Magical attachment: Children in magical relations with hospital clowns.

The aim of the present study was to achieve a theoretical understanding of several different-age children's experiences of magic relations with hospital clowns in the context of medical care, and to do so using psychological theory and a child perspective. The method used was qualitative and focused on nine children. The results showed that age was important to consider in better understanding how the children experienced the relation with the hospital clowns, how they described the magical aspects of the encounter and how they viewed the importance of clown encounters to their own well-being. The present theoretical interpretation characterized the encounter with hospital clowns as a magical safe area, an intermediate area between fantasy and reality. The discussion presented a line of reasoning concerning a magical attachment between the child and the hospital clowns, stating that this attachment: a) comprised a temporary relation; b) gave anonymity; c) entailed reversed roles; and d) created an emotional experience of boundary-transcending opportunities.

Introduction

Hospital clowns in medical care

The hospital clown as a fool – wearing colorful clothes and unwieldy shoes – marks with its red nose that things are different on the wards, that the regular rules don't apply. The signal sent to the ailing children is often a small musical tone, indicating that “unboundedness” will reign for a little while and that the unexpected and unimaginable are suddenly natural and pleasurable.

During recent years, a number of studies have revealed the value of the participation of hospital clowns in the care of ailing children. In their survey study, Battrick, Glasper, Prudhoe, and Weaver (2007) showed that the majority of children experienced delight in play situations with hospital clowns, and that the children's parents stressed the importance of the clowns’ presence at the hospital. Weaver, Prudhoe, Battrick, and Glasper (2007) as well illustrated how clown humor can alleviate the negative effects of hospital stays for children between four and 11 years of age. In a final report on The Clown Doctor Project, Marcon (2005) showed that the well-being of children, parents and staff increased in hospital environments frequented by hospital clowns. Golan, Tighe, Dobija, Perel, and Keidan (2009), Vagnoli, Caprilli, and Messeri (2010), and Vagnoli, Caprilli, Robiglio, and Messeri (2005) have all observed the value of trained clowns in relieving the anxiety of young children and their parents prior to an operation on the child. Fernandes and Arriga (2010) stressed the effects of clown intervention in children undergoing surgery. Their results showed the importance of clown intervention in reducing preoperative worries and emotional responses, not only in children but also in their parents. Although most studies have emphasized the positive aspects of the presence of hospital clowns, Gryski (2003) also stressed the importance of noticing signs of fear in young children.

At present, hospital clowns are established at most university hospitals in Sweden (Linge, 2008). The clowns’ working methods vary somewhat across hospitals, but most work in pairs using verbal and body language as important tools, and in isolated cases they work as the quiet, lone clown with only body language at their disposal. Hospital clowns have training in the theater, drama and music, supplemented by some kind of hospital clown education. The importance of hospital clowns’ work in medical care has been revealed in studies where clowns as well as care-givers have been allowed to express their viewpoints. Viewed from a hospital clown's perspective (Linge, 2007, 2008), we can see the importance of synchronized communication, where sensitiveness to the child's care situation constitutes the basis for an adequate clown relation, always keeping the child's well-being in focus. Viewed from a care-giver perspective (Linge, 2010, 2011), we can see how the importance of the affect joy, in this case joy without demands, has a lingering effect in the form of vitality, for both the children and the staff. We can also observe the importance of and enthusiasm over a magical relation, really a reversed relation, in which the child is strong and smart and the clown is weak and silly —a situation in which the child has the advantage and can experience joy.

If we consider the child perspective and what children themselves tell us about the magical relation to the hospital clowns, the research is scanty in terms of qualitative design. Another gap involves studies specifically looking at different-age children and their magical experiences in relation to hospital clowns. A study by Meisel, Chellew, Ponsell, Ferreira, Bordas and Garcia-Banda (2010) showed that further research is needed to determine the effects of clowns in hospitals, taking into account child age and sex, parents’ presence, and various types of hospital setting. With regard to the child's age and the child's magical relation to the clown the present approach is to try to understand several different-age children's experiences and reflections in order to comprehend the magical aspects of this clown encounter. This is done by positioning their lines of thought in a theoretical context, based on theoretical constructs found in psycho-developmental perspectives on children's humor (Martin, 2007; Wandersee, 1982) as well as on attachment patterns in developing children (Ainsworth, 1978; Bowlby, 1988).

The present study is part of a larger research project entitled Hospital clowns—in the care of ailing children and funded by the Swedish Childhood Cancer Foundation.

