Hospital Clown Narratives in Pediatric Palliative Care

Abstract

The goal of this qualitative research was to achieve a deeper psychological understanding of professional hospital clown work with hospitalized children during their end-of-life care period. Using a statistical text analysis with a co-occurrence strategy we showed several narrative categories from a clown’s perspective: “Tragic metamorphosis,” “Meditating on the mystery,” “An ultimate poetic atmosphere,” “Interconnectedness and interrelatedness of all things,” “An emotional catalyst,” “The deep need to say goodbye,” “Ethical guidance values.” We will interpret the narratives categories according to humanistic/existential framework as the theoretical base. The clown addresses those aspects of healing that are not well developed in modern Western medicine, the treatment of the whole person. The clown embraces human nature as physical, emotional, cognitive, and spiritual.

Keywords

professional hospital clown pediatric palliative care narratives humanistic/existential framework T-LAB linguistic software

Children of all countries are faced with life-threatening conditions. More children are living longer with life-limiting illnesses which often necessitate palliative care as part of their overall treatment (Martin, Kochanek, Strobino, Guyer, & MacDorman, 2005; Williams-Reade, 2013). The children’s most mentioned negative emotions were sadness, difficulty in talking to their parents about their feelings regarding illness and death, and fear of being alone (Theunissen et al., 2007). In addition to the illness itself, the children were also stressed by the separation from their parents, the strange environment, the fear of painful treatments, and/or the uncertainty of the treatment outcome (Rennick & Rashotte, 2009; Wilson, Megel, Enenbach, & Carlson, 2010).

In a palliative care perspective (Belasco, Danz, Drill, Schmid, & Burkey, 2000; Billings, 1998), hospital clowns, also known as clown doctors (Spitzer, 2006) help pediatric patients and their parents with the stressors and to circumvent the accompanying feelings of fear, helplessness and sadness, thus, supporting the healing process (Anes & Obi, 2014; Barkmann, Siem, Wessolowski, & Schulte-Markwort, 2013; Koller & Gryski, 2008; Linge, 2007, 2011, 2012, 2013; Spitzer, 2006; Tan, Hannula, & Metsälä, 2014).

Patch Adams, as a young doctor in the 1970s, began clowning for hospital patients in Virginia, USA. Big Apple Circus established the Clown Care Unit in New York City in 1987 as the first structured hospital clown program (Spitzer, 2006), with frequent and regular visits to host hospitals. Today, there are now many hospital clowning program around the world (Spitzer, 2006). Clowns meet their partner in a designated “dressing room” space. Next, begins the transformation into character: “The silly clothes, the oversized shoes, the white coat with too many pockets, the outrageous props and musical instruments are all checked” (Spitzer, 2016, p. 34). Hospital clowns are professional performers. They come from a variety of backgrounds—clowning, acting, physical theatre, mime, music, and close-up magic (Linge, 2011, 2012, 2013; Tan et al., 2014; Van Blerkom, 1995). In an exploratory study, Dionigi (2016) highlighted specific differences between clown doctors and the general population: Clown doctors showed higher agreeableness, conscientiousness, openness, and extraversion, as well as lower neuroticism compared with other people. Generally, benefits of clown care include creating a positive emotional state (joy, happiness, laughter, amusement and a sense of meaningfulness), promoting interaction between the parents and the child, and fostering affirmative environmental conditions (Anes & Obi, 2014; Linge, 2007, 2011, 2012, 2013; Spitzer, 2006; Tan et al., 2014). Generally it is known that hospital clowns’ activities included entertaining and comforting parents of children in intensive care units, and distracting AIDS or cancer patients during medical treatment (Linge, 2011, 2012, 2013; Tan et al., 2014; Van Blerkom, 1995), but little is known about the specific clowning attitudes in the palliative stage (e.g., in a child’s advanced cancer treatment), especially in a child’s the end-of-life care period.

