point for the analysis and involved moving back and forth between the analytical steps to increase understanding of the whole as well as to reveal the similarities and differences in and the specific aspects of the narratives. This transference to the whole finally resulted in the idea of observing new themes—themes that would come to reflect the experiences of the care-givers.

The theoretical interpretation of the results was the next stage in the analytical work. A theoretical construct based on affect theory (Tomkins, 1962; 1963; 1991) formed the basis for achieving a deeper understanding of what occurred in encounters between the hospital clowns, the children, and the healthcare staff. Tomkins's affect theory has been chosen in consideration both of staff members' descriptions of the presence of both positive and negative affects on the wards and of their understandings of how the hospital clowns have dealt with the various affect climates.

Results

A descriptive level

Understanding the work of hospital clowns

From the care-giver perspective, the hospital clowns were depicted as an “unexpected possibility”—as people who allowed themselves to test and transcend boundaries beyond what is customary:The hospital clowns were described as possessing all the forms of expression of verbal and body language, often accompanied by musical reinforcement. “The speaking hospital clowns” were in the majority and found at several of the university hospitals. Their approach included working in pairs and they met children of different ages, from 1 year olds to teenagers whose interest in the clowns varied. If fear of the unknown was found among the 1 year olds, skepticism was more pronounced among the teenagers. Several of the staff members described how, when faced with meeting the clowns, the teenagers depicted the situation as “childish” and “embarrassing.” But several of the staff members also mentioned positive forms of interaction between the hospital clowns and the teenagers, when their common interest in modern music was in focus. The age group said to be most enchanted by the hospital clowns were the preschool children.

The clowns live in a kind of safe area … they allow themselves to do more than the rest of us do … I think that's why adults can sometimes be non-plussed … the clowns do things you sometimes wish you could do … but don't dare to.

“The quiet hospital clown” was described as a clown who worked alone, only spoke using small bodily nuances and was able to read the children's moods in a very subtle manner. One example showed how the quiet clown worked with a young immigrant boy, who only expressed himself using body language:The staff reported how even the most severely ill children were able to experience the clowns' tricks. In one case when there was a risk for infection, the quiet clown was not allowed to enter the boy's room. The clown solved this using an unusual strategy. One staff member described this strategy: “She would take a stepladder and appear outside, in front of the window … it's like they had a connection anyway.”

A boy of maybe five … he's good at going to the clown, who is quiet … and helping her … he shows the clown how to do things … he laughs himself silly … then he feels good … they have such great contact when they're together … he's such a sensitive child … he feels good because he gets so much out of it … easier to express himself that way … he doesn't have to talk … he doesn't have to work so hard to be understood.

Understanding the role of healthcare staff and collaboration with the hospital clowns

Collaboration between the clowns and the staff entailed giving each other “hints” as to what was going on and taking each other's activities into consideration. One interviewee said: “I really think they're good at reading the situation … they can tell if something isn't suitable at the moment.” What was clear in all of the narratives was the importance of prioritizing the various treatments and examinations. These routines were vital to both the children and their parents—to helping the children get well. But the staff members also described how the clowns now had a place at the hospital and a mission, not to treat illness but to entertain and divert. Thus, it was also a question of satisfying the healthy side of the child's character, in terms of seeing “the bright side of life” or “the healthy side of the child.”Several of the staff members talked about the various roles that existed, both their own work roles and the hospital clowns' professional role. In their own work role there could be scope for play, which could be coordinated with the hospital clowns' professional role. Someone expressed this in the following way: “I get to have fun for a while” or “I join in on the playing sometimes.” One of the staff members described what was special about the clowns, that they also paid attention to the staff who were with the child in the situation by looking at their name tags. “They try to make eye contact with us too.”

The clowns have been down with the cast guys too … because sometimes changing a cast isn't all that fun either … even if it's just a broken arm … if the clowns are there it can be kind of exciting … children prefer to focus on one thing at a time … and then it's not on what I'm doing … instead it's on the soap bubbles or the red nose … they're not afraid … they're so busy keeping track of that red round thing.

