Applied performance practices of therapeutic clowns

In this chapter, we explore the ways that therapeutic clown practices in a rehabilitation hospital emerge from artistic practice, including theatrical clown and circus clown. This curated conversation takes place among therapeutic clown practitioner and teacher Helen Donnelly, applied performance and health humanities scholar Julia Gray, and critical qualitative health researcher, physiotherapist and former physical theatre practitioner Jenny Setchell. We sat down in person to discuss Donnelly’s practice (which was audio-recorded and transcribed verbatim), and followed up with a back-and-forth process among all three contributors to refine the written text. Through her clown persona of Dr. Flap at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Canada, Donnelly discusses the ways she and her clown partner provide liminal spaces for disabled children to instigate play with agency; engage aesthetically, imaginatively and relationally; and up-end traditional adult/practitioner – child/client hierarchies. We use the term “disabled children” rather than “children with disabilities” in keeping with current usage in critical disability scholarship (see for example Kafer, 2013; Shildrick, 2009). Disability is not considered a condition of individuals, as is implied by the phrase “with disabilities,” but rather something experienced as a result of prejudice, discrimination, and social exclusion. Centered in artistry rather than traditional medical or therapeutic approaches, the “aesthetic” care provided through clowning focuses on aspects of a child’s body, emotions, and relationality. Julia

Tell us about your experience in clown. You are not only a therapeutic clown, but also a circus and theatrical clown.

Helen

My clown roots are theatrically-based, specifically physical theatre. The circus aspect came later. I did a circus show at Ontario Place in Toronto [Canada], and that’s when I got scouted by Cirque du Soleil. I worked with them, touring and performing special events worldwide over a six-year period. After Cirque, I was the resident clown of Circus Orange, which is a pyro-technic dance-based circus, for ten years, until 2017. I am still involved with theatrical-clown in theatres and festivals, and through teaching too. Doing my own shows and creating cabaret nights with my students.159

With both theatrical and circus clown you are using a lot of the same clown-based muscles. But the kind of energy that you need to generate in order to start up a circus show is very, very different from the type of energy that is required to pull off a good theatrical clown show. With circus, it’s much more “360” and your role is to carry the show forward; you’re there to be the storyline, or the glue that fits the whole show together. Whereas in a theatrical clown show, it’s usually a one-woman show or a cabaret night where you’re with other physical theatre performers, your “kin” if you will. So you’re using different artistic muscles. You can start very subtly in theatre – you can start with a whisper. It’s a different kind of listening to your audience. It’s very, very difficult to be subtle as a circus clown.

Julia

How does that move into therapeutic clown, in terms of listening to audience, or using particular clown-based muscles?

For more insight into the process of transitioning from a circus or theatrical clown to a therapeutic clown, please see the documentary A Therapeutic Clown Emerges: Our Story of Recruitment and Training (Donnelly and Vanden Kroonenberg, 2018).

Helen

The obvious differences are the agendas. So in shows, whether it’s a circus or theatre show, your agenda is to entertain. And that’s it: Full stop. You have a particular kind of relationship with your audience. Whether you’re in a theatre or performance space, or they’re coming to a public space, they’re usually expecting some sort of entertainment.

And when you’re moving into a therapeutic context, so many things are different. First of all, your audience might be an audience of one. The context is more private, and your audience may not be expecting you or even know of your existence. They’re also potentially more vulnerable in ways that a public audience typically isn’t.

I am very aware when I am doing my theatrical or circus shows that there could be people out in the audience who have a cancer diagnosis. And maybe I’ve made their day a little lighter. I’m very aware that there are therapeutic benefits to putting on a good clown show.

But when you have someone in a hospital who isn’t expecting you, you might have someone who could be vulnerable physically, mentally, emotionally – all kinds of ways. Even if they are, you need to be ready for anything. Maybe it’s not the best time for them, or they change their mind half-way through, or you might be triggered and you have to leave, or you’re interrupted by something medically-based, or a family visitor comes in the room and you graciously step aside. It’s a different kind of attention.

Julia

And what about the children? What do they bring to your work as a therapeutic clown?