Aim and specific questions

The aim of the present study is to achieve a theoretical understanding of several different-age children's experiences of magical relations with hospital clowns in the context of medical care, and to do so using psychological theory and a child perspective. Several specific questions constitute the point of departure: (1) In what way does age play a role in children's experiences of hospital clowns? (2) What is the psychological meaning of magical relations between the child and the hospital clowns? (3) Of what significance is this magical clown encounter to the child's mental well-being?

Children's humor — Developmental aspects

Meisel et al. (2010) pointed out that “humour and laughter are central to some of the approaches currently most widely used for reducing fear, stress and anxiety in the hospital context” (p. 9). Humor and laughter are important tools in the work of hospital clowns. But the question is whether children of different ages experience humor and a clown encounter in the same way. Perhaps we can see developmental lines in the experiences of humor. Martin (2007) as well as Puder (2003) have presented a developmental perspective on children's humor and discussed the importance and healthful effects of smiling and laughter. Infants produce their first social smiles during the first months and laugh at around three to four months of age in a safe playful environment. Physical touch, special sounds and different facial expressions trigger laughter in infants. Given this agreeable relation, the child develops mental representations, thereby reinforcing cognitive skills throughout childhood in a continuous stream of pleasurable escapades.

Wandersee (1982) described how one-year-olds laugh in response to tickling, physical contact and bodily sounds. Two-year-olds laugh at clowning, peek-a-boo games as well as musical rhymes and word-play; three-year-olds laugh at “practical jokes” using a more aggressive form of humor; four-year-olds laugh at “crazy jokes,” riddles and puns; five-year-olds laugh at humor that is more good-natured and full of fun. Children around six years of age begin to understand the conditions of the world around them and are able to initiate their own jokes in varyingly advanced forms, often with an undertone of aggression. In schoolchildren from seven to12 years of age, carefree play still remains, play characterized by partnership in laughter at the unexpected resources of body language. However, if preschool children use more imaginative and free thinking, which does not require a logical structure or specific point, schoolchildren wish to test various verbal maneuvers, preferably in a group, for example riddles and puns marked by structure and stringency. Research in the area (Linge, 1997) has shown that school children incorporate more aspects of reality into their humor and can begin to value the content of a joke's message.

Martin (2007) described the course of cognitive, emotional and relational development during youth, and how it is manifested in various humorous ways of acting. Teenagers’ thinking is revealed in their more thoughtful, logical and decentered narratives, which can even involve another party's jokes. Part of the emotional development of youth is critical distance, with its corresponding dissociation from the “embarrassing and shameful,”. This is expressed in contradictory joking, where the content points at exactly what is being rejected (e.g., the conditions of childhood), but also at what is unattainable and eagerly awaited (e.g., the terms of the adult world). This critical distance, with its cognitive capacity in line with Piaget (1959) and his thoughts about abstract thinking, also entails a critical gaze directed at adults’ actions, which can be perceived as unrealistic and childish.

Attachment patterns in developing children

According to Martin (2007), the child's relational development, humor and laughter constitute an essential social phenomenon, such that children of all ages laugh in a context of interaction with adults. The child's capacity to approach others in a social relation, where humor is present, begins during infancy with the child connecting to a closely related adult, most likely the mother or father. Broberg, Granqvist, Ivarsson, and Risholm Mothander (2006) described the affectional bonds between the child and the adult, and characterized the common features of these bonds as follows: they endure over time, are directed at a specific individual who is not replaceable, are of affectional relevance to the individual, entail a quest for closeness as well as a feeling of discomfort in cases of involuntary separation. According to Bowlby (1988) and Ainsworth (1978), such a specific attachment relation implies that this closeness is crucial when the child seeks safety, comforting and protection upon experiencing stress.

If a secure base (Bowlby, 1988) is developed early, it constitutes the foundation for emotional and social development (Ainsworth, Bell & Stayton, 1991) to which the child can always return in situations of insecurity and fear later in life. Bowlby (1988) stressed three different behavioral systems, the first being the child's attachment system, the second the parents’ parenting system and the third the child's exploration system. If these early attachment and parenting systems have functioned well, they will provide a good foundation — a “secure base” — from which the child can dare to explore the surrounding world. This is revealed in the child's later attachment patterns, in that affectional bonds from childhood are renewed in new relationships, often positive in nature. Sometimes, however, there are negative outcomes, which in the child's first few years created insecurity, ambivalence or disorganized attachment. The relational consequences of these are manifested in the child's behavior, for instance in the form of avoidance, insecurity or inactivity.