Aims of This Study

The goal of this qualitative research is to achieve a deeper psychological understanding of hospital clowns’ work with the hospitalized children in the end-of-life care period, seen from a clown perspective. The more concrete question of the study is: How do the professional hospital clowns experience the relationship with the hospitalized children with advanced cancer and even in the last moments of a child’s life.

We argue that professional hospital clowns’ work in palliative care, especially in the end-of-life care period can mobilize spiritual processes such as the meaning of life, connectedness to humanity, harmony with universe, and a sense of the transcendence (Breitbart, 2002; Bryson, 2004; Byrne, 2002; Carroll, 2001; Dyson, Cobb, & Forman, 1997; Frankl, 1959; Taylor & Ferszt, 1990).

Method

Research Design

The present study utilizes a methodology focusing on the individual’s lived experiences and inspired by phenomenology and a narrative approach (Giorgi, 2009; Husserl, 1977; Mead, Morris, & Mead, 1934/2000; Neimeyer, 2006; J. A. Smith, Flowers, & Larkin, 2009).

This interview model (see the details and questions in the “Data Collection” section), was inspired by a Rogerian nondirectivity approach (Rogers, 1951). It was used to make a connection with the clown phenomenological world. The style of the interview is inspired by the Rogerian psychotherapeutic principles: empathy, congruence, nondirectivity, positive unconditional regard that empower and motivate the client in the therapeutic process (Rogers, 1951, 1961, 1975).

Our descriptive level is based on an automated semantic analysis (bottom-up method), using a text analysis software T-LAB Version 9.1.3 (Lancia, 2004, 2007). Bottom-up methods pursue the aim of mapping the meaning of the text, without a predefined coding system. The development of bottom-up procedures of semantic analysis are based on explicit, invariant rules of coding. Procedures of this kind would represent a highly significant contribution to the growth of qualitative process research. On the one hand, they would allow the automated implementation of the semantic analyses, and they would provide a shared ground supporting and constraining the nonrenounceable human inferential judgments, so increasing the intercoder agreement as well as the comparability among textual analysis (Salvatore, Gennaro, Auletta, Tonti, & Nitti, 2012). In choosing T-LAB version 9.1.3 (Lancia, 2004, 2007) text analysis software, two advantages were key: the multitude of instruments offered for text analysis and the possibility to use them in an integrated way (i.e., for examples, word association, thematic analysis, co-occurrence analysis, comparative analysis), and the possibility of analyzing a very large text. Finally, we will interpret the findings (the narratives) in a humanistic/existential framework as the theoretical base.

The text analysis software T-LAB has been used in a lot of recent articles: social science and medicine (see a complete bibliography on https://tlab.it/en/bibliography.php). In the field of palliative care, the software has been used in recent qualitative research (Caputo, 2015) to explore the main themes relating to euthanasia (moral values, professional ethics, end-of-life care, patient’s right to health care) as provided by psychology-related research. Saita, Molgora, and Acquati (2014), using T-LAB, presented the Cancer Dyads Group Intervention and preliminary findings about its effectiveness: a correspondence analysis of the verbatim transcripts of the first three groups was conducted. The findings highlight the evolution of the participants during the intervention and confirm the congruence between goals and the participants’ experience. Santarpia, Ricci, Meuche, Gamberini, and Destandau (2018), using T-LAB in a qualitative study, presented the narrative effects of detailed shamanic sessions (the use of the drum, telling and interpreting visions according to the shamanic mythology) in the context of psycho-oncological treatment. In particular, the narrative positions of a patient (Mrs. AA) are described as they occurred before and after shamanistic sessions. The authors suggested that these sessions enabled Mrs. AA to produce a larger and more singular narrative about her end-of-life experience: from the beginning narrative position of feeling “the acute consciousness of the finitude” to an emergent narrative position based on “the perception of an interdependence/interconnexion in all relation (human and spiritual world).”

Participants

In line with J. A. Smith et al. (2009) recommendation for homogeneous and purposeful sampling, professional clowns were invited to participate in the study if they went through a palliative experience with hospitalized children in which there were end-of-life moments. Our criterion, following Linge’s (2011, 2012, 2013) research in order to identify the category “Children” was 0 to 18 years. They were being treated and cared for on these wards during stays of various lengths.

