Clownselling: an in-depth narrative review on the therapeutic influence of clowning therapy in paediatric and adult cancer treatment and palliative care

INTRODUCTION

Cancer and its treatments, recognized as stressful and traumatic events, lead to various complications that significantly impact the quality of life in both children and adults. First-line therapy, such as chemotherapy, brings about physical consequences like nausea, vomiting, fatigue, alopecia areata, infection, stomatitis, eating disorders, and pain. Additionally, it results in psychological impacts, including anxiety and depression. Various physiological and psychological factors, along with chemotherapy or nutritional deficiencies, contribute to cancer-related fatigue in children, reported in 70-100% of patients undergoing chemotherapy.^1,2

Amidst the complexities of cancer care, the need for holistic and innovative interventions becomes paramount. Recognizing this imperative, the integration of clowning therapy into healthcare settings has gained traction. Historically rooted in entertainment, clowning has undergone a transformative evolution, finding purpose beyond the circus tent. It has evolved into a therapeutic modality that harnesses the power of humour, playfulness and human connection to address the emotional and psychological challenges posed by cancer.³ This blending of entertainment and healing constitutes the essence of clowning therapy, offering a unique approach to support cancer patients through their arduous journeys.

Clowning therapy, often referred to as ‘therapeutic clowning’ or ‘medical clowning,’ is a creative and compassionate approach to healthcare that employs the principles of humour, play and improvisation.⁴ Rooted in the age-old tradition of clowning, clowns possess expertise in finding order amidst disorder, deriving joy amidst loss and sorrow, extracting truth from a web of lies, laughing at human foolishness, and tolerating a degree of mess. As a result, they are well-prepared to offer relief and counsel in a hospital environment.⁵

At its core, clowning therapy goes beyond the conventional understanding of clowning as mere entertainment. A therapeutic clown, with proper training, operates with liberty, utilizing their own vulnerabilities to generate humour and sustain their character. This freedom enables them to adopt a distinct perspective on illnesses and disorders, assisting patients in overcoming such challenges. The therapeutic engagement is tailored to the individual needs of patients, they serve as companions to patients, demystifying their pain and distress while fostering a strong and meaningful bond to encourage open expression.⁶ Thus, clownselling is a specialized practice embodying medical, psychotherapeutic and entertainment expertise. A trained professional clown provides tailored support by eliciting intangible emotions, aiding expression, and facilitating adaptation to changes.

PURPOSE OF THE NARRATIVE REVIEW

This narrative review seeks to explore and synthesize the existing literature on the impact of clowning therapy in the context of paediatric and adult cancer care. By delving into the available research, the review aims to elucidate the multifaceted benefits of clowning therapy, examining its influence on emotional well-being, coping strategies, treatment adherence, overall quality of life and palliative care. Through a comprehensive analysis, the narrative review aspires to contribute to the growing body of knowledge surrounding this innovative and evolving approach to cancer care, ultimately informing healthcare professionals, researchers, and practitioners about the potential of clowning therapy as a valuable adjunct in the holistic treatment and palliative care of the cancer patients.

THERAPEUTIC PROCESS OF CLOWNING THERAPY

Trained as professional performers, medical clowns, also known as therapeutic clowns or clown doctors utilize improvisation, physical comedy, magic etc to instil laughter, promote physical and mental well-being in patients. In addition to conventional performance tools, medical clowns employ specialized props. They are rigorously trained in infection control, hygiene, confidentiality and medical facility protocols. They do not need to be physicians alone; individuals from any background can pursue this role with the necessary training.^5,7

In the clown, we observe the childlike mind within an adult, courage within the cowardly, confidence within the vulnerable, and control within the seemingly out of control. The clown acts as a bridge, connecting overlooked, shadowed and unconscious elements with prevailing conscious attitudes through its antics, dress and personality. Across various cultures and historical periods, clowns have aided us in confronting our human flaws and vulnerability in a safe manner, eliciting cathartic laughter. Cheryl Carp's groundbreaking paper in 1998 introduced a conceptualization of the therapeutic potential of clowns, termed Clown Therapy. Unlike medical clowning, this approach aligns more closely with drama therapy and psychotherapy processes. It asserts that developing the clown's role with a client, assisting them in discovering their inner clown, can be a therapeutic goal in its own right.⁸

Hinton's 1981 article ‘fools, foolishness, and feeling foolish’ suggests that change can occur through identifying with one's inner clown or fool nature. The experiential aspect of clown therapy, involving physical and mental exercises, fosters a sense of foolery and foolishness, leading to a connection with the healing power of the fool. According to the Ulanovs, the clown serves as a bridge between the conscious and unconscious, the known and unknown. They highlight the importance of consciously identifying with the clown to disentangle the archetype from harmful, unconscious ego associations.⁴

Clown therapy encompasses identifying dominant and oppositional personality roles, bringing them into connection, ultimately giving rise to the emergence of the clown.⁸ It incorporates elements from various sources, such as creative arts therapies (mainly drama and dance/movement), psychosynthesis, ego-psychology, Jung's theories of individuation and active imagination, and somatic psychology.

