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Guide VIII-124

Medical clowning

Michael Christensen, Patch Adams, Wellington Nogueira, Yaacov Shriqui1986New York
A 41 · L 42 · M 1722 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the professional hospital clown-doctor model run by specialist clowning organisations inside hospital teams. Sources are the Big Apple Circus Clown Care Unit as described by Koller and Gryski (2007), Doutores da Alegria as described by its founder (Nogueira interview, 2012), the standards of the European Federation of Healthcare Clowning Organisations (EFHCO) and the guidelines of its member RED NOSES. The Toronto Hospital for Sick Children "therapeutic clown" (Child Life) variant is used for the entry and permission procedure, and the Swedish pair-work research by Linge for the in-room process. [source: Koller & Gryski 2007; Nogueira 2012; EFHCO; RED NOSES; Linge 2013]

Medical (hospital, healthcare) clowning is a performing-arts practice in healthcare, not a psychotherapy and not a treatment for disease. Professional clowns, usually working in pairs and in a parody "doctor" persona, visit patients (mostly children) on wards, in clinics and during procedures. They use improvisation, physical comedy, magic, music, puppetry and parodies of hospital routines to ease fear, anxiety, loneliness and boredom, and to support children, families and staff. [source: Wikipedia, Clown care; EFHCO; Koller & Gryski 2007] It is an adjunct to medical and nursing care. It supports coping and the emotional climate around treatment and never replaces medical treatment, analgesia, sedation or psychological treatment. [source: EFHCO, which presents clowns as supporting care; synthesis for the explicit boundary]

How change is thought to happen: the clown takes the low-status, clumsy, vulnerable position, so the child gets to be the strong one who controls the play in a place where they otherwise have little control. Child-led play and gentle humour lower stress, give a playful frame of mind and build a supportive relationship over repeated visits. [source: Koller & Gryski 2007, whose model has three parts: empowerment, play and humour, supportive relationships] Linge calls the clowns' skill "humor attunement": the clowns pick up the child's current emotion, hold it, and give it back in a humorous, manageable form. [source: Linge 2013]

Origins (checked against sources): Patch Adams founded the Gesundheit Institute soon after medical school in the early 1970s and has led humanitarian clowning trips to hospitals, orphanages and prisons for decades. He presents clowning as care and connection: "Clowning is a trick to get love close." [source: Marsh 2008, Greater Good; Wikipedia] Michael Christensen founded the Big Apple Circus Clown Care Unit, and professional clown doctors started working in New York hospitals in 1986. [source: Wikipedia, Clown care; Koller & Gryski 2007] Wellington Nogueira saw the Clown Care Unit in New York in 1988 and started Doutores da Alegria in Brazil in September 1991. [source: Nogueira 2012] The interview does not name São Paulo as the founding city, although the organisation works in São Paulo hospitals [uncertain]. In Israel, Dream Doctors (founder and chairman Yaacov Shriqui) had about 90 clowns in 22 healthcare facilities by 2011, and a hospital physician described them as part of the medical staff. [source: Klein Leichman 2011, ISRAEL21c] The founding year of Dream Doctors (about 2001, implied by a tenth anniversary in 2011) is [uncertain].

Professional frame. Medical clowning is not a regulated health profession in most countries. In the UK it is not an HCPC-registered arts therapy, and it is not drama therapy [synthesis from absence in sources]. The standards come from the clowning organisations:

  • EFHCO full members hold a Quality Label with on-site managerial and artistic evaluation and audits every five years. Clowns are professional artists with at least 500 hours of specialised healthcare training. [source: EFHCO]
  • Doutores da Alegria requires a professional actor or clown registration (DRT) and a clowning specialisation. Selection has three stages (CVs, workshops, a test in hospital), followed by a year of weekly hospital work with a trainer clown plus a weekly training day. [source: Nogueira 2012]
  • In Canada, therapeutic clowns follow the Canadian Association of Therapeutic Clowns' Statement of Principles and Code of Ethics. [source: Koller & Gryski 2007]
  • In 2011 the University of Haifa offered a bachelor's degree in medical clowning as a paramedical profession. [source: Klein Leichman 2011]

A psychotherapist should not clown on wards without this specialised training and without membership of a recognised programme that holds a hospital agreement. A therapist's usual roles are to refer, brief, co-work and debrief alongside the programme (see 4.16 and 4.22). Patch Adams's view that volunteers need no prior training describes humanitarian clowning trips, not the professional hospital model. [source: Marsh 2008; EFHCO; synthesis]

2. Framework

Medical clowning is a programme delivered in recurring visits, not a course of sessions with a set number. Its structure runs on three levels. [source: EFHCO; Nogueira 2012; RED NOSES; synthesis for the phase labels]

Phase A: Programme set-up with the institution. Goal: a written partnership in which the hospital knows who comes, when, where and under which rules.