Understanding the children's well-being

All staff members described the “rush of joy” that swept over the wards when the hospital clowns arrived. There was an expectation inherent in the situation, and the staff talked about how the children's eyes “lit up” when the hospital clowns came near.One expression used by the staff was “place of refuge,” by which they meant that the children got a moment of relaxation and liberation from all the routine treatments and examinations at the hospital. Something different happened that lifted them above their daily hardships toward a more playful existence, where rules other than the prevailing ones applied:Several of the interviewees described how the children were acknowledged and paid attention to when the clowns used their names or even referred to their diagnoses:As a final acknowledgement of a young child and as a last greeting, several clowns attended a girl's funeral dressed in their clown outfits. One of the staff members talked about this:One working method used by the clowns in their profession was mentioned often—that they could “read” the children, or a special child, and discover exactly what that child wanted. Several staff members stressed what was special about this strategy, namely that it was different from the normal, routine work at the hospital, where it was the healthcare staff who set the day's agenda. The parents and children always had to submit to hospital routines, including the treatments and examinations that “were a must” if the child was to get well again. In contrast, the hospital clowns' strategy was to emphasize the “child's desires,” which often entailed bringing out the lively and vital aspects of the child's nature, things that were natural for a child of that age—that is, to be able to play and make “mischief.” Several of the interviewees described the hospital clowns' work as being important to the children's well-being. One said that the focus was determined “entirely on the ailing child's own terms.” Something different happened that was unexpected and unpredictable. One of the staff members described this:

It's so much fun for the children … cancer is so difficult for children and it makes things easier if something fun happens … and if it's a child who's been here for 3 days … and thinks it's hard … then a clown comes in … then there's something you can tell your siblings, your friends at school, and then the hospital visit is a little less dramatic … it spreads joy among children in unusual situations … and if it means happiness for the children then it means the same for the parents … many parents might not see their child laugh … in this situation they get to see their children laugh … it's wonderful during such a difficult time … really important.

I think it's important … relaxing … for the children, the humor and the music and laughter … the fact that people come in who they haven't counted on coming … who are very positive … a little place of refuge … very little … when they can forget everything else … because they do … very good for the soul … to let go of everything else … the kids here are severely ill … I'm sure it's very beneficial.

It's happened a couple times that the clowns have put bandages on themselves … sometimes the children have a lot of bandages, and then the clowns want to too … they sympathize with the children somehow.

A little girl of 2 1/2 died of cancer, she'd had so much fun with the clowns at the hospital … so that … then they took the time to go to the girl's funeral and played some funny songs … and did a little performance … something that was part of the communication they'd had with her before … it was so good for the parents to have the clowns there at her funeral.

It lessens the unpleasantness associated with a hospital visit … increases mental well-being … indirectly influences physical well-being … I think there are definitely benefits … positive effects for the rest of the care.

Theoretical level

A very obvious pattern in the descriptive result, as seen from the care-giver perspective, is the focus on the possibility of joy, in terms of experiencing a “rush of joy,” “the bright side of life,” and having “so much fun.” How can looking at things from the perspective of affect theory (Tomkins, 1962; 1963; 1991) give us a deeper understanding of the underlying meaning of the affect joy and the hospital clowns' strategy for achieving this affect?

Surprise/startle

Surprise/startle is precisely the affect the hospital clowns use to interrupt the situation the children find themselves in and to create the conditions for new and different experiences (Linge, 2008). The function of the affect surprise/startle is to reset the nervous system so that it can take in new information (Tomkins, 1962). This affect is visible in the facial expression, with raised eyebrows, wide open eyes, and a round open mouth. The hospital clowns want to “infect” the children with their facial expression and to get the children's complete attention. Thanks to recent research in neuropsychology (Bauer, 2005), we know how one type of neuron, the “mirror neuron,” contributes to the process whereby emotions “are contagious.” The function of mirror neurons is to activate a motoric pattern in the brain. According to Bauer, this is the same pattern that would have been activated had one performed the specific action oneself. If we relate this to the work of hospital clowns, we could say that the clowns promote surprise/startle through their external gestalt in order to capture the children's attention, in the absence of possible negative affects (e.g., fear or anger). The children are surprised and pause to seize the moment. In a short initial phase, this is the hospital clowns' primary task—to capture the children's attention.