The child's ability to dare to explore the world outside the “secure base” is also revealed among children at the hospital and their attachment patterns, and it is here the hospital clowns enter into the picture. In her article on hospital clowns, focused on joy without demands, Linge (2011) pursued a line of discussion on magical attachment, which entails a temporary relation and reversed roles in the magical room. The concept of magic can be defined as a kind of supernatural force, a thought or wish, that can be fulfilled in the situation Jerlang, Egebjerg, Halse, Jonassen, Ringsted and Wedel-Brandt, (2008). However, this line of discussion was based on knowledge from adult (hospital clowns’ and staff members’) narratives on the clowns’ activities at the hospital. The present article will emphasize several children's experiences of encounters with hospital clowns, thereby improving our understanding of the magical relations involved in these clown encounters —as seen from a child perspective.

A child perspective

Rasmussen (2004) nuanced the concept child perspective, stressing three different intellectual models, namely a) an adult perspective on children, including only adult theoretical frames of reference and interpretations of children's needs; b) the child's own perspective on his/her situation, where the child presents his/her own thoughts and needs; and c) a interactive perspective, where the child is the mediator and adults are the interpreters of the child's lines of thought. The question of a child perspective can be problematized, particularly with respect to children at the hospital. There are often different illness diagnoses, and the treatment programs used in medical care must provide for the children's physical recovery. However, if we wish to look at mental health despite illness, it is important that children present their own views of the situation in relation to the hospital clowns’ actions. The child's own statements, as found in intellectual model b) above, are probably not sufficient, in which case perhaps a comprehension perspective should also adopted. For this reason, using Rasmussen (2004) as a reference, the present article will focus on intellectual model c), an interactive perspective.

Methods

Research design

The methodological approach used here was inspired by Interpretative Phenomenological Analysis, IPA (Frost, 2011; Eatough & Smith, 2008), a qualitative approach aimed at achieving a deeper understanding of the individual's lived life experiences. According to Eatough and Smith (2008), the descriptions, conveyed through semi-structured or open interviews, emerge gradually, are context dependent and do not allow much generalization, owing to the small sample sizes. The goal of qualitative analysis is to identify relevant themes and categories, which are later given interpretive meaning. The present efforts have also been influenced by Gadamer's (1997) hermeneutic approach to language, as a guide to understanding and interpreting the individual's outer and inner lifeworld. Dahlberg, Drew, and Nyström (2001) referred to Ricoeur (1976), who saw the possibility to move between the manifest and latent messages in a text. In the present study, psychological theories have served as a guide in interpreting the latent aspects of children's narratives. The analytical procedure has been carried out through alternation between the parts and the whole, in what has been called “the hermeneutic circle” (Kvale, 1996), starting with children's direct narratives (manifest message) and moving to interpretation of the whole in what would seem to be the underlying (latent) message in their experiences of encounters with hospital clowns.

Participants

First, the hospital directors gave their permission for the researcher to visit the respective hospitals (in southern and central Sweden), as well as to interview the children and parents on the wards. The children were or had been admitted to an oncology, general medicine or orthopedics ward. One selection criterion was that the children interviewed were to have encountered hospital clowns at a hospital during the past few years. Another criterion was that the children were to represent an age range between 2 and 18 years of age so that the study would include different age levels. The final selection criterion was that the families were willing to participate, considering the child's diagnosis, health and wishes. The contact nurses at the respective hospitals then helped in identifying the names of families that might consider participating in the study. The goal was to be able to interview 10 families with ailing children, and possibly the children's siblings. Of the 10 families contacted, nine agreed to participate and one did not wish to because the child was too ill; in total nine children participated. The age distribution among the children was as follows: two years/one child, three years/one child, four years/two children, seven years/one child, 10 years/one child, 14 years/two children, 18 years/one child. Six girls and three boys took part, including two siblings (a four-year-old girl and a 10-year-old boy). The parents were represented by eight women and one man. Most of the children made regular visits to the hospital to undergo additional treatments and evaluations of their health.

Material

At the first meeting with the parents, which was arranged by the contact nurses at the respective hospitals, the parents received an information sheet describing the study. The children received their own information sheet containing age-appropriate terms. The older children had access to a semi-structured interview guide containing the themes that would be discussed: encounters with hospital clowns, their meaning and associated difficulties and possibilities. The semi-structured interview format included opportunities to ask follow-up questions. The younger children required an open interview format that would enable them to narrate freely about all their experiences with the hospital clowns. The present author was the interviewer in all of the interviews.

Procedure

The interviews were carried out at the children's hospitals, except in two cases, where they were conducted in a home environment. The interviews began by reiterating for the parents and children the study aim, ethical guidelines and what participation would involve. Thereafter, the parents gave their written consent for their own and their child's participation. The parents were present in the hospital room, listened in the background and on occasion commented on what the child had said. When the two youngest children (two and three years) were asleep following a cancer treatment, the parents shared their reflections on their child's encounters with the hospital clowns. The 18-year-old's parent did leave the hospital room, but could be reached by telephone if necessary. The interviews lasted between 45 and 60 minutes each. They were audio-recorded and later transcribed verbatim.