Professional Hospital Clowns

We interviewed four professional clowns, two women and two men (mean age = 48.5 years, SD = 11.5): Clown A (women, 68 years old), Clown B (women, 39 years old), Clown C (man, 46 years old), and Clown D (man, 41 years old). All of them work for a famous French company founded in 1991. It was the first clown-doctor company in Europe with hospital clowning programs. All of them have more than 4 years of professional experience in palliative care. As shown in the literature (Linge, 2011, 2012, 2013; Tan et al., 2014; Van Blerkom, 1995), they come from a variety of backgrounds—clowning, acting, physical theatre, circus, mime, music, and close-up magic.

Data Collection

An interviewing guide was prepared: three main questions for the professional clowns related to the relevance and credibility of having hospital clowns, framing the areas to be explored. The interviews were conducted by a trainee clinical psychologist (under professional supervision), using nondirectivity approach (Rogers, 1951), who carefully observed the phenomenological and lived experiences of clowns. She explored three main questions with the professional clowns. The interview approach was rooted in three key questions that were expanded upon using common nondirective interviewing techniques.

Can you describe your thoughts and feelings in palliative care?

Can you tell me some stories with the children and their family in their last day of life?

Can you tell me about some of the strategies you used to manage these moments of the existence?

Procedure

All the six interviews were conducted at the interviewees’ workplaces (coffee rooms, conference rooms, or staff rooms) or using a video–audio internet tool (Skype). The interviews lasted between 45 and 60 minutes. The interviews started with a review of the aims and questions. Following this was a short description of the ethical principles. The interviews were audio-recorded and later transcribed in their entirety. Professional hospital clowns signed a “consent to participate” form which specified that they could leave the study at any time and that all personal information about them would be kept strictly confidential, according to University Ethics Committee.

Data Analysis

The Descriptive Level

The interviews and sessions were recorded on a dictaphone and then transcribed accurately in a document. In the document (.txt type), we arranged the four clowns’ interviews into four variables (using a specific writing¹). This document was analyzed with the aid of the software T-LAB Version 9.1.3, a linguistic and statistical tool for text analysis, developed by Franco Lancia (2004, 2007). T-LAB tool allowed us to pick out co-occurrence and similarity relationships within any corpus or its subset (for example, in this study, the four clowns’ interviews). This strategy determined a potential local meaning based on associationist theories of thought (Chalmers, 1993; James, 1890; Locke, 1690/1975). Word co-occurrences are computed within the elementary contexts² (sentences or paragraphs). Each time the selection of associated words is carried out by the computation of an “Association Index” (Cosine, Dice, Jaccard) and their computation is quite fast. Moreover, the user had to take into account that the greater the number of words included in his or her list, the more reliable the similarity values become.

In our analysis, we organized a target conceptual category of TO_DIE based on the focus of our questions: the palliative care and the death of the hospitalized children (see the radial diagrams, Figure 2, composed of five French lemmatized keywords referring [to die, to decease,³ to pass away,⁴ to turn off,⁵ death] with the significant co-occurrent lemmatized words). We chose a level of word-association significance (p ≤ 0.05, cosine as the association index). Finally, this content analysis strategy generated a radial diagram, where the selected conceptual target is placed in the center and the other words are distributed around it each at a distance proportional to its degree of association (Figure 2). The significant relationships are therefore one-to-one, to the central lemma and to each of the others.

The Theoretical Level

The theoretical interpretation of the results was the next stage in the analytical work. The theoretical construct is based on the humanistic/existential approach (Angus, Watson, Elliott, Schneider, & Timulak, 2015; Maslow, 1943; Rogers, 1951; Santarpia, 2016). We offer the following working definition of the humanistic/existential approach for the purposes of the present article: “Humanism is concerned with such existential themes as meaning, mortality, freedom, limitation, values, creativity, and spirituality as these arise in personal, interpersonal, social, and cultural contexts” (Schneider & Längle, 2012, p. 428). In the 20th-century several clinicians and scientists (Frankl, 1959; Maslow, 1943, 1967; Yalom, 1980) in humanistic/existential framework (Bugental, 1964), described the ways in which critical life crises offered possibilities for positive personal change. More recent calls for an emphasis on positive psychology (Seligman & Csíkszentmihályi, 2000) represent a continuation of this tradition.