  • Before the first visit, agree on changing rooms, protective equipment, the areas clowns may enter and named contact persons. Clowns follow internal routines, for example temperature checks. [source: RED NOSES Austria, Covid-19 visit guidelines]
  • Clowns respect the facility's internal processes and do not take sides in disputes between staff or with management. [source: RED NOSES Behavioural Guidelines]
  • Move on when the agreement, the contacts and the hygiene and safeguarding rules have been confirmed with the ward lead and the infection-control team. [synthesis]

Phase B: Each visit day.

  1. Ward briefing: get updates from the ward and talk with staff before seeing patients. EFHCO members use standard procedures for contact, information flow and preparatory reports. [source: EFHCO] The work goes better when staff openly share information about each child's health status and each family's wishes. [source: Linge 2013]
  2. Encounters, room by room (see Phase C).
  3. Feedback and reporting to staff. Doutores da Alegria artists send a monthly report to each hospital. [source: Nogueira 2012] A short verbal handover at the end of each visit is [synthesis].

Phase C: The single encounter.

  1. Approach and permission at the door.
  2. Pair interplay, so the child can watch first.
  3. Child-led play and humour attunement, moving from surprise to interest to joy.
  4. Closure or graceful withdrawal.

[source: Koller & Gryski 2007; Linge 2013]

Move to the next step only when the child (and parent) has given permission and the child's cues show comfort. If the child refuses or shows unease, step back: increase distance, play from the doorway, or leave for the day. [source: Koller & Gryski 2007]

Typical format and dose (as published, by programme):

  • Doutores da Alegria: the same pair visits the same hospital twice a week, six hours a day, for a year. [source: Nogueira 2012]
  • Dream Doctors (2011): about 12 minutes per child on average. A pre-anaesthesia encounter of about 15 minutes was studied. [source: Klein Leichman 2011]
  • Big Apple Circus model: clowns always work in pairs. [source: Koller & Gryski 2007]
  • Children's National Hospital: "clown rounds" across inpatient units, ICUs, outpatient clinics and waiting areas. Families ask for a visit through the unit nurse or a Child Life specialist. [source: Children's National Hospital]

3. Guiding principles

  • Adjunct, not treatment. Clowning supports care and never replaces medical, nursing or psychological treatment. In practice: never delay, alter or argue against a clinical intervention, and never claim to cure. [source: EFHCO; RED NOSES (no work outside the artistic role); synthesis]
  • Permission first, and the child may refuse. Work starts from each child's permission. In practice: ask at the door every time. A no from the child or parent ends the visit for that day with no persuasion. [source: Nogueira 2012; Koller & Gryski 2007]
  • Child-led play. The child directs and the clown follows. In practice: offer, wait, then build on what the child does. [source: Koller & Gryski 2007; Linge 2013]
  • Status reversal. The clown is weak, clumsy and out of place, and the child is strong and brave. In practice: let the child win, correct or rescue the clown. [source: Koller & Gryski 2007; Linge 2013]
  • Humour attunement. Meet the child's current emotion before trying to lift it. In practice: mirror the mood first and lighten it gradually. [source: Linge 2013]
  • Work in pairs. Two clowns give the child an audience position, give each other artistic and emotional support, and can signal when a scene is going too far. In practice: plan roles and stop-signals with your partner before you enter. [source: Koller & Gryski 2007; Linge 2013]
  • Never alone with a child. Under the two-adult rule, at least two adults are present in a closed room with a child. A solo artist in a special format keeps the door open throughout. If the facility requires closed doors, the artist writes a memo to the organisation explaining why. [source: RED NOSES Behavioural Guidelines]
  • Part of the team. Clowns work within the healthcare team and keep its routines. In practice: brief before the visit, adapt to procedures, hand over after. [source: EFHCO; Koller & Gryski 2007]
  • Hygiene is part of the craft. Follow the facility's hygiene and safety rules. In practice: disinfect hands at every room change, use only disinfected props and comply with every access restriction. [source: RED NOSES Behavioural Guidelines; RED NOSES Austria]
  • Closeness with distance. Keep empathy together with appropriate distance and resilience. Clowns have no obligation to stay in contact outside the hospital. In practice: no private contact, no social-media connection with patients or families [synthesis for social media]. [source: EFHCO; RED NOSES Behavioural Guidelines]
  • Dignity, privacy, confidentiality. Use information from the facility only for the work and keep it confidential inside and outside the hospital. In practice: no names or medical details in conversation, notes or posts. [source: RED NOSES Behavioural Guidelines]
  • Never use trust for your own needs. Any physical, mental or sexual violence is forbidden, and so is manipulating a child's trust. In practice: the encounter serves the child, not the performer's wish for applause. [source: RED NOSES Behavioural Guidelines]
  • Sober and fit for work. No alcohol or drugs on duty, and do not come in if unwell. [source: RED NOSES Behavioural Guidelines; RED NOSES Austria]
  • Not everyone has to be won over. Graceful withdrawal can itself empower a child. [source: Koller & Gryski 2007]
  • Continuity. Familiar faces and repeated routines make play predictable and comforting. [source: Koller & Gryski 2007; Nogueira 2012]
  • Recognise and report. Clowns are trained to recognise and report safeguarding concerns and owe a professional duty of care. [source: EFHCO]