PRINCIPLES OF CLOWN THERAPY

Every individual possesses the ability to internally experience the qualities embodied in the clown. Play, spontaneity, light-heartedness, humour and creativity serve as primary elements in the healing process. The clown offers a creative outlet for the exploration and engagement with unconscious contents. The body serves as the medium through which the clown character expresses itself, providing a symbolic voice to the unconscious. The relationship between the therapist and the client is an integral aspect of clown therapy.

GOALS AND OBJECTIVES OF CLOWN THERAPY

Healing involves a process in which individuals or groups progress toward a deeper understanding and acceptance of themselves through the realization, clarification and integration of unconscious contents. Key objectives are to, foster increased trust in oneself and others, enhance spontaneity and playfulness, utilize the body as an expressive instrument, develop an improved ability to tolerate paradox and ambiguity and access unconscious contents.

TECHNIQUES AND SESSION STRUCTURE

The key feature of techniques in clown therapy is their adaptability, with the therapist tailoring methods to the individual’s/ group’s developmental needs.

Warm-ups

Physical warm-ups enhance energy flow and prepare the body for new experiences. Examples include embodying natural materials (e.g., mud, icicles, falling leaves, a tree, lightning) and allowing the mind to explore different body parts. Mental warm-ups disrupt standard thought patterns, introducing ‘clown logic’ for creative perspectives and problem-solving.

Games and exercises

Selected games or exercises should follow warm-ups, aligning with the goals of clown therapy.

Clown character development

Developing the clown character is challenging and requires consideration of participants' developmental stages.

Integration

Integration involves merging each session's material and integrating the newly created clown character into consciousness using techniques like inner dialogue, guided imagery, journaling, art, and movement.

This process allows uncomfortable or incongruent behaviours to become expressive options, expanding the individual's repertoire and fostering understanding and acceptance of their core nature.⁴

THEORETICAL FOUNDATIONS

Psychosocial theories supporting clowning therapy

Clowning therapy's efficacy is rooted in various psychosocial theories that illuminate its profound impact on emotional well-being and resilience.

The stress-moderator theory asserts that stress relies on the cognitive appraisal of events and coping skills. Individuals possessing a superior sense of humour tend to formulate more positive appraisals.⁹

Theories of humour, like incongruity theory and relief theory, propose that laughter arises from incongruities or the release of accumulated nervous energy, functioning as a coping mechanism to alleviate emotional distress.¹⁰ In the healthcare context, therapeutic clowns strategically use humour to create moments of joy, fostering positive emotional experiences for patients.

Play theories, emphasizing the therapeutic value of playfulness, align with clowning therapy's interactive and improvisational nature, promoting a sense of control and agency for patients amidst the unpredictability of illness.^11,12

Social interaction theories underscore the importance of human connection, asserting that positive social exchanges contribute to emotional well-being, playing a key role in enhancing cancer survival.¹³ In this regard, the genuine and empathetic interactions facilitated by therapeutic clowns provide a supportive social environment, enhancing the patient's overall psychosocial experience.

Neurobiological mechanisms underlying therapeutic effects

The term gelotology, introduced in 1964 by Edith Trager and William Fry, originates from the Greek root "gelos," meaning laughter.¹⁴ Gelotology involves examining the impact of laughter on the body, considering both psychological and physiological aspects.¹⁵

The neurobiological mechanisms elucidating the therapeutic effects of clowning delve into the intricate interplay between the brain, emotions and stress response. Research indicates that a robust immune system plays a crucial role in controlling and healing cancer, while a compromised immune system increases the risk of various cancer types. Stress, identified as an immune system suppressor, may contribute to the growth of cancerous cells. Therefore, it is essential to explore effective stress reduction methods. Laughter promotes a balance in the body's chemicals and hormones. According to Lidi, laughter reduces red globule sedimentation levels, enhances natural killer-cell activity, lowers cortisol, and boosts immunoglobin A. Fri asserts that laughter strengthens the immune system, supports the phagocytosis process, and aids the body in combating infections.¹⁶ Clown-induced laughter, a cornerstone of therapeutic sessions, triggers the release of endorphins-neurotransmitters acting as a natural analgesic and emotional tonic for patients navigating the challenges of cancer treatment.¹⁷ Additionally, the reduction of stress hormones which are immunosuppressive, such as cortisol and epinephrine presents a key neurobiological pathway.^17,18 By fostering a neurochemically conducive environment, clowning therapy not only enhances emotional resilience but may also contribute to physiological benefits, creating a holistic therapeutic experience for patients.