Results

As proposed in the research design, first, we presented a descriptive level (using T-Lab software) in which we showed the narrative of the clowns, and then second, we analyzed (using a narrative and humanistic theoretical approach) the narrative of each participant. The examined corpus (Figure 1) for four professional clowns was made up of 1,428 transcripted words, 10,317 occurrences, 1,306 lemmatized words, and the number of hapax⁶ was 770. The list of lemmatized words was based specifically on the palliative care experience of the four professional clowns (see the list in the appendix, ≥8 occurrences).

Figure 1.

Graph of words cloud for the professional clowns’ narrative.

In graph of words cloud (Figure 1) the lemmatized word CHILD has the greatest number of occurrences (94). This shows that the narrative of the participants was centered on the life of the deceased child.

Understanding the Work of Hospital Clowns in the Palliative Care

Concerning the conceptual category To_Die (in Figure 2, the details of statistical values of a co-occurrence relationship) for the clowns’ narrative, it is associated with the following words: “Day,” “Child,” “Image,” “Inside,” “Oncology_Unit,” “World,” “To_See,” “Daughter,” “Bed,” “Mother.”

Figure 2.

Clowns’ narrative.

Tragic Metamorphosis

From the clown perspective these word-associations (see repeated characters that have a bold font style in our narrative examples) conjure up a tragic and rapid metamorphosis of the child’s body that is articulated through several moments of the narrative:

It was really at the beginning of my practice. There was a small child. I was with my partner. I told him: “ah we see down now, yes we see down, two days later we will see small feathers, and a week after we will see the wings”. In fact, a week later the child died and went to heaven, you know. (Clown A)

These word-associations, linked to several adverbs of time (later, after), evoked a narrative concerning the acute consciousness of the finitude.

Meditating on the Mystery

Spirituality is much broader than religion (Mueller, Plevak, & Rummans, 2001; Taylor & Ferszt, 1990), as it concerns harmony with all the forces of universe (Carroll, 2001). Following these spiritual horizons, the next narrative concerning the last days of a girl’s life is based on “Meditating on the mystery”:

There is another story that came to me, it was a little girl who was in intensive palliative care in an oncology unit, she stayed in bed a long time, in an advanced tumor state. Suddenly she woke up, I was with her, she sang and danced for several days. She danced with everyone, the nurses, the doctors. A few days later she passed away. But you do not know why a child experiences these moments of pure life, and moments of energy and later that passes away. But we do not know why. It’s a magic moment. The clown is a human being not a built character, it can experience these magic moments in an oncology unit and elsewhere. (Clown B)

An Ultimate Poetic Atmosphere

Williams (1985) uses the word “poetry” in a very broad sense. Poetry represents the world of creativity and imagination; in other words, the fruit of our human desire to discover meaning in the world and in our lives. We do this in many ways: through music, painting, drama, and other arts, as well as through the gifts of spirituality and reflective living (Coulehan & Clary, 2005; Williams, 1985). Following this definition of “poetry,” we use the adjective “poetic.” We described these emotional encounters created by the clown, with the dying child and his parents, as “an ultimate poetic atmosphere”:

