Clowning for a Cause: Healthcare Clowns Offer Opportunities for Holistic Healing

Although the mark of countless successful theatrical performers is their passion, it takes a special combination of versatility and compassion to transition theatre skills into a healthcare setting. Tiffany Riley does precisely this work as a healthcare clown and a founder of the Laughter League and North American Federation of Healthcare Clown Organizations (NAFHCO). The mental health benefit provided by a clown’s visit is undeniable, leaving a “long-lasting shimmer of hope and good humor in the environment,” according to Riley. At a recent hospital visit, as she and her clown partner were leaving a child’s hospital room, they noticed three doctors standing outside the room, waiting until the clowns finished so they could enter. “That never would have happened twenty years ago,” she told me, “the trajectory has been doctors would barrel in and walk right past you as if you didn’t exist. But that relationship has changed through years of being present and doing good work. [Doctors have seen] the change in mood, how kids, families, and staff feel after being visited by a professional team of clowns.” Yet consistent, good work can only be observed by people in the healthcare setting. Many healthcare clowns struggle to explain their work to people outside of that environment.

So how exactly do healthcare clowns operate? Depending on the hospital, clowns make rounds in departments as varied as oncology, orthopedic, transplant, outpatient clinic settings, and even the emergency room. The goal of every healthcare clown is to offer opportunities for empowerment in their interactions with patients. In pediatric care, clowns are the only people in the hospital a child can say “no” to, as opposed to all the medical professionals who walk through their door. As Denise Arribas, former Company Director of Humorology Atlanta, says, “When a child enters a hospital, they change their clothes into hospital gowns, they are not in school surrounded by their friends, and they are not in their homes with their family and toys. Sadly, once in the hospital, a child is more likely to be identified by their illness than by their name.” Healthcare clowns reconnect patients to their vitality and individuality.

Most people’s first association with healthcare clowning is Patch Adams, either the man himself or Robin Williams’ portrayal of him in the eponymous 1998 movie. Although Patch is certainly “the first known person in the modern era to use applied humor in the health care setting,” according to Tiffany Riley in her book Beyond the Red Nose, the healthcare clowns I interviewed more frequently cited Michael Christensen as the “father” of healthcare clowning. Prior to his hospital work, Christensen co-founded the Big Apple Circus in 1977. After Christensen lost his brother to cancer and subsequently performed at a hospital function, which he described as “the most fulfilling twenty minutes of his career,” he adapted the Big Apple Circus’ signature parody style to the hospital environment by dressing up like doctors and parodying their behavior. In 1986, this method grew into the Big Apple Circus Clown Care Unit, which trained many (if not most) of the successive generation of healthcare clowns. Also important in healthcare clowning’s origin story is Karen Ridd, a professional clown and a specialist in the fields of child life and play therapy, who separately began a program in 1986 in Winnipeg, Canada, and made influential contributions to the field from the child life perspective.

Fast forward to 2022, when there are 214 international member organizations in the European Federation of Healthcare Clown Organizations (EFHCO) and nine member organizations in NAFHCO, and it’s easy to see how this work has flourished since Christensen founded the Big Apple Circus Clown Care Unit. When the Big Apple Circus declared bankruptcy in 2016, many of the Clown Care Unit programs were able to continue operation thanks to funding from their hospital partners. Healthcare clowning has also been embraced globally. Israel’s Dream Doctors founded the first formal training program in collaboration with the University of Haifa in 2006 and have spearheaded much of the scientific research behind the effectiveness of healthcare clowns in improving medical outcomes. In Buenos Aires, Argentina, a law passed in 2015 requires all public hospitals with pediatric services to work jointly with healthcare clowns. Yet healthcare clowns in the United States have struggled to prove their legitimacy and value, despite residing in the birthplace of modern-day healthcare clowning.

The goal of every healthcare clown is to offer opportunities for empowerment in their interactions with patients.

There is one inevitable barrier to acceptance that healthcare clowns face in the United States: Americans are afraid of clowns. While a statistically miniscule portion of the population has been diagnosed with coulrophobia (the fear of clowns), culturally, there is very little goodwill towards anyone in a clown costume. During the “Great Clown Scare” of 2016, Vox’s survey of 1,999 Americans indicated that more Americans were afraid of clowns than a possible terrorist attack, a family member dying, climate change, biological warfare, Obamacare, heights, needles, ghosts, and death. The roots of this fear appear to be multiple: clowns are represented negatively in cultural references such as Poltergeist, Killer Klowns from Outer Space, Stephen King’s It, and serial killer John Wayne Gacy. Another factor is the characteristic appearance of clowns, which Calvin Kai Ku, former Executive Director of the Medical Clown Project, says is “a very one-dimensional look, you’re going to see curly hair, white makeup, big clothing, big shoes—that’s the clown everyone stereotypically sees.” This look was originally designed for circus arenas where the clowns’ exaggerated costume and make-up would be seen from far away, and when observed from up close can appear unsettlingly uncanny. Regardless of cause, this fear is so pervasive that a 2008 University of Sheffield study of over 250 children ages four to sixteen found clowns to be “universally disliked” by all ages.