Ethical considerations

The regional ethics board at Lund University, Sweden, approved the study (reg. no.: 2009/357). The following four ethical considerations served as guidelines (Brinkman & Kvale, 2008): informed consent, confidentiality, consequences and the researcher's responsibility. These guidelines were shared with the families from the outset. The parents also gave their permission for the interviews, as the children were under 18 years of age.

Qualitative data analysis

Analysis of the results was based on reading through all of the interview data a number of times to achieve an initial understanding of the data as a whole. “The hermeneutic circle” (Kvale, 1996) served as a point of reference for the analysis, and entailed a movement back and forth in the interview data to improve understanding of the whole as well as the parts, but also to capture similarities as well as the specific and unique. In two cases, narratives from the youngest children's parents were included. The analysis resulted in a number of themes, which came to reflect the children's narratives and promote increased understanding: (1) of the children's experiences of the hospital clowns in relation to age; (2) of the children's experiences of the magical aspects of these encounters; and (3) of the children's experiences of well-being together with the hospital clowns. Another aspect of the analysis was the fact that some of the children in the study (the older ones) contributed to the results by not only reflecting on their own encounters with the hospital clowns, but also on the encounters of other children in the hospital. This collaboration in the interview situation was initiated by the child and accepted and appreciated by the researcher.

The psychological interpretation (Ainsworth, 1978; Bowlby, 1988; Martin, 2007; Wandersee, 1982) of the results entailed a deeper understanding of the magical world, which the children expressed in different ways. The idea underlying the theoretical interpretation was to illustrate two patterns, first a magical safe area, then a kind of magical attachment. The magical safe area is seen as a world of possibilities with the hospital clowns, where aspects of both fantasy and reality were present. Given an understanding of this magical safe area and its importance to the children's mental well-being, the last part of the theoretical analysis came to emphasize magical attachment in relation to the hospital clowns, which is presented in the discussion section with a focus on the children's developmental level.

Results

Understanding the children's experiences of hospital clowns — in relation to age

Viewed from a child perspective, the children's various experiences of the hospital clowns emerged, often through narratives about magic, music and play. In situations where the younger children could initially display fear of these strange figures, the older children described the clowns’ ability to adapt to and show respect for each child's prerequisites in the face of the unknown. The youngest children were said to have been afraid of the hospital clowns at the beginning of their hospital stay, but gradually got used to them, because the clowns maintained a physical distance and gave the children the time they needed to habituate:

We met the hospital clowns in the beginning, when Little Brother was ill… there weren't any problems with the clowns… the last time there was a male clown who was very tall… that scared Little Brother a bit… maybe he was used to them being women and this didn't fit in… but the clowns were so good at noticing when the children weren't interested… they kept their distance… because Little Brother was a little shy, but at least he didn't cry. (Child, two years, Parent)

The clowns tried connecting with our daughter… but she was quite ill, so she was afraid of them at first, which is pretty common… but they built up her trust… then two days later she had made a drawing for the clowns and put it in their mailbox. (Child, three years, Parent)

The seven-year-old boy had met the clowns since he was one, on several occasions during his stays at the children's hospital for heart surgery. He also described wanting to meet everyone in the clown team to see what they could come up with. The 10-year-old felt the clowns were better suited to younger children, but they were still fun for children his age. He felt they were good for his little brother, who had cancer.

I was never afraid of them… I want to see them all the time… all of them. (Child, seven years)

They're probably best for kids around five or six years old… My little brother made music with them and thought they were really funny. (Child, 10 years, Sibling)

Though the younger children only made positive judgements of all encounters with the hospital clowns, the results showed that the teenagers could be more doubtful about the clowns’ actions and that they provided a more comprehensive picture, revealing how views on clown activities could vary between individuals as well as across the age range, 14–18 years. One 14-year-old girl reported initially appreciating how the clowns created breaks in her hospital stays, but with time she “got tired” of what she saw as childish and more appropriate for small children:

They treat you like a baby… the older you get, the more mature you become… and then it's not fun to see somebody dressed up… I try to keep my distance… (Child, 14 years)