I always remember a room where the parents were waiting in the elevator. We arrived in plain clothes and the mother said to me “Madame, dress up quickly, my daughter will die this morning, she does not want to go to heaven without seeing yourself for the last time”. I did not know if it this desire came from the mother or from the child. I agreed to get dressed quickly enough, my partner who did not know the child, he was a little astonished, and said “But what are we going to do? What are we going to do?” I said “follow me.” So we arrived in her room, the child in the bed was clearly in the end of the life. I told to my partner to play the waltz with her guitar, and I took the mother in my arms and we began to dance softly. And it was magic, a little dance in an oncology unit. I danced with her husband, we changed the atmosphere in this room. They accepted everything because they trusted me. We knew all about their child . . . the diagnosis, the life and the death, you have the trust of the child, of the mother, of the father. When you have this strong trust you can dance during the extreme moments of a child’s approaching death. (Clown A)

This “poetic atmosphere” can evoke a form of flow experience (Csikszentmihalyi, 1990). “Flow” is the mental state of operation in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity. In essence, flow is characterized by complete absorption in what one does, and a resulting loss in one’s sense of space and time (Csíkszentmihályi, 1996; Nakamura & Csíkszentmihályi, 2012). In fact, in the next narration the clown describes this particular time experience:

At the end of the life with the child in an oncology unit, everything is ephemeral, you are in the present moment, here and now, we are in the present time. (Clown A)

And when I talk about life, I talk about a heart that beats. A child in a coma, he or she is alive. In our nation, a person is dead when the brain is dead. For me while the heart and lungs work, for me there is life. Because the clown does not make a difference, the clown is there in the present moment. I remember once we were in an intensive care in an oncology unit, there was a teenager who was dying. She had just had a lung transplant. We danced to Shakira with the mother who was filming and we had a magic moment. The mother laughed and it was great. We planned to go to San Francisco to see Shakira in concert. And a week later, her daughter died. (Clown B)

I talk a lot about resuscitation because I am referring doctor/clown, I perform a lot in resuscitation, in oncology unit. Often the child is in intensive care for many hours, and the child sees the clowns! This is very heavy in resuscitation, in an oncology unit! Because your child is there, they are in intensive care in an oncology unit because they are between life and death. Children are very fragile and they see these strange creatures. It’s powerful! We do not realize but it’s very powerful. (Clown B)

Interconnectedness and Interrelatedness of All Things

In the next narrative Clown D recalled a form of narrative, very similar to a shamanic consciousness (Meuche, 2015), recognizing the nondual nature of the universe and seeing the “interconnectedness and interrelatedness of all things”:

I see clowning in an oncology unit as a vital activity, we bring life to a place where it is lost. When the child passes away, it’s not just a child who dies, it’s the world who loses something. You lose something inside you. I think about death. I have this cosmic image from the beginning when I arrived at the hospital, in the oncology unit. You have to struggle against death, often you lose someone and the hospital calls that person to mind her, you have to ensure that death doesn’t take your vital energies. You have to inject life into yourself. Inside you. (Clown D)

An Emotional Catalyst

Emotion regulation refers to the processes by which we influence which emotions we have, when we have them, and how we experience and express them (Gross, 1998). Clowns have a tendency to approach people, places, or things so as to regulate to emotion. They express, experience, provoke primary emotions (Gross, 2007) through strange objects. They can express immediate empathy with a mother who finds the strength to cry. The professional clowns can be seen as “an emotional catalyst”:

I remember once in an oncology unit, a child who was in palliative care. I had the false teeth. This child was crazy, excited by these false teeth. So I played with these teeth. He found these teeth, and this discovery opened him to another universe. And he wanted to keep them. I said “no” and after the mother said “I never thought I would see my child laughing with teeth like that, and he wails because he wants the teeth”. I gave him my teeth. I said “Well, I’ll lend them”. After some days this child passed away, and then I found my false teeth in the oncology unit where there were the nurses, they had retrieved the false teeth. (Clown B)

I work in an oncology unit, I see children who have died or are dying. I accompany them at this moment there, but it is true that it leaves a mark which last long periods of your life. There are a lot of tears in those moments. Two days ago in the oncology unit, there was a child who was dying. In his room, I sang and the mother cried, she could cry. I’ve never really been afraid of those tears at that moment, it’s something that’s normal, I think. It’s just a valve that opens, a thing, a little resistance that lets go so I do not think it hurts to cry. (Clown D)