Interest/excitement

Interest/excitement is the new affect that takes over, when surprise over the new and different has subsided. Their curiosity about what is different gives the children an opportunity to either interact with the clowns immediately or bide their time in the background, later daring to take a step toward careful interaction. According to Tomkins (1962), the interest affect is an intensifying affect, which means that curiosity is not subdued immediately but increases in its frame of reference to unexpected heights, which Tomkins (1962); Izard, 1977) calls excitement. The purpose of the affect interest/excitement is first to “capture” the individual so that he/she will later act. When they try to stimulate the children's interest in something pleasurable, the hospital clowns' objective is to open the door to the ailing children's life force, thereby giving them the courage to come up with fun games together with the clowns. Tomkins (1962) stressed the face, particularly the crucial role of the gaze in triggering the affect interest, where smiles and laughter are important companions. But the event also has a communicative effect, where interactions with the hospital clowns constitute encounters on the children's own terms. If the children are seen and heard (using eye contact and names) along with all of their inherent affects—both positive and negative—then a picture emerges of a child whose nature includes both healthy and ailing parts. In this way, the children do not need to struggle to be obedient, but can find a safe area in the situations scope of play by being themselves, something that also reinforces their own self-esteem. Once in a while, interest becomes over-excitement about the course of events, and the staff members described sometimes having to “help to set limits for the children.”

Enjoyment/joy

Enjoyment/joy is the last affect in the interaction between the children and the hospital clowns. According to Tomkins (1962), the positive affect of enjoyment/joy is needed to form and maintain relationships. Bauer (2005) described how the feeling of joy is infectious in social situations, something that clearly emerged in the staff members' reflections on the clowns' activities. Enjoyment/joy is a diminishing affect (Izard, 1977), which means that the affect decreases over time and makes room for smiles and laughter—often well-being as well—after the affect has peaked. Memories of the hospital clowns' pranks remain, something that also leads to interaction with staff after the clowns have left. These “colorful memories” may also be long-term, lasting into adulthood (upon repeat visits) as a positive experience from childhood stays at the hospital.

Comprehensive understanding

A comprehensive understanding of the complexity of experiencing clown encounters in child patients and hospital staff indicated that the deeper meaning of the sequence surprise/startle (first the reset of the nervous system), interest/excitement (then the positive affect takes over), and enjoyment/joy (finally a clown relation is established) could be interpreted as bridging the gap between the negative and the positive affects. The pleasurable “unexpected possibilities” helped both the staff and the children to relax and to find a “place of refuge.” The care-givers emphasized “the bright side of life” and the hospital clowns' strategy of fulfilling the children's desires in joyful fellowships, a strategy important to the children's well-being. The healthcare staff clearly described the joy that ensues on the wards when the hospital clowns arrive as a kind of “non-demanding joy.”

The next step in the discussion section will be to put this non-demanding joy in a psychological context and, in the light of theory, to link it to some psychological aspects.

Discussion

Joy without demands

A confirmation of the body's possibilities

The relation between the hospital clowns, the children, and the staff is built on verbal communication as well as non-verbal communication, where particularly the sense modalities vision, hearing, and touch are of great importance. The clowns' clear signal of a visual game is their red noses, expressive faces, and colorful clothes; for the auditory game, music and special sounds are a source of inspiration; and for the game of touch, one example is using soap bubbles, which can provide a brief magical state of “being or not being.” In the relaxed state of joy, the hospital clowns acknowledge and affirm the children as well as the staff: “You are seen and accepted just the way you are, your entire body too!” Sonnby-Borgström (2005, p. 45) wrote: “Pleasure/joy is a diminishing affect, as opposed to interest, which is an activating affect. The body is in a relaxed state and is ready to play and relax …/… this state is connected to a feeling of vitality.”