The 18-year-old girl had experienced many clown encounters, as she had been admitted to the hospital several times between 11 and 18 years for her chronic intestinal disorder. She talked about many encounters over the years with other children on the wards. She said that several teenagers were skeptical about the clowns’ sometimes childish image, though owing to her illness she did not recognize this embarrassment in herself. Instead, she took advantage of all breaks in the daily routine that could lighten up the mood and give some relief from all her difficulties and burdens. The 18-year-old girl also felt the hospital clowns adapted well to the children's age and mood. She said:

I shared a room with a girl before who was my age and she thought it was so embarrassing… she'd only seen them in the hall… at a certain age kids think lots of things are embarrassing… maybe they haven't found themselves really… I've never been in that age of thinking like that… considering that life at the hospital gives you lots of experiences…. that maybe others don't have… you have to live with heavy burdens… I've been coming to the hospital for 7 years… what a loss it would have been if I hadn't let them in… they're really good at adapting to kids’ ages… they adapt to your mood too… so they do try to adapt to each person… and they're very successful. (Child, 18 years)

Understanding children's experiences of the magical encounter with hospital clowns

All of the children talked about the clown encounters as playful and “magical,” from the younger children's emphasis on external phenomena (e.g., playing doctor, magic and blowing soap bubbles), to the older children's thoughts about the internal phenomenon of finding oneself in a state between fantasy and reality (e.g., fantasy in reality, a magical state). The children 10 years of age and younger described the magic encounter as follows:

I think they began with us playing doctor… like they were going to prick somebody's finger… take a blood sample… and then they checked us with a stethoscope… it worked great. (Child, 3 years, Parent)

Magic… with balls… I held them in my hand… and then I said abracadabra… all gone… once the clown was going to pick up a feather duster… then it flew up… up, up, up… they have things in their pockets they can do magic with… they have soap bubbles too… I popped them. (Child, 4 years)

She made an egg appear out of nowhere… that turned into a hen… I asked her why she couldn't make a dog appear for me instead… then she said she could only do magic twice, and she'd already done it… she made an egg appear first, then a hen… I know that Fiffikus can walk through walls… I've never seen that they can do magic and walk through walls, but they can do other things I don't know about. (Child, 7 years)

You can place the card in the pile like this… that's for sure… Then we watch this while the clown watches… so that card is in front… I remembered the card here… the clowns couldn't learn it… they're usually pretty stupid. (Child, 10 years, Sibling)

Of the two 14-year-old girls, one never talked about wanting to be in a magical state, quite the opposite; she stressed the importance of being treated like an adult and adapting to reality.

If they did come then they could forget the clown role for a while and be a regular person, a little more private. (Child, 14 years)

The other one joined in on the magic games and had fun with the younger children on their terms, playing the role of assistant clown.

The 18-year-old girl, however, clearly described the magical aspect in terms of fantasy in reality, trance and magic; she felt the clowns constructed a world together with the children —a world that was not the real one, but one in which the children were seen and acknowledged in an atmosphere of joy, in her case through music and words. In the world of fantasy, this teenage girl did not see herself as ailing, but as a person who simply wanted to see herself in a more healthy way:

It's a kind of reality you build with them… a fantasy in reality… it's very magical… it's a mixture between music and words… you construct a world together with the clowns that becomes your own… it feels so great that they're spending time on me… just for me… it feels like I mean something to them… I think it's important that they build this world together with us, the patients… a world that maybe isn't the real world… but for us, at the time, it is… they don't see the illness… they only see us… and the message of joy and music… like magic… you're almost in a trance, you could say… a little outside reality, but still in our reality… right, in the fantasy… because at the moment, you don't see yourself as a sick person… you just see that you should have fun. (Child, 18 years)

The 18-year-old girl reflected on the younger children's interest in magic and described how one four-year-old boy identified with a clown who performed magic:

There was one little boy (4-5 years old) who has been in the hospital as much as I have… he loves the clowns too and as learned how to do magic from them… he has a favorite clown and behaves just like him. (Child, 18 years)

Understanding children's experiences of well-being with the hospital clowns

Opportunities for dissociation and experiencing joy

What emerged clearly from the interview data was the fact that for children the clown encounter was a matter of being able to relax in the hospital situation and feel a sense of joy together with the clowns. This was described as being given a moment of distance from the problems by being able to laugh and dance. One example, provided by the two-year-old's mother, depicted a relaxed encounter before the doctor was to arrive and perform a six-month evaluation following the child's cancer treatment:

We were going to talk to the doctor… the clowns came in and they'd hidden a guitar behind their backs, and they said to Little Brother-Where's the guitar?… There!… he yelled… Little Brother thought that was so much fun… they played the guitar and Little Brother danced… he really got going… after a while he started playing with the Legos again and that was enough for him… the clowns backed out of the room, saying Bye, bye!… it was completely wonderful… we sat there waiting for our 6-month evaluation… we were so caught up in the clowns and the laughter… and then the doctor came and could see that Little Brother was feeling good. (Child, 2 years, Parent)