The Deep Need to Say Goodbye

The clowns can go beyond a professional relationship in palliative care. They can feel the need to attend the child’s funeral as sign of their strong and intense relationship. In the next narrative, we collected a narrative from a clown’s perspective concerning “the deep need to say goodbye” to the child:

I remember a child, a little girl in the oncology unit, she had an advanced cancer, but for us she was eternal, full of life, impossible to think that she could pass away, she had a bond with the health care staff and with us. Suddenly her medical situation went into decline. It was Friday, I was worried for her, I felt a sad sensation and a sad intuition. . . . I wanted to say goodbye, I went with my partner and the girl was in a serious situation, and even in that state, she could laugh with us. She passed away two days after our meeting. It’s important that I followed my feelings and intuitions concerning this child, so I avoided a strong feeling of guilt. It would have been hard for me if she had passed away before that I could say goodbye. (Clown C)

In the next narratives, “the deep need to say goodbye” is associated with a strong relationship with the child’s family. The clown becomes an emotional and social support for the parents:

There’s something to be aware of concerning a child’s end of life in the oncology unit, we are the last people he or she sees in their life, the last bonds, and especially that you know them in this state of the disease, the parents know it, they often say to you “you were very important for me.” I remember, I still have the images, a child died on the bed. I was in a clown dress. I had a warm relationship with this child and her parents. When the child died, I hugged the mother, the child died on the bed she said to me “my child likes you so much”. It was a strong relationship. After, I removed my clown clothes and with my partner we went to see the child’s body with the parents. And so I remember, I have the image of her daughter, she was on the bed, she had the red nose, that we had put it on. It is quite a shock to see a dead child with a red nose, you know, it’s not common! (Clown C)

I remember a small child, she had a brain tumor. The tumor was growing, she fell into a coma, she was in the bed. She was a little girl with whom we had very good contact. She was in the coma in the oncology unit for a long time, during which, we continued to see her, and to sing for her. For us, she was present. We met her family, her father, her mother, the grandfather, the grandmother, the little brother. We followed this family with joy in the oncology unit. Often we did not come directly for the daughter, but for the family. There was always life in the room. We played music and danced with the mother, the father, the little brother. The end is a little difficult to talk about. The day the daughter passed away, we were not in the oncology unit. I had to go to the funeral because I wanted to say goodbye to the little girl. (Clown D)

Ethical Guidance Values

In the next narratives, Clown D described two “ethical guidance values”: solemnity and authenticity (Rogers, 1951, 1977):

I confess that I have never witnessed a really near death experience. I never was there when the child really dies. It was always a little before, a little after. There are clowns to whom it happened. The parents came after death to ask the clowns to come and to sing. Often in the precise moment of the child’s death, we have the impression that the presence of the clown is inappropriate but the situation is changing. These are moments, where we must also assume, the child is dead, he or she has passed away. In an oncology unit, we should have a moral order, we should behave like this, we should conduct ourselves with solemnity at that moment. (Clown D)

As I said, I haven’t never seen the exact moment of the child’s death, in an oncology unit. I think that sincerity and authenticity are crucial, essential in this social world. We live in a social world full of emotional barriers. It’s really important that energies and emotions can circulate, especially in extreme moments such as death. It’s right to be clear with everyone in that delicate moment. When someone is open, authentic, then we can look inside ourselves. (Clown D)

