The Arts in Psychotherapy 38 (2011) 267–275

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The Arts in Psychotherapy

Therapeutic clowning and drama therapy: A family resemblance

Susana Pendzik, PhD, RDT a,∗ , Amnon Raviv, MA, RMC b
a
Theatre Studies Department, Hebrew University of Jerusalem, Israel
b
The Graduate School of Creative Art Therapies, Haifa University; Barzilai & Tel Hashomer Medical centers, The Dream Doctors Project, Israel

a r t i c l e i n f o a b s t r a c t

Keywords: This paper compares therapeutic clowning and drama therapy, starting with a brief survey of the devel-
Therapeutic clowning opment of medical clowning as a profession, a definition of the field, and a claim to its ancient link with
Medical clowning drama therapy. It then proceeds to analyze four vignettes describing the work of a medical clown in a
Drama therapy
hospital, and examining them through the lens of drama therapy concepts and theory. The paper shows
Applied theatre
that the clown’s working techniques can be conceptualized using drama therapeutic models and theory,
Social theatre
and that using this approach as a method of analysis can serve to enhance the body of knowledge of the
rapidly growing profession of therapeutic clowning.
© 2011 Elsevier Inc. All rights reserved.

“I will remember that there is art to medicine as well as science, life specialist. Inspired by these examples, analogous experiments
and that warmth, sympathy, and understanding may outweigh the began simultaneously in other places. Nowadays, the profession
surgeon’s knife or the chemist’s drug.” is practiced in many hospitals – predominantly in pediatric units
– as well as in other health care settings worldwide (Koller &
Hippocratic Oath
Gryski, 2008). The profession’s rapid growth still continues, as
research offers considerable evidence pointing to the effectiveness
The birth of a profession of therapeutic clowns in providing complementary aid, which may
noticeably “enhance the efficacy of medical treatment” (Miller Van
The birth of medical clowning as a profession is a recent occur- Blerkom, 1995, p. 462).
rence. Although clowns have been involved in health care since Another line of thought links the spread of this profession to
ancient times (Campbell, 1976; Miller Van Blerkom, 1995; Warren, new cultural phenomena that took place in the performing arts
2002), and presumably, have volunteered in hospitals as enter- in the last decades, particularly regarding the interaction between
tainers for a couple of centuries (Citron, 2011), the advent of the performers and audiences. Citron (2011) claims that the devel-
profession as it is currently known in modern health care settings opment of the Modern Circus in Europe – the ‘single-ringed art
goes back only a few decades ago. Prompted by the revolutionary circus’ – infused the trade with a renewed professionalism, which
work of Patch Adams in the 1970s, medical clowning gained public created a new concept of the clown. Fox (1994) strengthens this
recognition, first, through the publication of Adams and Mylander’s view by including clowning as one of the current branches of non-
(1993) Gesundheit!, and later, thanks to the movie Patch Adams scripted theatre, and stating that the emerging genre of the “new
(1998) in which actor Robin Williams takes the role of the red- vaudeville facilitates a more intimate, human contact with the audi-
nosed, legendary doctor. ence” (p. 59). Ott (2007) places therapeutic clowning among other
Koller and Gryski (2008) state that the field’s professional devel- interactive clowning practices (such as clown ministry, clowning in
opment can be traced back to two main models that originated education and in social activism), through which clowns have tried
independently from each other in North America during the 1980s: in recent years to extend their work beyond the traditional realms
one is the New York Clown Care Unit, which was initially estab- of the stage and the circus.
lished as a collaboration between Michael Christensen of the Big The variety of denominations, such as ‘medical doctor,’ ‘ther-
Apple Circus and the New York Babies and Children Hospital; the apeutic clown,’ ‘clown-doctor,’ ‘hospital clown,’ ‘clinic clown’
other is the Therapeutic Clown/Child Life model in Canada, where (among others), denote differences in style, emphasis, place of
Karen Ridd was hired by the Children’s Hospital of the Winnipeg work, or even place of training. For instance, one tradition states
Health Science Center in Manitoba, both as a clown and as a child that clown doctors should always work in pairs, claiming that
this allows them to support each other (both in terms of the
performance and otherwise), as well as freeing the patient from
∗ Corresponding author. Tel.: +972 2 679 2750; fax: +972 2 679 0950. the pressure to participate (Linge, 2008; Simonds & Warren, 2004;
E-mail address: [email protected] (S. Pendzik). Warren, 2002). In contrast, another approach poses that the single