In essence, the integration of psychosocial theories and an understanding of neurobiological mechanisms provides a comprehensive framework for appreciating the intricate and multifaceted therapeutic foundations of clowning therapy in the context.

EVOLUTION OF CLOWNING IN HEALTHCARE

The history of clowning is extensive and rich.³ For centuries, clowns have been a source of entertainment and, for a significant duration, have played a role in the healing process in addition to bestowing the gift of laughter.¹⁹ The presence of a 'Jester' figure is notable in numerous ancient cultures, such as Egyptian, Greek, Chinese, Roman, medieval Europe, Mayan civilization and India.^20,21 The clown, rooted in the trickster, jester and fool aspects of the human psyche, has appeared in various settings from royal courts to circuses, theatres and silent cinema. In Native American cultures, the sacred clown serves as a shamanic figure, contributing to community healing rituals.⁸ In the 1970s, the transformative power of laughter gained attention in healthcare circles, prompting the first wave of therapeutic clown programs when Dr Hunter Doherty 'Patch' Adams, the pioneer of clown doctors, initiated the integration of clowning into clinical practice. As the therapeutic value of clowning became apparent, the 1980s and 1990s witnessed the formalization of medical clowning programs in hospitals worldwide. Clown doctors are currently active worldwide, serving in various organizations such as the big apple circus clown care unit in the USA, Theodora foundation in Europe, Africa, and Asia, and the humour foundation clown doctor program in Australia.²⁰

In India, while healthcare clowning is still in its early stages, numerous doctors recognize its therapeutic advantages and are incorporating it into their practices. Initiatives like crown corner, doctor parrots’ initiative, CanKids, CanSupport and various other associations have emerged actively employing clown therapy in India.^23-25 Laughter yoga, a concept coined by Madan Kataria, a general practitioner in India, emerged in 1995. It integrates laughter with yogic breathing exercises. What sets laughter yoga apart is the incorporation of laughter followed by intervals of meditation.¹⁴

Various countries have established different federations with the aim of serving as a central point of reference for numerous clown care units. These federations combine health and social professionalism with expertise, addressing the need to elucidate the role of clown doctors and establish standardized vocational training for aspiring professionals. Additionally, these Federations offer comprehensive training programs and adhere to a specific code of ethics emphasizing sensitivity to patient needs and the ability to navigate the intricacies of medical settings.⁵ This evolution reflected a paradigm shift, recognizing clowns not only as entertainers but also as valuable members of the healthcare team contributing to the psychosocial well-being of patients.

IMPACT OF CLOWNING THERAPY IN PAEDIATRIC CANCER TREATMENT

Emotional and psychological well-being

Research consistently underscores the positive impact of clowning therapy on the emotional and psychological well-being of paediatric cancer patients. Multiple studies have highlighted the impact of hospital clowning in diminishing preoperative anxiety and postoperative pain severity among children.²⁶ Clown doctors play a vital role in establishing a positive emotional state, fostering hope, and encouraging interaction between parents and children. Exhibiting adaptability, sensitivity, and attentiveness, they tailor their approach to each patient and procedure. Embracing the idea that 'laughter is the best medicine,' these medical professionals leverage humour to address psychosocial needs, promoting emotional expression and empowerment. Therapeutic clowns' unique ability to connect with children emotionally significantly contributes to creating a supportive and uplifting atmosphere, positively influencing the emotional landscape of paediatric cancer care.²⁷

Coping mechanisms

Clowning therapy is a pivotal support for children facing cancer treatment challenges. The clown's presence, seemingly incongruous in the hospital, mirrors the child's vulnerability. Together, they form a supportive alliance. The clown's portrayal of ineptness enables the child to navigate roles, enhancing coping and control. Clowns use parody to unravel medical mysteries, employing imaginative spaces for therapeutic play. Games like hide and seek explore feelings of being missed or not, while imagery like bursting bubbles conveys insights about the presence, growth, or absence of a tumour. Magic tricks transforming a small object into a larger one and back again might offer avenues for expressing changes in body image. Through unfolding play, a creative and safe space helps children explore profound concerns, offering opportunities for self-expression and an escape from illness-related stresses.²⁸