4. Intervention inventory

These procedures are for trained clowns working in a recognised programme and for the clinicians who coordinate with them. Where a psychotherapist's own role differs, this is stated. Example language is illustrative and is not taken from any programme's scripts.

4.1 Pre-visit ward briefing

  • Purpose / when: Every visit day, before entering any room. This is where you learn who can be seen, who must not be disturbed, isolation status, procedures planned for the day, family wishes and safeguarding flags. [source: EFHCO; Linge 2013]
  • Steps:
    1. Report to the nurse in charge or the named contact at the agreed time. [source: RED NOSES Austria (named contacts); synthesis for timing]
    2. Go through the patient list. For each child note: OK to visit, not today, or doorway only; infection precautions; procedures where clowns are wanted; language; known fears (for example of masks or of being laughed at); whether a parent is present. [synthesis, built on Linge 2013 and EFHCO]
    3. Agree which procedure accompaniments the staff want and who leads them (see 4.12). [synthesis]
    4. Agree roles and a stop-signal with your partner. [source: Koller & Gryski 2007 (partner signals); synthesis for the explicit signal]
  • Example language (illustrative): "Who would you like us to see first, and is there anyone we should leave alone today?" / "Are any rooms on precautions? What do you need us to wear?"
  • Watch for: Rushed briefings, or staff who keep information back. Linge found the work went more smoothly where staff shared openly. Keep the information confidential. [source: Linge 2013; RED NOSES Behavioural Guidelines]

4.2 Hand hygiene and personal protection at every room change

  • Purpose / when: Before and after every patient contact and every room, plus whatever extra protective equipment the facility requires. [source: RED NOSES Austria]
  • Steps:
    1. Disinfect hands on entering and leaving every room, and wash them regularly. [source: RED NOSES Austria] Follow the hospital's hand-hygiene policy, usually based on the WHO "5 Moments" (the model the Israeli clown study used). [source: Neumark et al. 2022, for the WHO model]
    2. Wear the protective equipment agreed with the facility. In the Covid-19 guidelines, special protective clothing was mandatory in intensive care and oncology, and face shields or goggles were worn only in addition to a mask. [source: RED NOSES Austria]
    3. Keep nails short and avoid rings and wrist jewellery on clinical areas, according to local policy. [synthesis; standard hospital practice, not found in the clowning sources]
    4. Do not come in if unwell. Report symptoms or infectious contacts to your supervisor at once. [source: RED NOSES Austria]
  • Watch for: Hand rub can be built into the play, for example as a "magic potion", as long as the hygiene step itself is done properly. [synthesis]

4.3 Props, costume and laundry hygiene

  • Purpose / when: Preventing props and costumes from carrying infection between patients.
  • Steps:
    1. Use only disinfected props and instruments. [source: RED NOSES Austria]
    2. Choose costumes that can be washed at 60–90 °C. Wash, iron or disinfect costumes, cloth masks and props before each deployment. [source: RED NOSES Austria]
    3. Choose props with hard, wipeable, non-porous surfaces. Clean them between patients with the ward's approved wipes and contact times, and agree the product with the infection-control team. [synthesis]
    4. Do not hand out foam noses or balloons where the facility restricts it. The Covid-19 guidelines banned them. [source: RED NOSES Austria] Ask the ward about latex balloons, because of latex allergy, and about small parts with infants (choking). [synthesis]
    5. Give out single-use or gift items only when the ward allows. Such items stay with the child and are never reused. [synthesis]
    6. Ask before using bubbles near immunocompromised patients, respiratory patients or patients with wounds. [synthesis; not addressed in the sources]
  • Watch for: Fabric puppets and soft toys are hard to disinfect, so keep them for low-risk areas or give them away under ward rules. [synthesis]