Helen

They bring so much. Much like a theatre or circus audience, but in a different way. Let’s say there’s a teenager who purely wants to be entertained. He’s asked for it: “What have you got for me?” And you give him the goods – not the cheap stuff! So, you might perform an improvised soap opera, or a hip hop song which has to do with him in the hospital – that kind of thing. And he is totally satisfied because he is receiving a full, ridiculous, and entertaining experience. Compare this to a very 160tender moment with a child, where maybe you’re talking someone down from a crisis. And you’re doing it artfully, making up a song about how weird this moment is, or how we are feeling – that kind of thing. The practice is that varied, and there are different approaches that are appropriate for different scenarios. We need to be trained and ready for the client to choose what kind of clown they get in that moment. I’ve also taken totally different approaches with the same client. They recognize that, and they drive that boat.

Clients are really smart about how to manipulate their clowns, and how to do it for their benefit. They know how to get the goods from their Fools, and it’s really clever.

In a contemporary health care settings, there are ongoing extensive discussions about the nature of the client–practitioner relationship. There is now a widespread acknowledgement of the considerable harms of the traditional paternalism of Western health care approaches where the health practitioner unilaterally makes decisions on behalf of the person they are caring for (Bensing 2000). In the past few decades, a response to these concerns has been to attempt to shift the nature of health care interactions to a “person-centred care” approach (often this is called “child-centred” or “family-centred” in childhood health care) which involves efforts to make care more collaborative (McCormack et al., 2015). There are a number of different person-centred approaches underpinned by different ways of thinking about how to address these issues (for more details, please see Pluut, 2016; Leplege et al., 2007). Although there have certainly been some shifts in practice to more collaborative approaches, there continue to be difficulties implementing this type of care in practice. There is also considerable research highlighting that most health care practices continue to be health practitioner driven and led, rather than collaborative (Hiller et al., 2015; Naldemirci et al., 2018; Gibson et al., 2019).

Jenny

It’s interesting to think about that in a health care context. What you’re describing sounds quite different from most health care provider–client relationships. Most doctors or other health care providers don’t expect children to drive the boat to the same degree that you are describing.

Helen

Yeah, I can see that. We’re unique in that way in a hospital setting.

Julia

And how do you place yourself in that relationship with children as a therapeutic clown?

Helen

In this particular therapeutic context, it’s not about you. So it takes a huge amount of humility – the ability to set your ego aside. Your “brilliance” as a clown is secondary to their well-being, to their comfort, to their choices. It’s a different kind of togetherness, riding that particular wave when things are going well with a particular child, and seeing where that wave can take all of us, sharing that ride together. But, also the ability to admit when it’s not working.

Of course, the roots of therapeutic clown practices are in the art of clown itself. There is a lot of cross-over, and you’re riding a wave all the time when you’re in live theatre and a circus too. You can hear the audience, you can repeat the same line, or you can repeat the same gesture and get a bigger laugh.

In therapeutic clown, we employ those techniques too, but only when appropriate. We don’t push. There are lots of other things that we need to have in our minds 161– things like not to over-excite. For example, I’ve never thought in a circus or theatre show: “Oh, am I going to over-excite them? What will happen if I’m too funny right now?” That’s never been a concern. But over-stimulating someone with stitches after surgery – that is a real concern. Over-stimulating someone with a certain diagnosis, like autism, could be problematic where there may be sensory issues. You just need to be aware that the artistic choices are going to have a potentially big impact on the moment; so you attend to the relationship differently.

Jenny

How do prepare yourself to start? Is it different with therapeutic clowning, when compared to theatrical or circus clowning?

Helen

Yes. Preparation is very different. I have rituals for both; warm-up rituals. Usually when I’m preparing for a circus or theatre show I’m doing solo work. So, a warm-up is a thing that I do with myself; a physical, vocal warm-up.

Jenny

And that’s just before you go on stage?

Helen

It is. But then I also breathe in the audience just outside of their view, off stage. I breathe them in and I wish them well – it’s a little well-wishing thing I do.

But with therapeutic clowning, although there’s still the physical, vocal warm-ups, you’re working in partnership. Working with a partner is really important. It offers more choices for the client – artistically more is possible with two clowns; you can set up amusing conflicts, harmonize while singing, use slapstick routines, stuff like that. As well, working in duo helps to make sure children never feel obligated to engage since they see there are two of us. They have more time and space to “get to know” us as they decide about inviting us inside their room to play. It’s also helpful for us as clowns to have an extra pair of eyes on what we’re doing when we play with children – it’s a kind of safety to have someone else witness the work, and even an accountability. This is also important because after our shift we provide feedback to each other, where we exchange artistic and logistic ideas, so we can learn from what we’re doing in the hospital units and improve for next time.