0197-4556/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2011.08.005
268 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275

clown may promote intimacy and a sense of collaboration with This fact is reflected in the professional literature that has been
the environment, and that the single clown’s vulnerability may act generated in both fields. A wealth of literature has appeared on
as a mirror to the patient’s feeling of being out of place. Based on medical clowning, particularly in the last two decades. Although
this discrepancy in practice, Koller and Gryski (2008) distinguish in their pioneering book, Adams and Mylander (1993) refer to
between ‘clown doctors’ and ‘therapeutic clowns,’ by maintaining art as primary care, speak about theatre as a healing resource,
that the latter often work alone. Grinberg (2009) claims that it is and provide links with the American National Coalition of Arts
more common for medical clowns in Europe to work in pairs, while Therapy Associations (NCATA), references to drama therapy are
Citron (2011) points out that, in Israel, the issue of working alone or missing from the book. The same can be said about most litera-
in pairs has split the medical clown’s community in two. Bornstein ture on therapeutic clowning: many articles discuss the curative
(2008) and Grinberg (2009) agree that the denomination ‘clown potential of humor and laughter, presenting it as the main theoret-
doctor’ is more typical of the U.S., whereas in most other countries ical foundation of the field (Adams, 2002; Glasner, Zaken, Biton,
they are called ‘medical clowns.’ Bornstein (2008) also affirms that & Leibobitz, 2009; Golan, Tighe, Dobija, Perel, & Keidan, 2009;
the name ‘clown therapist’ expresses a wider scope, presenting Koller & Gryski, 2008; Miller Van Blerkom, 1995). Research com-
therefore a more accurate representation of the profession. ing from the medical sciences and psychology focuses primarily on
To a certain extent, these differences reflect some of the under- the impact of medical clowns on patients, their effect on preoper-
lying conflicts inherent in the profession, as well as the stage of ative anxiety, on the forensic examination of children, etc. (Cantó
development at which it finds itself. Such conflicts are also notice- et al., 2008; Fernandes & Arriaga, 2010; Golan et al., 2009; Vagnoli,
able in the recent attempted definitions of the field. According to Caprilli, Robiglio, & Messeri, 2005, 2010; Tener, Lev-Wiesel, Franco
Gervais, Warren, and Twohig (2006), a clown-doctor (CLDr): & Ofir 2010). Other studies look at the influence of medical clowns
with adults, in rehabilitation (Warren, 2002), fertility treatments
. . .is a specially trained professional artist who works in a ther-
(Friedler et al., 2011), or with the aged (Spitzer, 2006). A few oth-
apeutic program within a health care setting. Unlike clowns
ers focus on the interaction between clowns, patients, families,
who make occasional visits to hospital bedsides to “entertain,”
and staff (Linge, 2008; Nuttman-Shwartz, Scheyer, & Tzioni, 2010;
professional CLDrs are skilled and valued members of a clinical
Schayer, Nutman-Schwartz, & Zioni, 2008). The transformative and
team and are therefore an integral component of the treatment
healing powers attributed to clowns have also been examined from
process in the settings in which they practice (p. 77).
anthropological (Bouissac, 1990; Miller Van Blerkom, 1995) as well
This definition highlights the clown’s artistic excellence and as from performance theory perspectives (Citron, 2011).
professional training, thus marking the difference between an occa- From their side, drama therapists have not ventured or even
sional entertainer and the qualified caregiver – the specialized looked into the drama therapy structures at play in therapeutic
paramedic who is an integral part of the team of the health care clowning. To illustrate this point, there is no mention of medical