4.4 Isolation rooms and restricted areas

  • Purpose / when: Patients on contact, droplet or airborne precautions, protective isolation (for example oncology or transplant), or wards with access bans.
  • Steps:
    1. Follow access bans strictly. Where rooms may not be entered, the source programme played from the corridor, the waiting area or the garden. [source: RED NOSES Austria]
    2. Before entering an isolation room, confirm with the nurse which precautions apply and put on the required equipment in the correct order. [synthesis; standard IPC practice]
    3. Take into the room only props that will be cleaned according to the ward protocol or left with the patient. [synthesis]
    4. Play through the glass door or window, in a distanced mime "conversation", or by phone or video where available. [synthesis; Koller & Gryski 2007 describe doorway play and bubbles sent in without entering, though not specifically for isolation]
    5. Visit isolation rooms at the end of the round when the ward asks you to, so the clowns do not move between precaution rooms and other patients. [synthesis]
  • Watch for: Children in isolation are often the loneliest on the ward, so do not leave them out simply because entry is harder. Make sure the protective equipment does not frighten young children: name it and play with it from a distance first. [synthesis]

4.5 Safeguarding frame for every encounter

  • Purpose / when: Always. It protects children and clowns.
  • Steps:
    1. Two-adult rule: never be alone with a child in a closed room. The pair, a parent or a staff member counts as the second adult. If you are a solo artist in a special format, keep the door open the whole time. [source: RED NOSES Behavioural Guidelines]
    2. If the facility insists on closed doors, write a memo to your organisation explaining why. [source: RED NOSES Behavioural Guidelines]
    3. Touch: only touch the child when the child invites it, and keep it brief and non-intimate, such as a high five or a hand puppet's "handshake". Never touch intimate areas, never lift or restrain, and never touch medical lines or devices. [synthesis; the sources forbid any physical, mental or sexual violence but give no detailed touch rules]
    4. Photos and video: none without the hospital's permission and parental consent. Never post patients on social media. [synthesis; the sources do not address this]
    5. No private contact outside the hospital and no exchange of personal details. [source: RED NOSES Behavioural Guidelines (no obligation, balance of closeness and distance); synthesis for the explicit ban]
    6. Report concerns through the programme's case-management procedure, and tell the ward's safeguarding lead or nurse in charge the same day. Local mandatory-reporting law applies to you as to any adult working with children. [source: RED NOSES Behavioural Guidelines; EFHCO; synthesis for the local-law note] Programmes usually require criminal-record or background checks; check your country's rules. [synthesis]
  • Watch for: Disclosures made during play. Do not question the child. Stay calm, acknowledge what was said, do not promise secrecy, and report it in the child's own words. [synthesis; standard safeguarding practice]

4.6 Permission at the door: consent and assent

  • Purpose / when: At every room, every time. The child's assent and the parent's consent come before any play. [source: Nogueira 2012 (work starts from each child's permission); Koller & Gryski 2007]
  • Steps:
    1. Check the briefing note (4.1) for that child.
    2. Knock, or make a small clown sound, and wait at the threshold.
    3. Ask the child, and the parent if present, whether you may come in. With infants or non-verbal children, read the cues and the parent's answer. [source: Koller & Gryski 2007 (ask permission, watch cues of child and family); synthesis for the infant detail]
    4. If unsure, offer play at the doorway first, for example a few bubbles or a small gag, and let the child invite you closer. [source: Koller & Gryski 2007]
    5. If the child or parent says no, accept it warmly and leave for the day. Do not use a second clown to persuade, and do not come back later the same day. [source: Koller & Gryski 2007; synthesis for the no-persuasion detail]
    6. Agree consent for the visit in general with parents (the programme's information leaflet or hospital admission information), but always ask the child in the moment. [synthesis]
  • Example language (illustrative): "Knock knock, it's the funny-bone doctors. May we come in, or shall we just wave from here?" / "No? Thank you for telling us, that was very clear. Bye!"
  • Watch for: A child who says yes only because an adult says so. Look for real interest, such as watching, smiling or moving closer. A refusal handled with respect gives the child control, and that is an aim in itself. [source: Koller & Gryski 2007 (empowerment); synthesis]