A “magical attachment”

In a “secure attachment” (Bowlby, 2010), it is adults who stand for the ability to maintain a “secure foundation” for the child; here, the child's interest in inquisitive exploration is based on the fact that he/she can return to the adult world when insecurity or fear is at hand. On the other hand, in a “magical attachment” we may see a temporarily permissive relation, such that the roles in “the magical room” (Linge, 2008) are reversed. Using body language, the hospital clowns reveal “the conditions of the common man,” who pleads for help and comfort. This reversed relation, in which the child is strong and smart and the clown weak and silly, gives the child an advantage and a feeling of joy. The spontaneous interplay, without demands and ulterior performance motives, becomes a different kind of attachment where the hospital clowns' strategy is to reinforce the child's life force. Gryski (2003) described how the positive spirit of community with the clowns builds up the child's competence and hope of getting well. Through these reversed roles, the hospital clowns acknowledge the child's chances to overcome the situation. Seen through the child's eyes, what is magical is that an adult is so “silly and ignorant.” Given this, the child's self-esteem grows as a result of “just being able to exist” in this center of possibilities, but also as a result of being able to influence the course of events. If there is fear or wariness, the child can seek out his/her parents or staff to gain access to “the secure foundation.”

A chance to transcend boundaries

In regular play, children have every opportunity to test the conditions of everyday life. But along with the hospital clowns' humorous way of acting there is also the exaggerated, the unexpected, and the different. Seen in affect theoretical terms (Tomkins, 1962; 1963; 1991), the ability of surprise to reset the mental apparatus for something new and exciting gives interest and joy free scope within the child. The experience that “everything is possible in the context of mischievous pranks” gives the child a feeling of freedom—a feeling reminiscent of a healthy life outside the hospital walls. Smiles and laughter are indicators of the pleasurable aspects of the situation. The staff described the relaxing effect of the clowns for everyone on the wards: It was “very good for the soul.”

A non-demanding situation

This joy without demands does not put the child under any obligation. There is only the “here-and-now,” which promotes the feeling of freedom from demands and counter-demands. The hospital clowns require nothing in return—they are simply there and provide what the child needs. The question is whether this helps the child “just be” who he/she is deep down—a child free from disease and suffering. When no demands are made on the child to be good, cooperate, be brave, or look happy “a safe area” for recovery is created. Such an experience is on the child's own terms; he/she does not need to assume responsibility for the disease or the situation. Instead, it provides a place of refuge for forgetting all the difficulties for a little while in playful cooperation and this applies to the staff and parents as well.

Of what significance is this “joy without demands” in relation to the children? Nathanson (1992) related the joy affect to the child's experience of “healthy pride” in having been able to overcome the situation and saw three necessary conditions for generating this form of pride: through the presence of (1) a meaningful, goal-oriented, and purposeful activity under the influence of the affect interest/excitement; (2) an activity that is successful in meeting the goal and, in the end (3) the presence of the affect enjoyment/joy. These aspects are found in the present study, in that the hospital clowns stimulate the affect interest/excitement, which arouses the child's curiosity about things that are different in a deliberate way, adapted to the child's needs. In most cases, the goal of acknowledging the child's situation is achieved, the end result being a triggering of the affect enjoyment/joy. Nathanson (1992) related “healthy pride” to Broucek (1979) and the concept of “competence pleasure,” where the child's competence is tested in an atmosphere of interest/excitement and where the concomitant joy is integrated into the child's self-image and the formation of a solid identity. According to Nathanson (1992), the opposite of this would be a feeling of shame, where the child is not given the opportunity to discover his/her own mental resources and experience his/her own competence pleasure.

How credible is the discussion, here focused on “joy without demands”? Perhaps it can be applied to other similar children's hospitals at which hospital clowns are represented? It should be noted, however, that the working methods of hospital clowns may vary across children's hospitals, as may their professional training. An individual's suitability for working as a hospital clown must be elucidated as well.

Conclusion

From a care-giver perspective, the descriptive results showed how the staff emphasized a psychological quality of care alongside the physical quality of care. The hospital clowns' “unexpected possibility” provided a safe area for recovery for both the children and the staff. The interpretation of the results in a theoretical frame emphasized the presence of the affects surprise/startle, interest/excitement, and enjoyment/joy as well as specifically how “joy without demands” often had a lingering effect in the form of vitality. Joy without demands was discussed in relation to psychological theory with emphasis on: a confirmation of the body's possibilities, a magical attachment, an opportunity for transcending boundaries, and a non-demanding situation. Furthermore, the results highlight the need for future research focusing on the experiences of children and parents and stressing their perspective on the work of hospital clowns.