Healthy Humor: The Clowns Helping Healthcare Happen
When we all appeared on the Zoom call, there was a fizzling energy I hadn’t realized was possible in virtual formats. I settled in to interview Deborah Kaufmann, Healthy Humor Co-Founder, Director of Training and Education (also known as Dr. Dibble, Chief of Osteo Humorology), and Matthew Pauli, a performer with Healthy Humor since 1999 (also known as Dr. Spats). These professional theater artists offered me a front-row seat to the inner workings of the walking, talking, fun facilitators at Healthy Humor. These incredible performers work alongside healthcare professionals to make healthcare accessible to children around the United States. It was a joy to see them light up my screen, an honor to hear their stories, and now my delight to share their work with you.
Since 1987, when Big Apple Circus started the Clown Care program, Healthy Humor (and its previous iterations) has been “creating moments of joy, wonder, laughter, and comfort for hospitalized children and all others who are most in need.” Their web of almost 70 performers around the US primarily partner with pediatric hospitals to help create emotionally accessible and downright fun environments during medical experiences often associated with fear. Each performer is a professional artist. They have varying backgrounds as actors, clowns, magicians, dancers, puppeteers, jugglers, and musicians. They are then rigorously trained in the specific needs of healthcare environments such as infection prevention, safety, privacy, HIPAA, along with developmental stages and basic child psychology, to ensure their work feels accessible to kids. They bring to life a philosophy from Michael Christensen: "The hospital is full of people who can take care of what's wrong with a patient. [Healthy Humor’s] job is to take care of what's right with them."
Creating Safe Spaces
The clowns at Healthy Humor work in pairs to do rounds in a similar format to physicians. Their biggest difference in tone is that their work is opt-in rather than mandatory. This is part of how the performers partner with patients to give them status in an environment that is mostly out of their control. As Matthew mentioned to me, "We are the only people in white coats who will go away when asked and that can be very empowering." Healthy humor empowers children by giving them agency to develop relationships of their own volition. Matthew continued, "Often, the parent will be [motioning] 'Come here, come here,' but we're looking at the child to make sure the same permission applies to the child as it does to the parents." There is inherent value to listening when a patient asks the clowns to leave; it is how many relationships are built. I learned, "There have been long-term patients that for months we would come, knock on the door, [say] 'Hi, would you like a visit?,' 'NO!,' 'Alright, thank you very much.' It gets to the point where you know the kid is kind of looking forward to telling you to leave. If I can give you that gift, please take the gift."
There is also a difference between a hard “no” and a soft “no.” To figure out whether a patient is looking to exercise their right to say no, or if they are genuinely disinterested, the clowns perform a “Hat Test.” The test is named for one of the first clowns in Healthy Humor who, upon being asked to leave, would tip his hat and drop it on the way out. If the child laughed or responded, they would take a moment to say goodbye again and again, allowing the child to enjoy that moment for as long as possible. Matthew described what this method has meant in his experience:
"We offer an invitation to play. We're never gonna perform at someone. That's just exhausting. I would rather play with you. [If they say no,] back up, get small. Fall over each other trying to get away. There's lots of ways to put the play into respecting and honoring the reaction that you're getting. If you empower those people by saying yes to their offer of 'I don't want to play with you,' then they're gonna relax. And especially if you're in a hospital situation where a family is gonna be coming regularly, the fact that you respected them and empowered them means that the next time, they may pay a little more attention to you... We're not in a hurry. We have no agenda. Our agenda is whatever your agenda is. That's also something that sets us apart from most people in the hospital. Our work does not have to be done.”
Helping Physicians and Families Make Care Happen
On a daily basis, Healthy Humor primarily partners with the departments of Child Life and/or Family Services. They work with administrative staff to determine where there is a need, then have schedules to guide their day (though the times are definitely flexible). They also identify where in the hospital their work is most needed. Nurses often help in the process by describing the population (who's there on a given day) and the general mood. The mood changes frequently and it is important to know who is having a tough time-- “if you know, you might be of tremendous use.”
I was surprised to learn that knowing the mood does not always mean a patient or family should be joyful and excited. A story Matthew told described the experience of accompanying a family as their child nears the end of their life. He said, "For many people, that would mean 'let's not bring clowns into that right now,' and yet we have found that sometimes when we arrive in those situations and just appear in the peripheral vision at the end of the hall... families will call us down, 'Please, come here. We need clowns right now. We need you.’"