4.7 Pair interplay before engaging the child

  • Purpose / when: Opening an encounter, so the child can watch from a safe audience position. [source: Linge 2013; Koller & Gryski 2007]
  • Steps:
    1. Enter as two clowns interacting with each other, for example squabbling over who is the "senior doctor" or failing at a simple task.
    2. Keep your attention partly on the child and let the child choose when to join in.
    3. When the child shows interest, offer an opening: a question, a mistake for the child to correct, or a prop held out.
    4. The partner watches the child's cues and gives the agreed signal if things move too fast. [source: Koller & Gryski 2007]
  • Example language (illustrative): "I'm the head doctor." "No, I'm the head doctor!" (to the child) "Which of us looks more like a head doctor?"
  • Watch for: The child setting the pace. Linge reports the interplay lets the child get used to the unusual encounter on their own terms. [source: Linge 2013]

4.8 Status reversal and child-led play

  • Purpose / when: The core of the encounter, once the child has engaged.
  • Steps:
    1. Take the clumsy, weak, mistaken position.
    2. Give the child the power to decide, correct, rescue or direct. Koller and Gryski describe a role reversal in which the child directs the adult clown, for example a music-box game. [source: Koller & Gryski 2007; Linge 2013]
    3. Follow the child's ideas rather than a prepared routine, and build on them through improvisation. [source: Koller & Gryski 2007]
  • Example language (illustrative): "You're the doctor now. What's wrong with me? Oh no, not that!"
  • Watch for: Rising initiative and confidence. Linge reports children gaining confidence in their own power to take initiative. [source: Linge 2013]

4.9 Humour attunement: surprise, interest, joy

  • Purpose / when: Meeting the child's current emotional state. This is useful for anxious, sad, angry or withdrawn children.
  • Steps:
    1. Notice the child's emotion: fear, boredom, irritation, sadness.
    2. Mirror it gently and hold it, for example a clown who is also scared of the big machine.
    3. Give it back in a humorous, manageable form. [source: Linge 2013 ("humor attunement")]
    4. Follow the sequence Linge describes: surprise at the new situation, then interest in the present with the child's initiative in focus, then joy. [source: Linge 2013]
  • Watch for: Spot uncertainties early in the session. Some children fear being laughed at, and teenagers may feel treated childishly. [source: Linge 2013]

4.10 Reading cues and adjusting distance

  • Purpose / when: Continuously, and especially with a child who is uneasy.
  • Steps: When you see unease, react at once. Increase distance, avoid eye contact, crouch to the child's level, or turn sideways. [source: Koller & Gryski 2007] Lower volume and speed, and drop the clown "business" in favour of quiet presence. [synthesis]
  • Watch for: Breath, gaze, body tension and the parent's face. If a relationship does not form, withdraw gracefully (4.14). [source: Koller & Gryski 2007]

4.11 Medical parody routines

  • Purpose / when: Demystifying frightening routines and objects in the hospital, and letting the child laugh at the system. [source: Koller & Gryski 2007; Wikipedia, Clown care]
  • Steps:
    1. Use the doctor persona, for example a white coat over the costume with a red nose. Koller and Gryski describe this as making the medical setting friendlier and less intimidating. [source: Koller & Gryski 2007]
    2. Parody routines, using the published examples: "red nose transplants", "kitty cat scans", "funny bone exams" and "prescriptions for laughter". [source: Koller & Gryski 2007; Children's National Hospital]
    3. Let the child be the expert who corrects the clown doctor's absurd medicine. [source: Koller & Gryski 2007 (status reversal); synthesis for the application]
    4. Never parody a procedure the child is about to have in a way that misinforms them, and never use real medical equipment. [synthesis]
  • Example language (illustrative): "Hmm, your funny bone is very ticklish. I'll have to prescribe two giggles before bedtime."
  • Watch for: Children who find doctor parodies confusing or threatening, for example very young children or children with recent trauma from procedures. Switch to plain play. [synthesis]