The hospital clowns stand for harmony and fun… I think that with time… the more times you meet them, you come to trust them… our daughter is so happy when she sees them… she can even ask in advance, if they'll be there on the day she goes to the hospital. (Child, 3 years, Parent)

The 10-year-old boy had often accompanied his little brother to the hospital and experienced how the clowns were able to brighten the mood and get the children to laugh. He related this to the notion that the children needed music and play to create a distance to their illness. He could also see an indirect benefit for himself, as he also got to laugh. But the 14-year-old girl had another opinion:

They make the kids happy, and then they laugh and that's good for me… they play a lot of music and things… I never get sad, because I don't think it (his brother's cancer) will return and that's because you think about something else. (Child, 10 years, Sibling)

I don't think anything about the clowns is fun… nothing is fun at the hospital… rather be with friends. (Child, 14 years)

The 18-year-old girl had experienced long hospital stays and stressed several things that had been important to her, such as moments of joy laughing with the clowns, but also inspiration to move on in her life through various forms of artistic expression, i.e., art, poetry and drama. She described the acknowledgement she felt when the clowns wrote a special birthday song for her, and how her self-confidence increased as she received help with finding her own resources and new, creative solutions:

I was sad and felt very bad… then the clowns wrote me a song and it made me so happy, and touched… they sang the song for me… I stood there and cried… they've given me so much joy, but they also inspired me to move on… because when you're ill maybe you don't have the energy to do what you want… so they help you get started. (Child, 18 years)

Opportunities to alternate between different emotional states

One common aspect that children in the entire age range stressed was how they alternated between sorrow and joy: sorrow in terms of being sad, crying and feeling bad because of the illness; joy in terms of having fun, being happy and laughing:

There're funny, happy and strong… otherwise you're sad all the time. (Child, 10 years, Sibling)

So the children maybe get to laugh a little too… instead of crying. (Child, 14 years)

It's a lot of fun… it means a lot… I have a hard time laughing when I've been sick so long… hard to crack a smile… but when one of the clowns shows up… then something happens… if I'm in pain then I don't feel it as much… I get my endorphins going… then I lie around thinking about what they did and said… and you have that with you for the next time. (Child, 18 years)

You get some peace and quiet… if you're only sad then it's hard to move on in your illness… they get you on your way, motivate you and joke around… they can transform your problems into the funniest thing in the world. (Child, 18 years)

Opportunities for anonymous identification

Another aspect stressed by the teenagers in particular was identification with the clowns, in terms of being an "assistant clown," a "100% clown working half-time" and having "a favorite clown and being just like him." One of the 14-year-old girls felt the clown sessions were most appropriate for younger children, but she resolved the situation by acting as an assistant clown, helping the young children who did not dare to interact with the clowns. She also wanted to call attention to the embarrassing aspect of the situation, the fact that several people laughed, but also that she overcame this, because her willingness to help was greater than her feeling of wanting to give up. The following excerpts show the 14-year-old's reflections as well as the 18-year-old's description of being a 100% clown working half-time:

I helped out as a clown the first time… it was sort of embarrassing… everybody stood there laughing… but it went well… you can be an assistant clown. (Child, 14 years)

A year ago a clown said to me… You're one of us -you're a 100% clown working half-time. (Child, 18 years)

Opportunities for hope and acknowledgement

In the children's narratives, there is a common thread in the form of memories of having been acknowledged in their illness state by the hospital clowns. Yet this acknowledgement did not stop at the children's clinical picture, instead it started from the inner strength and mental resources, which strengthened their self-confidence and gave hope of improvement. The 18-year-old illustrated this in the following way:

It seems like your self-confidence increases quite a bit… because they want to encourage that as much as possible… you often lose your self-confidence when you feel bad and can't do the same things as other people… the clowns want you to keep going in your own little way…. they make you understand that you can do things even if you have limitations… you take your own short cuts and find new ways. (Child, 18 years)

Comprehensive understanding

A comprehensive understanding of the complexity of child patients' experiences of clown encounters reveals how the deeper meaning of the sequences age, magic and well-being can be interpreted as bridging the gap between the healthy and non-healthy parts of the child's life in the hospital. The pleasurable unexpected possibilities in the magical safe area helped the children distance themselves from their problems, by alternating between different emotional states and through anonymous identification with the clown character. This distance from their problems gave free rein to hope, acknowledgement and self-confidence. But the age of the children played an important role in how the magic aspects of the encounters were experienced.