Enhanced treatment adherence

Hospital clowns positively impact outcomes for paediatric patients, particularly those with acute conditions and undergoing medical procedures. There is a growing belief that hospital clowns play a complementary role in healthcare by facilitating the recovery of these patients.²⁷ Evidence suggests that clowning therapy may play a role in improving overall well-being during hospitalization, adherence to physical examinations, compliance with treatment, and even treatment outcomes as children exhibit increased cooperation.^29,30 The positive and enjoyable experiences facilitated by therapeutic clowns during medical procedures contribute to a more favourable perception of treatment interventions. The distraction and emotional support provided by therapeutic clowns create an environment where children are more likely to actively participate in their care, fostering a collaborative and positive relationship with healthcare interventions.²⁸ This improved adherence not only facilitates the effectiveness of treatment but also contributes to a more positive overall healthcare experience for paediatric cancer patients.

IMPACT OF CLOWNING THERAPY IN ADULT CANCER TREATMENT

One of the most notable elements associated with clowning is humour. The aim of clowning is to elicit smiles and laughter from audiences of all ages. Contrary to common belief, clowns are not exclusively entertainers for children, as adults can also find enjoyment in clown performances.⁵ In highly stressful illnesses like cancer, humour eases physical pain, the shock of diagnosis, and the psychosocial effects of treatments for both patients and their companions.²⁶

Alleviation of treatment-related stress

Studies consistently highlight clowning therapy's significant role in relieving stress associated with adult cancer treatment. Kuiper and Nicholl identify two coping mechanisms: cognitive appraisals and distancing. Cognitive appraisals view illness positively, fostering personal growth. Distancing shifts perspectives, reducing the impact of symptoms. Coping humour, as evidenced by Thorson and Powell's study, alleviates anxiety about death. Clowns provide therapeutic engagement, offering emotional support and creating a relaxed, positive treatment environment.³¹

Improvement in quality of life

Oncological treatments involving pharmaceuticals impact the patient's quality of life across physical, psychological, and social dimensions.³¹ Numerous studies have found that humour has the power to enhance the quality of life for patients.²⁶ Clowning therapy, beyond stress reduction, notably improves the overall quality of life for adult cancer patients. Laughter and positive social interactions enhance emotional well-being, fostering closeness and bonding. Humour serves as a coping strategy, decreasing stress and anxiety, leading to positive emotional, cognitive, and behavioural responses. In hospitals, humour releases tension, facilitates communication, and strengthens the patient-staff relationship.³¹

As a result, the overall quality of life for adults undergoing cancer treatment is markedly improved, underscoring the transformative impact of clowning therapy on holistic well-being.

Support for coping with treatment challenges

Clowning therapy emerges as a valuable resource in assisting adults in coping with the unique challenges posed by cancer treatment. The interactive and personalized nature of therapeutic clowning allows for tailored interventions that address individual coping needs.³²

Researchers from diverse clinical disciplines proposed the hypothesis that the humorous distraction offered by clowns could enhance patient cooperation, and reduce the need for sedation.²⁸ Certain studies suggest that the practice of clowning may diminish the perception of pain and alleviate anxiety in hospitalized individuals. Adults facing the physical and emotional rigors of cancer treatment find solace and resilience in the companionship of therapeutic clowns.²⁶ The supportive role played by clowns extends beyond mere entertainment, becoming an integral part of the patient's coping arsenal, fostering a positive outlook, and aiding in the navigation of treatment challenges.

CLOWNING THERAPY IN PALLIATIVE CARE SETTINGS

Enhancing end-of-life experiences

In palliative care, clowning therapy profoundly enhances end-of-life experiences for paediatric and adult cancer patients. Healthcare clowns positively impact psychological and physical symptoms, improving patients' quality of life and social support. Their influence extends beyond the surface, validating the entire spectrum of human emotions, with substantive evidence supporting their favourable impact on oncological patients' well-being in palliative care.³³ Through personalized and empathetic engagement, therapeutic clowns create lasting memories, fostering a sense of warmth and humanity in the face of life's most profound moments.²⁷