setting. On a similar note, Koller and Gryski (2008) call for a defi- clowning in the last edition of Current approaches in drama therapy
nition of medical clowning that takes into consideration issues of (Johnson & Emunah, 2009) – a comprehensive collection essays of
professionalism and accountability, in light of the proliferation of the main drama therapy methods and techniques being used and
the field: taught in the U.S. and Canada. References to therapeutic clowning
are also absent from recent British compilations on drama therapy
At their most professional, therapeutic clowns are respected
practice (Jennings, 2009; Jones, 2010).
complementary care providers who are able to articulate their
One exception to this rule is the work of Grinberg (2009). In
role in the care of the patients as integral members of the
her unpublished M.A. thesis, Grinberg questions and challenges the
health care team. At the other end of the spectrum, volunteer
prevalent view by which it is mainly the clown’s use of humor, his
clowns, though well-intentioned, may be simply dressed-up
or her ability to “put a smile on the patient’s face” and to create a
people with little training and less understanding of the role
light and amusing atmosphere, that are accountable for the success
and potential of the therapeutic clown (p. 17).
of the profession. According to her, research in medical clowning
A working definition proposed for this article is that therapeutic focuses primarily on the link between laughter and well being:
or medical clowns (also called clown doctors), are clown therapists
Most of the organizations dealing with medical clowning
who work in hospitals and other health care settings. The goal of
declare that their goal is to put a smile on the sick child’s face,
the medical clown is to provide support for the sick and their fam-
and rely on the researchers to find the connection between
ilies, promote their recovery process, and minimize stress in every
laughter and the improvement in the patient’s mental and phys-
possible way – including in the health care setting itself. The med-
ical state. . . (p. 42).
ical clown achieves these goals through the use of clown’s skills,
and by sensitively interacting with patients, families, and staff by In her opinion, the therapeutic aspects of clowning are not exclu-
means of humor and laughter, fantasy and empathy. sively associated with humor and joy; they are also related to the
dramatic tools (or more specifically, drama therapy tools) utilized
Drama therapy and therapeutic clowning by clowns. These include the facilitation of an encounter with the
patient in the realm of imagination, and the variety of roles that the
“Where is my fool? Ho, I think the world’s asleep, how now? Where’s clown plays. In a genuine attempt to develop this view, she analy-
that mongrel?” ses medical clowning practices using drama therapy theories and
concepts (among others, Landy’s role-system model and Jennings’
King Lear, I:4
EPR paradigm).
The development of medical clowning as a profession followed a It is rather odd that drama therapy and medical clowning would
completely independent path from that of drama therapy. Although not be more closely related as professions, since both are equally
clowning is undoubtedly a theatrical means, and its therapeutic concerned with the therapeutic aspects of performance. In fact,
implementation in health care is akin in many ways to the concepts profound historical and structural parallels suggest a family-tree
articulated by Jennings (1974) in her seminal work, Remedial drama, connection between these fields: clowns have been considered
therapeutic clowning and drama therapy became established as as healers in both ancient and contemporary cultures (Campbell,
separate professions, growing up like two family members being 1976; Charles, 1945; Clews Parsons & Beals, 1934; Highwater, 1981;
raised in different countries. Miller Van Blerkom, 1995). Moreover, according to Kirby (1976),
 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275 269