The next step in the discussion section will be to position this phenomenon of magic in a psychological context and, in light of theory, to link it to certain psychological aspects in children — such as developmental level and mental well-being — in order to gain a deeper understanding of the magic relations to hospital clowns.

Discussion

The child's developmental level in relation to the magical safe area

To shed additional light on the relation between the child and the hospital clowns, the discussion section will deal with magical aspects by focusing on developmental level. To achieve a deeper understanding of the children's narratives about what happens during encounters with hospital clowns, the pattern magical safe area can be used. The magical aspect can be seen and interpreted as a symbolic place, a temporary state of freedom, where non-standard rules apply. This is instead a question of creative possibilities in the borderland between fantasy and reality. When children can play and test their possibilities instead of feeling their limitations, they can be seen and acknowledged in the state they find themselves in. In this way, they have an opportunity to trust the possibilities of their body, which increases self-confidence and gives hope of improvement. One interesting result in the present study is the older children's mental strategy of collaborating with the researcher and sharing their reflections in an analytical way, for instance in this example: "A kind of reality you build with them… a fantasy in reality… it's very magical". In trying to understand children's mental strategy of reflecting on their own thoughts, and taking a developmental perspective, Piaget (1959) discussed teenagers' capacity to think logically and to have an outdistancing look at themselves. We found no evidence of this outdistance function in thoughts in the younger children's experiences. They simply seemed to have fun in the moment without reflecting on their own magical thoughts.

The present study shows clearly that the child's developmental level is related to the way in which he/she enters (or does not enter) the magical safe area with the hospital clowns. Whereas the younger children show their delight at the creative possibilities of physical expression, in line with theory by Wandersee (1982), the teenagers give a more nuanced verbal picture of inner mental processes, reaching over the childish aspects of the clown encounter, to the feeling of being in a different kind of reality (fantasy in reality). What emerges from the younger teenagers' descriptions concerns the childish and embarrassing aspects, in particular. These aspects can be related to the work of Martin (2007), who pointed to the notion of critical distance, which is part of teenage emotional development. Critical distance refers to a dissociation from the incapability of childhood and to a longing for the as yet unattainable: the terms of the adult world. Whereas one of the 14-year-olds gradually distances herself from the childish clown encounters, the other develops a strategy, which involves her dealing with the embarrassing aspects by entering the role and identifying herself as an "assistant clown" so as to support the youngest children, who are sometimes afraid of the clowns. If fear of the unknown and deviant can sometimes make small children insecure, the hospital clowns can deal with this with distance and respect, something also stressed by Gryski (2003). Again, the 18-year-old girl, on her way to adulthood, reflected in an analytical way on how the clinical picture and long hospital stays can influence one's attitude toward visits from hospital clowns.

Mental well-being and magical attachment

To gain a deeper understanding of the children's experiences of well-being with the hospital clowns, we can consider the fact that the clown encounter was a matter of being able to relax in the hospital situation and feel a sense of joy together with the clowns. This was described as being given a moment of distance from one's problems by being able to laugh and have fun together. Another aspect stressed by the teenagers in particular was identification with the clown, which gave the child an opportunity to assume another form and test new strategies in life. The children's narratives contain a common thread in the form of memories of having been acknowledged in their illness state by the hospital clowns. Yet this acknowledgement did not stop at the children's clinical picture, instead it started from their inner strength and mental resources, allowing them to move on and find "their own short cuts," which strengthened their self-confidence and gave hope of improvement. This form of relaxation can be seen as a distancing from one's problems and occurs in a magical safe area, without demands of control. In the magical safe area, where anything can happen, the child is in his/her relation with the hospital clowns and can connect in a way that is otherwise not common in the social situation at the hospital. Thus, in this way, we can see the hospital clowns as practical mediators of the possibilities of humor in a magical relation with the children.

Broberg et al. (2006) described, referring to Bowlby (1988) and Ainsworth et al. (1991), how the normal affectional bonds between the child and the adult develop, and characterized the common features of such bonds as follows: they endure over time, are directed at a specific individual who is not replaceable, are of affectional relevance to the child, and entail a quest for reconnection in cases of involuntary separation. In her article on hospital clowns, Linge (2011) pursued a line of discussion on magical attachment. This type of attachment, however, entails a temporary relation, where the affectional relevance is present, but where the roles in the magical safe area are reversed. The child "sets the tone" of the relation, and the hospital clowns follow the child's intentions. In this context, it is the child who is wise and the clowns who are ignorant, in need of guidance and help. The present study supports this line of discussion, putting the children's voices in focus. The children's developmental level is indicative of how they express the possibilities of magic. Although age does play a great role in the nature of the experience between the child and the hospital clowns, certain aspects can be pointed out that characterize magical attachment, when it occurs, and that hint at the importance of this attachment for the child's mental development.