Discussion

The death of a child defies the expected order of life events: We can feel cast into a world that is absurd, alien, unimaginable, uninhabitable (Neimeyer, 2011; Wheeler, 2001). In the humanistic/existential theoretical approach (Angus, Watson, Elliott, Schneider, & Timulak, 2015; Frankl, 2004; Kierkegaard, 1941; Maslow, 1943; May, 1969; Rogers, 1951; Santarpia, 2016; Yalom, 1980, 2009), these tragic existential assumptions evoke “the meaninglessness” or “the absurd.” It refers to the conflict between the human tendency to seek inherent value and meaning in life (Frankl, 1959) and the human inability to find any. In this context “absurd” does not mean “logically impossible,” but rather “humanly impossible” (Kierkegaard, 1843/1985). As noted by Irvin Yalom (1980) “meaninglessness” is a crucial experience of the four ultimate concerns (the inevitability of death, freedom and its attendant responsibility, existential isolation, and finally, meaninglessness). Frankl (1959) insisted that meaning can be found in all circumstances, even in the most miserable experiences of loss and tragedy. In fact, this article addressed the loss of a child, considered as a devastating, absurd and meaningless human tragedy. In this study, we wanted to explore how professional hospital clowns experience this painful event with the hospitalized children even in the last moments before a child’s death. We argued that professional hospital clowns’ work in palliative care could mobilize spiritual values such as “meaning of life,” “connectedness to humanity,” “harmony with universe,” and “a sense of the transcendence” (Breitbart, 2002; Bryson, 2004; Byrne, 2002; Carroll, 2001; Dyson et al., 1997; Frankl, 1959; Taylor & Ferszt, 1990).

In our findings, we showed four narrative categories from a clown’s perspective (Meditating on the mystery, An ultimate poetic atmosphere, Interconnectedness and interrelatedness of all things) that can evoke spiritual values such as harmony with the universe and a sense of transcendence (Breitbart, 2002; Bryson, 2004; Byrne, 2002; Carroll, 2001; Dyson et al., 1997; Frankl, 1959; Taylor & Ferszt, 1990). Several pieces of research (Charles, 1945; Van Blerkom, 1995; Willeford, 1969) have compared professional clowns to shamans. They can connect to the rational as well as the magic events of the universe. For example, shamanic consciousness recognizes the nondual nature of the universe and sees the “interconnectedness and interrelatedness of all things” (Meuche, 2015, p. 4).

Concerning connectedness to humanity, we found four narrative categories related to the clowns’ attitudes (Tragic metamorphosis, An emotional catalyst, The deep need to say goodbye, Ethical guidance values). Finally, following the narrations gathered, the professional hospital clowns seemed to affirm:

(a) A poetic presence (a combination of imaginative and creative verbal and nonverbal communication) as response to the absurdity of dying of the child. In this perspective, Linge (2012) identified a magical attachment between the child and the hospital clowns, stating that this attachment: constituted a temporary relationship, gave anonymity, entailed role reversal, and created an emotional experience of boundary-transcending opportunities. This magical attachment touched the humanity of the clown deeply and his sense of empathy

(b) A presence evoking the flow experience (Csíkszentmihályi, 1990), characterized by the complete absorption in what one does, and a resulting loss in one’s sense of space and time (Csíkszentmihályi, 1996; Nakamura & Csíkszentmihályi, 2012) with imaginative and surrealist actions

(c) A spiritual positioning based on the harmony with the universe and a sense of transcendence. Van Blerkom (1995) compared professional clowns to shamans. Both clowns and shamans mediate between order and chaos, the sacred and the profane, real and supernatural, culture and anticulture, or nature (Charles, 1945; Van Blerkom, 1995; Willeford, 1969)

(d) A deep connection with humanity based on emotional consciousness (Lane, Quinlan, Schwartz, Walker, & Zeitlin, 1990), emotional empathy and ethical guidance values such as solemnity and authenticity (Rogers, 1951, 1977). In the humanistic approach (American Humanistic Association, 2003; Bugental, 1964; Mann, 1996; Santarpia, 2016; Schneider & Längle, 2012) moral values are properly founded on human nature and experience alone. Human life is based on guiding principles, not dogmatic rules

(e) An existential dimension according to the four ultimate concerns: the inevitability of death, freedom and its responsibility, existential isolation, and finally, meaninglessness (Yalom, 1980). Working with children and witnessing their death would of course activate the clowns’ own existential concerns pertaining to their own mortality and fears of death. Similar concerns about freedom and isolation are salient as well for these individuals

Conclusion and Limitations

The clown, like the shaman (Charles, 1945; Van Blerkom, 1995; Willeford, 1969), addresses those aspects of healing that are not well developed in modern Western medicine, the treatment of the whole person. The clown embraces human nature as physical, emotional, cognitive, and spiritual. In this perspective, the hospital clowns could help the patient and family provide meaning to the experience of illness, even in the end-of-life period in pediatric palliative care. Future research will be crucial in understanding if hospital clowning can bring a positive contribution in reconstructing meaning, helping the parents to address this potential crisis of meaning in the context of bereavement.