In addition to family relationships, the clowns’ partnerships with healthcare professionals make the work possible in ways the professional cannot do themselves. For example, "We have also found we can partner with physical therapists very well. Asking a child [to use their right arm] is a monotonous... assignment. Whereas, if clowns stand on the right side of the bed and blow bubbles and you pop them, you're going to be using your right arm. Getting somebody to walk can be a challenge if they are recovering from a broken leg... but if clowns discover that certain floor tiles squeak when you step on them, you can create an obstacle course and a child may be more interested in finding all the squeaks than they are in pushing through a painful walking process." That being said, the clowns are very conscious of their limits and see their work as therapeutic interventions while reserving the right to fail (both for themselves and for the patient). Clowns are not the therapists and need to be able to still be clowns on the next visit rather than associating bad memories. By reserving the right to fail, they can preserve the relationship and continue to assist in the future, rather than becoming another person the child associates with things they have to do that might hurt or be negative experiences.
Shortly after this part of the conversation, Matthew told a story that is famous in their community, which I think speaks for itself. One day at Johns Hopkins, there was a famous surgeon there to work. There was a large cohort of people (students, staff, and generally interested parties) following the surgeon around. When they came upon a room with clowns at work, one of the people following told the clowns to leave, implying that it was time for the “real work” to begin. The neurosurgeon made a point of saying "Don't ever stop the clowns. The kids aren't going to behave normally with us, but they will behave normally with the clowns." Because of the clowns, the team was able to get a better assessment of the child by seeing how they play. Then, when it was time to leave, the clowns absolutely deferred to the surgeon’s authority. There is a time to leave, and that can be established with mutual respect and honor for each professional’s contribution to the medical space.
The clowns’ work also sets the tone for families, which is why Matthew and Deborah emphasized their role in waiting rooms. Together, they explained, "One of our specialties is to reset the waiting clock. If a family's been in there waiting... a team of our Red Nose Docs comes in, does a show, interacts with them individually a little bit, it's almost like the clock's been set to zero and they forget that they've been there for half an hour or an hour. They were waiting for something and then they had something and it's a reboot." This makes the space feel more accessible and relieves the tension people feel in medical settings due to fear, anxiety, and the medley of other things on their minds. In addition to the waiting room performances, more general roles include setting examples: "We are very proud of the fact that a lot of our hospital partners will say to someone, 'if you wanna know how to wash your hands, go watch the clowns'."
The last kind of relationship they described was the casual relationship between hospital staff and clowns. Team means a variety of things: internal teams (clown partner pairs), organizationally (hospital staff), and professionally (patients and families). It is their job to draw out the playfulness of the adults too, and develop relationships outside of the patient rooms. Their presence interrupts burnout and makes for better patient care by bringing joy to providers as well as patients. This does mean that the clowns do not get a lot of breaks-- if someone can see you, you have to be "on," but it certainly seems worth it to this community.
Clowning in the Emergency Department
Healthy Humor’s work adapts to match their environment, and that is particularly true when they are in the emergency department. When children are in the hospital long-term, they are of course very sick, but their primary day-to-day feeling is often boredom. Their stay is anticipated to some extent, and the clowns help break up the monotony. They also develop relationships over time with each patient. In the Emergency Department, no one expects to be there. There are always new relationships. People are happy to see the clowns, as there is often minimal special programming in Emergency Departments. This means that the team at Healthy Humor can fill a gap not only for the individual patients and families, but in the hospital system to break down emergency department stigmas. They are able to do this because of the trust that comes with being hired, trained professionals, rather than volunteers in the chaotic environment of an emergency room.
The Emergency Department is different every time, especially in range of seriousness. There is a huge amount of assessment that has to be done in the moment, and in a given space they may have a 9 year old and 16 year old with just a curtain apart. Each curtain and “neighbor” offers another opportunity for a unique relationship. The curtain can be pulled back (with consent), to develop relationships between patients. They can find solidarity with one another rather than being in the isolation admitted patients often experience. Otherwise, the curtain can be used to maintain mystery and create a sense of playfulness for the patient. Either way, the environment becomes a tool the clowns can use to create safe, accessible spaces, and set a positive tone for the patient’s healthcare experience.
The work of clowning has also been changed with COVID-19, as the line between pediatric and adult emergency departments is blurred when the immediate needs of patients is greater than any one building or department can handle.
Pandemic Changes
In addition to changes in population, the format of Healthy Humor’s clowning has transformed with the pandemic. There are of course significantly fewer visitors in the hospitals, so the problem of patient boredom is often exacerbated. This has created a conundrum by making the work of Healthy Humor’s team more necessary, but also less possible due to health concerns. Each hospital’s response has looked different, but every one has adapted over the last year.