Magical attachment:

Constitutes a temporary relation, where the encounter only applies to the moment and where the child indicates the closeness or distance of the relation. The younger children experience magic in the present, by first approaching the clowns with caution, then delving into the creative games, and thereafter marking when the encounter is over. The older children express both a longing for the clown encounters and a delight at being seen and acknowledged. At the same time, however, they indicate clearly that the encounter is temporary and only enriching at the moment.

Contributes anonymity, in that one or several clown persons may enter the scene, persons who are interchangeable, as they work in different teams. The clown figure is an anonymous person, with its red nose, big shoes and colorful clothes. The child has to accept the different and deviant in the clown encounter, and enter the play on his/her own terms. The very youngest children are guaranteed security by having their parents nearby; for them trust in the hospital clowns grows over time. The somewhat older children find pleasure in identifying with the clowns, as "assistant clowns" or "100% clowns working half-time," which allows an external trust in the clown figure, as well as an internal trust in their own creative abilities.

Entails reversed roles, where the child is wise and knowledgeable, and the clown "stupid and clumsy." The existence of these reversed roles promotes self-esteem in the child. The younger children express their delight at the clumsy, crazy clown, who does everything wrong, but wants to rectify the silly situation right away using his/her "smart" solutions. The teenagers understand how the game is played and can take the challenge to assume different roles without feeling guilty, as the clown role provides an anonymous opportunity to, e.g., joke about authorities, which would otherwise be impossible.

Creates an emotional experience of boundary-transcending opportunities in the situation, which promotes creativity and joy. It dissolves the boundaries between what is ailing and what is healthy, given the experience of being in a magical safe area, between fantasy and reality. This magical experience blurs the boundaries and makes the impossible possible. The younger children indulge more in the possibilities of fantasy than in those of reality, whereas the older children see the limitations of reality, but can nevertheless allow themselves to flee reality to derive power and strength in a safe area of unlimited possibilities. Hope and self-confidence grow through the feeling of being able to take control over the incomprehensible and to master various humorous situations, which gives a lasting effect of well-being that can generalize to other, more everyday and trying circumstances.

Implication for practice

In practice, it is important to stress the child perspective and be sensitive to children of all ages and to their experiences of their relations with hospital clowns. It is also important to understand that younger children's experiences in the magical safe area are more concrete, while teenagers have a reflective and distancing attitude toward their relation with the hospital clowns. The best approach for all children is to give them the opportunity to meet the hospital clowns, and to respect a refusal, especially from teenagers. Understanding a refusal involves considering the child's age, the diagnosis, the relation between the child and the clowns as well as grasping the particular circumstances of this special encounter. On the other hand, understanding the child's wish to have a magical contact involves recognizing her/her need to be in a magical safe area, where anything can happen and anything can be fulfilled. Such contact gives the child hope of seeing the brighter side of life and of future health, and serves as a contrast to real life in the hospital setting, with all its problems.

Critical considerations

Using Interpretative Phenomenological Analysis (Frost, 2011; Eatough & Smith, 2008) implies a quest for the essential meaning in the narratives the children related during the interviews. According to Lindseth and Norberg (2004), we can never discover the absolute truth through interpretation, but only give the interpreter's own interpretation of the text, understanding that the interpretation also affects the interpreter in a constant process of deliberation. An aware attitude toward a theoretical interpretive approach must include the insight that a given text can have more than one meaning and that the interpretation is tied to a particular theory, in this case developmental and attachment theories in psychology. It is hoped that the present theoretical discussion can contribute to continued reasoning around the importance of hospital clowns in the care of ailing children.

As regards interviews with children, there are always aspects to take into consideration, particularly the child's age, developmental level and clinical picture, as well as the parents' presence, trust in the interviewer and situational factors (hospital room, home environment). Cancer treatment can be trying and drain the child's physical resources. For all of the children, except the 18-year-old, there was a parent present in the interview room, in line with the children's wishes. At the same time, all of the children were very willing to talk about their encounters with hospital clowns and narrated spontaneously and with feeling. The present sample was limited to a relatively small number of children of different ages. Thus, the ability to generalize the results is limited. Still, this small sample of children of different ages can give some insight into how age is related to attitudes toward hospital clowns' visits and what importance these encounters have had for the children's mental well-being. In future research on hospital clowns, it would be desirable to get a more comprehensive picture of clowns' working methods at the various children's hospitals throughout Sweden.