4.12 Procedure accompaniment and distraction

  • Purpose / when: At staff request, before or during frightening or painful procedures. Programmes have accompanied pre-anaesthesia waiting, injections, needle procedures, scans and forensic medical examinations. [source: Klein Leichman 2011; Wikipedia, Clown care; EFHCO] Clowns support procedures. They do not replace analgesia, sedation or anaesthesia, which are clinical decisions. [synthesis] The 2011 report that clowns sometimes made sedation unnecessary describes clinicians' own decisions within studies. [source: Klein Leichman 2011; synthesis for the caution]
  • Steps:
    1. Confirm with the clinician leading the procedure: whether you are wanted, where to stand, which body parts and equipment to keep clear of, and how they will tell you to step back. [synthesis; EFHCO notes clowns help staff during procedures]
    2. Prepare the child and parent: ask the child whether they want the clowns there. [source: Nogueira 2012 (permission); synthesis]
    3. Position yourselves out of the clinical field, usually at the child's head side or eye line, and keep sterile fields and lines clear. [synthesis]
    4. Offer focused distraction: a story the child steers, a simple counting or breathing game, bubbles if permitted, or a puppet. Match the intensity to the child (some want calm, not comedy). [synthesis; Linge 2013 notes some treatment phases are too stressful for intense play]
    5. Stop at once when staff say so. Afterwards, praise the child's courage and give credit to the child, not the clown. [synthesis]
  • Forensic medical examinations of children: This was reported in Israel (Tener et al. 2010, cited on Wikipedia; Poriya hospital in Klein Leichman 2011). Accompany such examinations only under a protocol agreed with the child-protection medical team. Do not ask about, discuss or play out the alleged abuse, and pass on anything the child says without comment. [synthesis; paper itself not drawn on, so [uncertain] on its protocol]
  • Watch for: Getting in the way of staff. Koller and Gryski report one study where staff opposed a programme because clowns interfered with procedures. [source: Koller & Gryski 2007]

4.13 Magic, music, puppets and bubbles as play partners and metaphors

  • Purpose / when: Bridging contact and giving the child symbolic play about what is happening to them. [source: Koller & Gryski 2007]
  • Steps / examples from source:
    • Magic: a trick that changes an object's size can let a child explore changes in their body during treatment. [source: Koller & Gryski 2007]
    • Music: bridges the gap between clown and child or parent. Koller and Gryski describe a music-box game that empowers the child through role reversal. [source: Koller & Gryski 2007]
    • Puppets and props: act as extra play partners and give a shy child something to talk to that is not an adult. [source: Koller & Gryski 2007]
    • Bubbles: usable from the doorway, and in one account a metaphor for a tumour's growth or absence. [source: Koller & Gryski 2007]
    • Keep the volume low in wards, ICUs and near infants, and agree music use with staff. [synthesis]
  • Watch for: Let the child set the metaphor. Do not interpret the child's play to them or to staff as a psychological finding. [synthesis] Clowning observations are not assessment data. [synthesis]

4.14 Closure and graceful withdrawal

  • Purpose / when: At the end of every encounter, and early when contact is not forming. [source: Koller & Gryski 2007]
  • Steps:
    1. Signal the ending, for example the clowns "get called away" to another emergency. [synthesis]
    2. Leave the child in the strong role, for example the child "discharges" the clowns. [synthesis, built on status reversal]
    3. When contact does not form, withdraw gracefully. Koller and Gryski note this can itself empower the child. [source: Koller & Gryski 2007]
    4. Do not promise a return you cannot keep. [synthesis]
  • Example language (illustrative): "Doctor, you've cured us both. Can we go now? Thank you!"
  • Watch for: A child who becomes sad at the goodbye. Name the next visit only if it is scheduled. [synthesis]

4.15 Continuity: the same pair, repeated visits

  • Purpose / when: Long-stay, oncology and chronic-illness wards. [source: Nogueira 2012; Koller & Gryski 2007]
  • Steps: Assign stable pairs to a hospital, as Doutores da Alegria does with the same pair twice weekly for a year. Build recurring games and characters that the child can expect. [source: Nogueira 2012; Koller & Gryski 2007]
  • Watch for: Children re-admitted after a long gap, whose condition or mood may have changed. Get a briefing on each child again rather than assuming. [synthesis]

4.16 Non-verbal clowning alongside a play therapist

  • Purpose / when: Children who cannot easily use words, for example because of language barriers or communication difficulties. [source: Linge 2013]
  • Steps: Linge describes a silent clown working with a play therapist and following the child's bodily signals in a "dance of reciprocity". The child steers through body language, and the clown mirrors and answers in movement. [source: Linge 2013] The play therapist holds the therapeutic frame and records anything clinically relevant, and the clown stays in the artistic role. [synthesis]
  • Watch for: Over-stimulation. Keep movements slow and predictable. [synthesis]