At Children’s National Hospital in Washington, DC, they have begun a television series. Each week, Healthy Humor performers record a segment to be produced and shared by the hospital. These segments are pre-recorded, which increases accessibility by making them available at more times, and to larger populations. At Johns Hopkins in Baltimore, MD, they were able to develop live Zoom programming. Healthy Humor expanded their close partnership with the Department of Child Life when they created a program called Comedy on Call. Child Life Specialists made the program possible by carrying tablets to patients’ rooms and making the program accessible to patients in the moment. Using tablets and virtual programming has created unique opportunities for engagement by using green screens, digital effects, and household tools that were not available in person.
Like many healthcare consults, Healthy Humor has developed extensive virtual programming. They pulled their in-person clowning in March 2020, and had already pivoted to virtual content by April. They started recording to keep content ready for everyone, which I am sure is a familiar story, thus creating ways to keep the fun present in patients’ rooms even though clowns themselves couldn’t be there. To do this, they created teaching kits to accompany videos: juggling with grocery bags, folding origami, etc. The Child Life Specialists could then facilitate Healthy Humor’s work virtually, to still engage without adding burden to already-overwhelmed staff or needing special resources. This program, Fun with Fools, also allows for long-term accessibility where it was difficult before. Whether the difficulty was due to individual circumstances (isolation rooms) or to the available resources (paying for full time clowns or finding a large enough talent pool in small towns), these are circumvented by having virtual content available. This means that some virtual content is here to stay, even as the return of clowns to hospitals symbolizes movement back toward pre-pandemic life.
The team at Johns Hopkins has also begun allowing in-person rounds, which is incredibly exciting! Now, in-person rounds include masks and face shields, and more public hand-washing, temperature taking, etc., to make sure every population knows what actions are being taken to preserve safety. While this is understandable, it also makes the work of the clowns more difficult, as much of their work relies on facial expression and close connection with patients. The barrier of the mask poses a unique challenge, which they have risen to in a variety of ways. First, they now wear the red nose over the mask (but behind the face shield) so the clown face does not totally disappear. They have also added hats and big shoes, which emphasizes the “clown” look. Finally, each clown doctor has a big maskless picture on their identification badge. This has been one of the most important parts of preserving relationships, to ensure they are recognizable. Matthew said it has had the most obvious impact, and told a story to illustrate the point. He explained that one child he had a long-term connection with was extremely sad and scared when he saw the clowns in the pandemic. His parents were surprised, and noted that he had always liked the clowns before. He said he liked “his clowns,” and did not recognize these ones, but the ID’s made it possible to show that they were "his clowns," just with masks. This speaks to a theme all healthcare professionals have felt: how can we maintain relationships and emphasize safe spaces, without the familiar smiles and expressions that emphasize our humanity?
Coming Back
At the end of our interview, I asked Matthew and Deborah what keeps them coming back: what spark does this work bring? I think Matthew said it best, and that the reason is one all healthcare workers can relate to: "At the end of the day, I can absolutely say, 'I did something worthwhile today.' This makes the world even just a little better." There is something different to do every day, and every bit of work they do helps make healthcare spaces feel accessible and positive, to make sure people feel safe getting the care they need. Being able to facilitate wellness that extends beyond physical needs is incredibly gratifying work, which they make possible so everyone else can play their roles as well. The team at Healthy Humor grows community wherever they go, and spreads joy in the process. It also allows for deeper community development in comparison to other theater work, which can sometimes feel contractual between ticket purchasers and performers. Instead, their role here is to transform painful contexts into joyful ones.
Deborah emphasized how their work affects the lives of patients. They are "Changing the texture of their time in the hospital... [so that it's not just terrifying]. All of the sudden, there is a moment of joy. I don't think there is ever a day where a parent doesn't say, ‘That's the first time my child has smiled since we've been here’.” She went on to tell the story of a patient who was a few years’ in remission from childhood cancer. At the child’s Bat Mitzvah, the family asked the clowns to come perform. Although it was a painful experience to go through cancer treatment as a young child, what she remembered was the joy they brought to her and her family. This is the work of the clowns, which parallels PTSD treatments: associate positives with negative memories and traumas instead of focusing on the bad. Their electric presence, whether virtual or in-person, helps bring out the best of the rest of the healthcare community in the process.
For more information on Healthy Humor, please see their website at: https://www.healthyhumorinc.org/
To contact a member of Healthy Humor’s team, please email: admin@healthyhumorinc.org