But, I digress. Back to preparation! Together, my clown partner and I settle on a focus of the day. It might be, “Because I’ve been so verbal these days, I want my focus of the day to be the most non-verbal clown ever! Dr. Flap is going to have no opinions at all!” And then my partner will say, “That’s good to know. I will support that by not asking a whole bunch of questions, and I’ll be just as curious.” So by voicing our focus when we prep, we try to support each other as clown partners, to help each other get through the day. We find that by saying a concrete focus out loud, it helps us tune into each other. This is vital; listening and being present with each other as clown partners. It’s vital because it’s the corner stone of everything, from being an excellent listener on the units, to not missing out on some obvious things, like paying attention to a family who is struggling emotionally or an opportunity to connect with a child who takes longer to communicate verbally because of a brain injury. Being tuned into each other grounds the work as a therapeutic clown.

So, then as a duo, we usually do a silly warm-up. Like Nurse Flutter ¹ and I do this kind of “10, 9, 8, 7, 6…”, a kind of clapping, schoolgirl thing that I made up. She loves it! And she always loses, so she giggles going into it, knowing she’s going to be a big loser. Getting the laughing going is really important. And it’s authentic – based on real stuff, our own stuff, rather than laughter coming from nothing.

Julia

I love what you’re saying about what the audience brings and your relationship with them. Even using language like “breathing in the audience.” I know you do that with 162the circus clown and the theatrical clown. And it sounds like you do that, or a version of that, within the therapeutic setting as well.

Helen

We do! In a bunch of different ways. For example, the first half of our day is looking up clients, their charts, talking to other health care providers. One could say we’re kind of “breathing in” all of that information about what the clients are up to. And what is their weekend like? And have they been sleeping? Or are the parents at bedside? Or no, they’re missing their parent. Or they’re really bummed out because their best friends haven’t visited yet. This is their third week in rehab and they’re really, really super lonely and scared.

So you’re taking in all the psycho-social trauma, plus their physical situation and what’s happening with their bodies. And you can kind of “breathe that in” and pay attention to that when you play with those children.

And you get deep, deep, deeply into the family situations. Of course, we are always paying attention to the whole family (parents, grandparents, siblings) – they need us too. It’s a real privilege to serve the parents, guardians, siblings, and all sorts of people at a time when lightness and joy can seem miles away. Sometimes it can be very difficult because of challenging family dynamics, or what the whole family is going through emotionally – if a child’s been in an accident, let’s say. It’s the whole family that’s dealing with it. As a therapeutic clown, you’re carrying the responsibility of being a caregiver, you’re a kind of artist-caregiver. So, you can imagine what it’s like for any caregiver, like a teacher or another health care provider. You know the whole family’s situation, all their dirty laundry. As a therapeutic clown, your job is to be this instrument of joy and lightness. And you have to present yourself in this non-judgemental, completely open, curious form of play-dough. And it has to be honest: That laughter and joy have to be authentic. And we get there – we can do it, because of our training. All of that is a part of “breathing them in.” You’re breathing everything that they are suffering with.

And you’re also delighting in all of the triumphs. And there are so many, oh my God! On a good day, that far outweighs all of the challenges, as we know.

Julia

What do you mean by honest, when you say “it has to be honest”?

Helen

You can’t fake honesty when you’re clowning. Because people will sniff that out right away.

It’s about seeking out a real, honest connection. To be called upon as a therapeutic clown is to be authentic, real, loving, patient, and non-judgmental, even when sometimes the situations are very difficult to deal with – some of the things you overhear staff or families say can be very challenging. But I’m able to do that; authentically and honestly, I’m able to love and forgive things I hear or see because our focus is on what is “working” rather than what is dysfunctional.

Of course, there have been times when I’ve failed. And that’s when I remove myself from the unit. I turn to my clown partner and say, “My gosh, it’s break time!” We rely on each other in that way. One of us is triggered, and we know we’re flipping out of clown. That’s when you take a break. Because, after all, you’re only human.

Jenny

Does that also happen with young people who you work with? The triggering, the flipping out of clown?

Helen

Oh yeah. I get hopping mad about all kinds of things. It’s hard to blame children for anything. I might get irritated by some of the choices they make. But there can be difficult family dynamics, sometimes. Things like when parents let their children play 163really excessively violent video games. That’s really hard, to be in the room during that, and you’re seeing it more and more. It’s brutal. We’ll leave the room if that happens, but it will certainly take you out of your clown.

Jenny

It’s harder to connect.