4.17 Parents and family

  • Purpose / when: Parents are usually present and part of the relationship. Clown care can increase interaction between parent and child. [source: Koller & Gryski 2007; Wikipedia, Clown care (Tan, Metsälä & Hannula 2014)]
  • Steps: Greet parents, include them as allies or audience, and respect their no as you would the child's. Linge reports parents felt seen and got a moment of rest. [source: Linge 2013; Koller & Gryski 2007] Ask the parent's permission for siblings to join. [synthesis]
  • Watch for: Families who do not want contact must be respected. [source: Linge 2013] Do not take sides in family tensions or complaints about care. Pass complaints to staff. [source: RED NOSES Behavioural Guidelines (no siding in disputes); synthesis]

4.18 Clowning for staff: hand-hygiene promotion

  • Purpose / when: Supporting staff compliance with infection control, as an agreed project with the infection-control team. [source: Neumark et al. 2022]
  • Steps: In a feasibility study in three Israeli hospitals, professional medical clowns used humour to prompt staff hand sanitising based on the WHO "5 Moments". Each clown visited each department seven times over two weeks, and compliance was observed before, during and after. [source: Neumark et al. 2022] Agree targets, tone and limits with infection control and ward leadership in advance. Never shame individual staff in front of patients. [synthesis]
  • Watch for: The authors call the approach "feasible and welcome by hospital staff". Results varied a lot between departments. [source: Neumark et al. 2022]

4.19 Palliative and end-of-life visits

  • Purpose / when: Within palliative care, as part of the interdisciplinary team. [source: EFHCO; Koller & Gryski 2007]
  • Steps: Get a detailed briefing from the palliative team on the child's state and the family's wishes. Offer quiet, gentle presence, with music or a familiar routine, rather than performance. Follow the child's play, including play about absence. Koller and Gryski give the example of hide-and-seek letting a child test whether they would be missed. [source: Koller & Gryski 2007; synthesis for the visit steps] Patch Adams describes clowning at many deathbeds. [source: Marsh 2008]
  • Watch for: Your own grief. Arrange supervision or a debrief after such visits. [synthesis; EFHCO stresses resilience alongside empathy]

4.20 Adolescents and adults

  • Purpose / when: Teenagers, and adult wards where the programme covers them. [source: Wikipedia, Clown care (some programmes visit adults; Melvin et al. 2025 on an adolescent psychiatric unit [uncertain])]
  • Steps: Lower the "childish" register and use wit, music, irony and the young person's interests. Offer an easy opt-out, and never perform for an audience that has not agreed. [synthesis; Linge 2013 notes teenagers may feel treated childishly]
  • Watch for: Embarrassment in front of peers, and privacy in shared bays. [synthesis]

4.21 Documentation, reporting and feedback

  • Purpose / when: After every visit day, and periodically to the institution. [source: EFHCO (preparatory reports); Nogueira 2012 (monthly reports)]
  • Steps: Give the nurse in charge a brief verbal handover of anything relevant: a child who was distressed, a refusal pattern, or any safeguarding concern (which goes through the formal route). Write programme reports without identifying details beyond what the hospital agreement allows. [synthesis; RED NOSES confidentiality rules]
  • Watch for: Clinical language in clown reports. Describe what happened and avoid interpreting it. [synthesis]

4.22 Psychotherapist's role alongside a clowning programme

  • Purpose / when: For a hospital psychologist or psychotherapist working on wards where a programme runs. This whole section is [synthesis], built on the staff-coordination practices in the sources.
  • Steps:
    1. Refer or request: identify children who might benefit, for example isolated, long-stay or procedure-anxious children, and request visits through the ward nurse or Child Life contact as the hospital specifies. [source: Children's National Hospital (request route); synthesis]
    2. Brief: share only what the clowns need, such as fears, triggers, recent bad news, a preference for quiet play or topics to avoid, within confidentiality rules. [synthesis; Linge 2013 on the value of staff information]
    3. Co-work: for selected children, plan a joint encounter where you hold the therapeutic frame and the clown holds the play, as in Linge's silent clown with a play therapist. [source: Linge 2013; synthesis]
    4. Integrate: in your own sessions, use what the child gained, such as experiences of control, courage or laughter, as material. Do not treat clown visits as therapy sessions. [synthesis]
    5. Support clowns: offer debriefs after difficult visits, for example deaths, safeguarding disclosures or distressing procedures, if the programme agrees. [synthesis]
  • Watch for: Keep the boundary between arts activity and therapy clear. Clowns do not do therapeutic interpretation, and therapists do not take on a clown persona without training. [synthesis]

5. Handling problems

The sources name some of these problems: refusal, unease, teenagers, families who decline, interference with procedures and stressful treatment phases. The responses are largely [synthesis] unless a source is cited.