A potential limitation regards the methodology, as our automated semantic analysis (bottom-up method) can provide a shared ground supporting for the researchers but it cannot totally cancel the nonrenounceable human inferential and affective judgments/interpretations. Another potential study limitation is interviewing a relatively small sample of clowns, all of whom were employed by the same agency. This may limit the generalizability of the findings as it is possible that clowns from other agencies and countries conceptualize their work differently. Further research could focus on the children’s experiences of the clown care: The authors touch upon that in the introduction, but any other thoughts they could offer on this would be most intriguing to readers in the future.

Footnotes

Appendix

List of Lemmatized Words for the Four Professional Clowns.

Lemma	Occurrences	Lemma	Occurrences
BEDROOM	23	TO_ARRIVE	33
BUBBLE	13	TO_CRY	20
CHILD	94	TO_DANCE	10
CLOWN	37	TO_DIE	51
COMA	11	TO_FEEL	12
DAY	19	TO_GIVE	8
DISTANCE	9	TO_GO	14
FAMILY	11	TO_IMPORT	8
HOSPITAL	26	TO_KNOW	17
KID	19	TO_LAUGH	24
LIFE	48	TO_LIVE	11
ME	67	TO_LOSE	10
MEANING	9	TO_LOVE	9
MOMENT	59	TO_MEET_AGAIN	14
MOTHER	12	TO_PASS	11
MUSIC	9	TO_PLAY	11
PALLIATIVE_CARE	14	TO_PUT	11
PARENT	61	TO_RETURN	8
PARTNER	10	TO_SEE	75
PEOPLE	12	TO_SING	22
PLACE	8	TO_START	12
RELATIONSHIP	10	TO_STAY	9
RESUSCITATION	14	TO_STOP	8
SONG	9	TO_TAKE	9
STATE	11	TO_TALK	14
STROKE	11	TO_TRUST	9
THING	38	TOOTH	9
TIME	15	WORLD	25

Acknowledgements

The authors would like to express their thanks to Tonino Anzante for commenting on, and proofreading this work. A special thanks goes to the clown doctors of the French association, “Le Rire Médecin.”

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

ORCID iD

Alfonso Santarpia

Author Biographies

Alfonso Santarpia, PhD, is an associate professor of clinical psychology at Aix-Marseille Université (France). His research project in clinical psychology and psychopathology is principally concerned with approaches in the humanistic–existential and socioconstructivist traditions. He is interested in the effects of narrative on states of relaxation and altered/modified consciousness (hypnotic induction, hypnosis, shamanism), for the purpose of improving psychotherapeutic treatment. He is also interested in the therapeutic effects of artistic mediation, and especially of poetry, in the experiences of cancer and the end of life. In particular, He has worked to develop techniques that use poetry (Haiku) in an attempt to modify consciousness of the self in these tragic and emotionally difficult moments.

Marjorie Romani-Cesaro is a clinical psychologist, she is very interested in the clown therapy and she is specialized in pet-assisted therapy.

Caroline Simonds, born in Washington, DC, she began studying medicine and later switched to theatre & music at Bennington College in Vermont. She moved to Paris to study mime with Etienne Decroux and music with Betsy Jolas. She was cofounder of “The Palace of Marvels,” a street theatre company that toured Europe for 10 years. She is the director of Le Rire Medecin (), a company she founded in 1991. It was the first clown-doctor company in Europe. In addition, she is now training doctors and nurses at several medical institutions in France as well as assisting and supervising professional companies to develop new clown-doctor programs in hospitals.

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