Helen

Completely. Well, actually, we did wean a boy off of his video-game device. With him, we had assumed that the parents had caved early; like “Oh, he loves devices, so we’re just going to plug him in!” And frankly, what exhausted parent hasn’t done that? But they were so shocked that he kept stealing glances up at us. And as the weeks went on, he eventually just put the device down, which apparently was a huge change for him.

Jenny

And, of course, being in a rehab hospital, your audience may be there for weeks! There’s a courtship that happens over quite an extended period to time.

Helen

That’s a good way of putting it. And relationships with children build differently. Sometimes it will come together in a flash. I’m thinking of one child, I think he was three years old. All he had to do was look at us and go “Bam bam, you’re dead!” And we would go, “Aghhh!” We were just his forever. And then he just followed us around and that was it. We tried to alter the game, but he wouldn’t have it. For three months, that was the game.

Then, you know, we had this other little one whose parents were really cautious about us, saying, “You know, he’s always hated clowns.” And our response, of course, was, “No problem. We’ll never approach him. But you know we are around, you might see us.” So, it went from him panicking when he saw us, like visible panic, to eventually never, ever leaving us alone over a course of a few weeks. He literally followed us into every room.

And everything in between!

There are emerging discussions around the interrelationship among aesthetics, relationality, and care across disciplines. As one example, applied performance scholar and practitioner James Thompson discusses an aesthetics of care as a “quality in the touch, the attentiveness, and the focus of the relationship…” as part of health care practices that might “more usually [be] associated with artistry” (2015, p. 432). He additionally queries the ways that applied and social justice-oriented theatre practices might be re-oriented within a framework of care emerging from feminist ethics, including mutuality, reciprocity, and personal and political interdependencies (see also Gray and Kontos, 2018; Gray, 2019). Similarly in dementia care, the notion of relational care has been suggested as an ethical re-centring of caring practices around relationships beyond individually-oriented patient-centred care, to include how persons living with dementia might be cared for and supported in a range of contexts including familial, environmental, cultural, social, aesthetic, spiritual, as well as biomedical (see for example Kontos et al., 2016; Greenwood, 2007; Kontos et al., 2017). From the visual and avant-garde arts, art critic and scholar Nicholas Bourriaud’s (much critiqued) Relational Aesthetics can be understood as engaging in artistic practices “which take as their theoretical and practical point of departure the whole of human relations and their social context, rather than an independent and private space” among artist, artistic technique and artistic form (2002, p. 113).

164 Julia

What would you say is the kind of care you provide? You talk about being an “artist-caregiver,” or that a child is “looking for certain things” from you as a therapeutic clown. What are those things? What you provide to children is different from, say, a medical doctor, or even an occupational therapist, where there’s a particular focus or approach to “care.”

Helen

We’re not focusing on the diagnosis of the child. We have to be aware of it, sure. In order for the good care to happen, we need to protect them from harm. So being aware of triggers and the diagnosis, different ways of communicating, and likes and dislikes, and all that kind of stuff, is so important. And that is a part of being a caregiver.

It’s attention to particular kinds of details, as well. We observe the children carefully. The more present we are with them, the more precisely we’re attending to minute alterations in their mood, in their breath, in their body language, in how they respond to us, and to what they’re responding to.

But there’s also a presence with my clown partner. I might signal to her in the moment of play that I just saw something that I know she missed. Or vice-versa. How does the practitioner underneath the nose make sure that everyone’s on the same page, and not lose the thread of the play? So it’s very complex.

You’re working in the moment, being present. It’s spontaneous; there’s no plan, other than how can we tend to the healthy part of this individual child that we’re serving through clown? What does that look like, in this moment? Do they need us in this moment, and if so, what does the need look like? And how do we, as clown partners, agree on that need and what it will look like through a silent negotiation?

A big part of being a good artist-caregiver is tending to those really specific, subtle signs.

Julia

Like those signs from a child’s body and movements.

Helen

Yeah, all that. You have to be present, so you can pay attention to that stuff in another person.

Julia

In our paper with Barb ² about therapeutic clowns and foolishness (Gray et al., 2019), we wrote about “aesthetic attention.” We had discussed how, when clowns play with children in a hospital, there’s a kind of sensory engagement and emotional awareness, but that happens through playing and through doing, not through talking or too much “in-your-head.” That can open up creative and imaginative possibilities for that child.

Helen

Yes, exactly. And that happens because we pay attention in those ways. We are trained to do this as artists.