In the face of Americans’ general ignorance and fear, healthcare clowns have fought on because they know the value of their work and have seen results over the past thirty years. There is increasing evidence supporting the benefit of healthcare clowns’ presence in healthcare settings. In scientific terms, “laughter reduces blood pressure, reduces heart rate, increases respiratory rate, increases oxygen levels in the blood and reduces anxiety,” as Tim Cunningham writes in “Clowns in Crisis Zones: The Evolution of Clowns without Borders International.” In addition, “long-term stress reduction strengthens the immune response and therefore helps protect an individual from various infections.” Studies have shown that the presence of healthcare clowns benefits both children and adults’ health outcomes. While it is an overstatement to say laughter is the best medicine, it does help our bodies feel less pain and heal more efficiently.

What’s more, holistic approaches to healthcare are recently being embraced by a larger portion of the population in the United States. For example, at Cook Children’s Medical Center in Fort Worth, Texas, Laughter League’s services have been considered essential during the COVID-19 pandemic; they were back on site in the hospital on 1 June 2020. At Boston Children’s Hospital, every new hospital employee gets a forty-five-minute session with Laughter League’s healthcare clowns to learn what they do and what tools they share, including making eye contact, reading the room, being present, and breathing. Many of the clowns I interviewed have been spending more time than usual working with young people suffering from mental and behavioral health issues, at the request of the hospital, as part of the care team addressing the surge in adolescent mental health issues.

Giving children back their agency is instrumental in reconnecting them with their own personal power in a situation where it’s easy to feel powerless. Riley writes in Beyond the Red Nose, “We treat the healthy part of the child during the hospital stay.” Rekindling a child’s spark through laughter and play, if only for a moment, restores them to themselves. Becca Chapman, Executive Director of Prescription Joy, says, “The biggest thing I’ve gotten from doing this work is everyone has a right to joy, especially people in locations you think don’t have access to that. People everywhere deserve it, late night nurses, people that are incarcerated… I feel honored to be a fighter for that right.”

Giving children back their agency is instrumental in reconnecting them with their own personal power in a situation where it’s easy to feel powerless.

When I interviewed healthcare clowns, they all stressed the importance of professionalism and the rigorous training they’ve undergone to be where they are today. Currently, Helen Donnelly’s Therapeutic Clowning Certificate Program, founded in 2018, is the first and only training program in North America. Another instrumental step in setting industry-wide standards and coalition building was the formation of NAFHCO in 2019. All healthcare clowns within the NAFHCO network abide by a code of ethics that standardizes their approach in any healthcare environment. Among other requirements, all clowns must be paid for their work, respect patients’ privacy, and always work in pairs. Working in pairs allows for more opportunities to create material, gives the patient more agency about their level of engagement on a particular day, and ensures that there is more than one set of eyes looking out for the medical equipment and personnel in the room.

Looking forward, several healthcare clowns I interviewed spoke to some recurring themes and aspirations. NAFHCO member organizations are focusing on increased equity and inclusion within the healthcare clowning profession. According to Meredith Gordon, a founding member of Humorology Atlanta, “Many of these [healthcare clown] programs are staffed by largely if not all white performers, and they tend to be in metropolitan areas with large Black/BIPOC [Black, Indigenous, people of color] populations. We need to have more representation of that [diversity]—racial, ethnic, and gender—to better reflect the culture at large and the clients and populations we’re serving.” Gordon shared his frustration about being the only Black person in gatherings of forty or fifty healthcare clowns and feeling pressure to address racial issues when they came up at those gatherings. In response to the field-wide desire for increased diversity, Gordon joined forces with four other healthcare clowns across the country—Leah Abel, Denise Arribas, Calvin Kai Ku, and Mal Malme—to create DRIVE Forward, which fosters conversations around equity and inclusion. DRIVE Forward workshops address microaggressions, accountability, approaches to difference, and punching up (rather than down) with humor.

As clowns and humans, we have to acknowledge and hold space for our grief and loss, but our job is not to jump into the sadness.

In addition to the focus on increased equity and inclusion, almost everyone I spoke with hoped for more respect for the profession. Several interviewees likened it to music therapy and child life services, which are relatively new additions to medical care teams that had to work to prove their value and legitimacy. They pointed to more funding, more scientific research on the quantifiable medical benefits of healthcare clowning, and more professional training—especially within medical school settings—as important stepping stones towards building respect for the profession.

Although most of the people I interviewed have continued pursuing careers in other performing arts concurrent to their work as healthcare clowns, they all agreed that their work in the hospitals is more powerful than any other performance they’ve given. Malme, who’s been a healthcare clown since 1997 and currently works with The Laughter League, says, “We live in an incredibly critical and judgmental culture; this work can’t erase that…but it reminds me we have no idea what somebody’s walking in or dealing with.” Time and again, folks said that this work made them better communicators, better listeners, more empathetic, more vulnerable, more creative, better able to put things in perspective, more patient, and less afraid of death.

For healthcare clowns, this work is not “sad.” Instead, their job is to find the joy, life, and laughter in healthcare settings. Malme says, “There’s sadness, obviously. There’s nothing sadder than when a kiddo you know dies, and the family is left with this black hole. As clowns and humans, we have to acknowledge and hold space for our grief and loss, but our job is not to jump into the sadness. Our job is to engage in connection, empowerment, play, humor, and magic—that’s where the kid lives.” Alex Smith, Artistic Director of Prescription Joy, concurs, adding that “places of healing aren’t inherently dark, scary, and sterile. Joy is there. It just needs permission to bloom.