  • The child refuses or is frightened of clowns. Accept the no, leave for the day, and note it for the next briefing. Offer doorway-only or no-costume contact next time if the child wants it. Never persuade. [source: Koller & Gryski 2007 (respect refusal, leave for the day; therapeutic clowns use minimal make-up and costume); synthesis for the follow-up]
  • The parent says yes, the child says no (or the reverse). The child's no stops the play. If the child says yes but the parent says no, respect the parent and leave, and tell the nurse if the disagreement seems significant. [synthesis]
  • Withdrawn or "stuck" child (no response over several visits). Lower the intensity: quiet presence, music, playing from a distance, a repeated small ritual. Ask staff or the psychologist whether something else (pain, depression, bad news) needs clinical attention. [synthesis; Koller & Gryski 2007 on graceful withdrawal]
  • Over-excitement or overwhelm. The partner gives the stop-signal, the clowns lower volume and pace, and offer a calm ending. If the child is distressed, step out and inform the nurse. [source: Koller & Gryski 2007 (partner signals when a scenario gets out of hand); synthesis]
  • Child becomes distressed by a medical parody or a prop. Drop the routine at once. Name it simply ("that was too silly, wasn't it") and give the child control of what happens next. [synthesis]
  • Teenager feels patronised. Change register, offer an exit, and do not perform in front of peers without agreement. [source: Linge 2013; synthesis]
  • Staff see clowns as interfering, or the ward is too busy. Follow the ward's lead, keep visits short, re-negotiate timing and areas with the contact person, and ask for feedback. [source: Koller & Gryski 2007 (staff concerns); EFHCO; synthesis]
  • Staff conflict or a family complaint about care. Do not take sides. Pass it to the nurse in charge or your coordinator. [source: RED NOSES Behavioural Guidelines]
  • Infection-control breach (for example a prop used between patients without cleaning, or a clown with symptoms). Stop, tell the nurse in charge and infection control, remove the item, and follow their instructions. Clowns with symptoms stay away and inform their supervisor. [source: RED NOSES Austria (illness rules); synthesis]
  • Isolation room or access ban. Play from the corridor, window or garden, or use video, rather than skip the child. [source: RED NOSES Austria; synthesis]
  • Pressure to be alone with a child (door closed for privacy, parent leaves). Keep the door open, or wait for the partner or a staff member before continuing. Document why if closed doors are unavoidable. [source: RED NOSES Behavioural Guidelines]
  • Disclosure of abuse or a safeguarding concern during play. Stay in a calm, warm presence, do not investigate, report the same day through the programme's procedure and the ward safeguarding lead, and record the child's words. [source: RED NOSES Behavioural Guidelines; EFHCO; synthesis for the steps]
  • Family seeks private contact or social-media links. Decline kindly and explain that the clowns only meet children in hospital. [source: RED NOSES Behavioural Guidelines (balance closeness and distance); synthesis]
  • Expectations that clowns treat illness or replace sedation. Explain that clowning supports coping and does not treat disease, and that decisions on pain relief and sedation belong to the medical team. [synthesis]
  • Clown distress or burnout (deaths, repeated sad news). Arrange regular artistic and emotional supervision and peer debrief within the pair. EFHCO frames empathy together with distance and resilience, and the pair gives mutual emotional support. [source: EFHCO; Koller & Gryski 2007; synthesis for the arrangements]
  • Language and cultural differences. Rely on non-verbal play and the child's body language. Ask staff or the family about cultural norms on humour, gender and touch. [source: Linge 2013 (body-language-led interaction); synthesis]
  • Mistaking clowning for therapy. If a child's play shows serious distress, or a child is at risk of self-harm, the clown passes this to staff and the psychologist handles it clinically. Clowns do not counsel, assess or interpret. [synthesis]

Sources

Sources:

Further reading (cited via the pages above; not drawn on) [uncertain]: Tener D et al. (2010), Journal of Child Sexual Abuse 19(2):128–140; Tan AKP Jr, Metsälä E, Hannula L (2014), European Journal of Humour Research 2(2); Melvin G et al. (2025), Child Psychiatry & Human Development 56(1):142–152; Linge L (2008), Hospital clowns working in pairs, International Journal of Qualitative Studies on Health and Well-being 3(1):27–38.

Book: Adams P (with Mylander M). Gesundheit! (cited from Marsh 2008; edition and year [uncertain]).

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