Addressing spiritual and existential dimensions

Clowning therapy in palliative care extends beyond the physical realm, addressing the spiritual and existential dimensions of patients' experiences like the meaning of life, connectedness to humanity, harmony with the universe and a sense of transcendence.³⁴

The presence of therapeutic clowns provides a unique avenue for patients to explore and express their spiritual and existential concerns. Through gentle and non-intrusive interactions, clowns offer a space for reflection and connection, acknowledging the profound questions that often arise at the end of life ³⁵. This holistic approach recognizes the importance of not only alleviating physical distress but also supporting patients in finding meaning and peace as they navigate the existential aspects of their journey.³³

Support for patients, families and caregivers

The impact of clowning therapy in palliative care is not confined to the individual patient; it extends to family members and caregivers as well.³⁵ Therapeutic clowns facilitate discussions about death, creating a space for emotional expression and connection. They foster a supportive environment for families facing imminent loss by engaging patients and their support networks in shared moments of joy, contributing to positive memories during a challenging time. This inclusive approach acknowledges emotional interconnectedness in palliative care, offering solace and support to all involved in the end-of-life journey.³⁶

CHALLENGES AND CONSIDERATIONS

Cultural and ethical considerations

Clowning therapy's acceptance varies across cultures, requiring a nuanced approach. Humour, a universal phenomenon, is shaped by societal and cultural norms. Cultural considerations influence what is acceptable to laugh at, and a subjective element exists in humour interpretation. Given its linguistic complexity, understanding humour poses challenges for second-language speakers.³⁶ Cultural sensitivity is crucial for aligning clowning therapy with diverse beliefs. Ethical considerations, pertinent to homecare, healthcare, and both paediatric and adult contexts, emphasize confidentiality, transparency, individual preferences and boundaries.³⁷ Striking a balance between cultural sensitivity and ethical practice is paramount to the successful integration of clowning therapy into diverse healthcare settings.

Potential limitations of clowning therapy

Despite its positive impact, clowning therapy is not without limitations. Individual preferences regarding humour vary, and not all patients may find therapeutic clowning appealing. Research on coulrophobia (fear of clowns) in cancer patients is limited. While hospital clowns have gained widespread popularity, a few studies suggest that some children and adults find them terrifying and distressing.²⁷ Other obstacles to clown care encompass the patient's psychological and emotional state, the gravity of the medical condition, developmental stage, and the timing and context of the intervention.³⁸ Recognizing these limitations ensures a realistic understanding of the scope and applicability of clowning therapy in diverse cancer care settings.

FUTURE DIRECTIONS

Future directions for clowning therapy in cancer care should involve diversifying research to understand cultural influences, incorporating technology for broader accessibility, developing standardized protocols and conducting longitudinal studies to assess long-term impacts. Integration into interdisciplinary care teams, comprehensive education for clowns, public awareness campaigns to destigmatize and specialized programs for diverse demographics are essential. Collaborative research initiatives can strengthen the evidence base and advocacy for institutional support is crucial for recognizing clowning therapy within healthcare policies. These measures ensure the continued evolution and effective integration of clowning therapy, contributing to the holistic well-being of cancer patients and promoting its acceptance as a valuable component of comprehensive cancer care.

CONCLUSION

Masks and costumes, integral aspects of global culture, are deeply rooted in India's artistic traditions, finding resonance in therapeutic expressions such as Vidushaka (jester), Yakshagana, Pilivesha, Mohini Attam and more. Beyond mere entertainment, these performances serve as conduits for therapeutic expression, allowing audiences to connect with masked personas on a subconscious level. Clownselling, an innovative and complementary approach, taps into the transformative power of art, music and charm to bridge the conscious and unconscious realms. This method facilitates healthy emotional expression, nurturing adaptability and inviting individuals to unmask their emotions for self-discovery.

The evolving landscape of clowning therapy in cancer care presents promising avenues for transformative patient support. Emphasizing cultural sensitivity, technological integration, and standardized protocols enhances accessibility and efficacy. Longitudinal studies will unravel enduring impacts and collaboration between healthcare institutions and clowning organisations can fortify research efforts. Education programmes and public awareness campaigns are vital for dispelling misconceptions and fostering acceptance.

As clowning therapy proves its positive influence on emotional well-being, treatment adherence, and the overall quality of life in paediatric and adult cancer patients, as well as in palliative care, its recognition within interdisciplinary care teams and institutional policies becomes imperative. Advocating for institutional support ensures the sustained integration of clowning therapy, contributing to a more comprehensive and compassionate approach to cancer care, where laughter and human connection play integral roles in healing.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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