clowning derives from the same archetypal source from which offer the client “empathic feedback in embodied, imaginal form”
many dramatic forms spring, namely, shamanic ritual. Sketchily (2009, p. 96).
defined as “the practice of trance for the purpose of curing the Medical clowns are always ‘in role:’ they do not leave it for a
sick” (Kirby, 1976, p. 140), shamanism is considered an ancestor to moment; and in fact, neither do patients. As Citron (2011) brilliantly
both drama therapy (Pendzik, 1988; Snow, 2009) and therapeutic explains, the hospitalization process is reminiscent in many ways
clowning (Koller & Gryski, 2008). In Kirby’s (1976) words: of the liminal position which characterizes most rites of passage,
as articulated by Van Gennep (1977) and Turner (1982). Separated
. . .the performing arts that develop from shamanist trance may
from everyday life reality by the hospital’s rules and regulations,
be characterized as the manifestation of, or conjuring, of an
stripped of their status and personal symbols, (for example, by
immediately present reality of a different order, kind, or qual-
homogeneously wearing the hospital’s gown), patients are bound
ity, from that of reality itself. Shamanistic illusionism seeks to
to stay in the role of ‘patient’, almost devoid of individual identity,
break the surface of reality, as it were, to cause the appearance
for as long they are hospitalized. Yet within this fixed role, a sense of
of a super-realty that is “more real,” than the ordinary (p. 148).
flexibility may emerge as the clown approaches, as he or she rep-
As parallel descendants of shamanism, drama therapy and ther- resents someone who defies the role’s very structure, plays with
apeutic clowning also coincide in the purpose for which this other it, and expands its variations, shifting from one aspect to another,
reality is invoked or called for, namely, healing, alleviating, and pro- introducing paradox, and moving within the role with the freedom
moting well being. And the main mechanism employed in order to that only the Fool and the Trickster archetypes can offer. In this
make this reality manifest is dramatic imagination. sense, like the drama therapist, the clown uses the role on-stage in
Drama therapy thrives on imagination. In fact, a central ther- order to make interventions from within dramatic reality.
apeutic tool in drama therapy is the capacity to ‘download’ the
world of imagination in the here and now in such a way that it Professor Doctor through the drama therapy looking glass
is experienced as almost real. Through the use of dramatic real-
ity, drama therapists add a complementary dimension to everyday “Clowns vivify the widest possible vision of reality by showing us
reality – one which concretizes the subjective realm of imagina- human nature in all of its manifestations.”
tion in the physical space, allowing it to be legitimized, explored, Jamake Highwater
mastered, and transformed (Pendzik, 2006). As current research
In an attempt to bring together these two fields, we will ana-
demonstrates, imagination is a powerful tool that can support both
lyze four vignettes described by medical clown Amnon Raviv from
physical and emotional improvement, as well as promote thera-
the Dream Doctors Project, from a drama therapy perspective. The
peutic change (Kaplansky, 2009; Karpelowsky & Edwards, 2005;
Dream Doctors Project is a unique program that was founded in
Lahad, Farhi, Leykin & Kaplansky, 2010; Sabatinelli, Land, Bradley,
Israel in 2002 with the purpose of integrating therapeutic clowns
& Flaisch, 2006; Sheikh & Allman, 2003). According to Lahad (1992,
into hospitals and other health-care institutions, particularly in
2000), imagination is one of the primary coping means that peo-
the service of children. The main goals of the project are to sup-
ple possess in order to confront stressful situations or, in general,
port the rehabilitation of patients, to transform their experience of
to meet the world. Drama therapy uses human imagination as a
hospitalization (as well as those of their families) into a less trau-
healthy psychological strength. It works by helping people put their
matic one, to be a bridge between the different cultures, ethnicities,
imagination into action in ways that activate positive attitudes and
and religious groups that conform the population of Israel, and to
outcomes.
integrate the Dream Doctors as creative arts therapists and para-
Medical clowning is equally based on imagination. When a per-
professional care-givers into multidisciplinary medical teams. The
son is in a state of shock, pain, or distress, the normal access to
program also seeks to establish medical clowning as an officially
this helpful psychological resource gets blocked. People are either
recognized paramedical profession, thus, promoting research and
too immersed in their feelings, or on the contrary, too stressed, too
academic training in the field. The project is currently established
much ‘outside of themselves’, to be able to use their imagination as
in 18 medical settings throughout the country, with about 70 medi-
a coping mechanism. The clown is a symbol of the world of imagi-
cal clowns active in various pediatric wards and clinics. In addition,
nation, a distinctive representative of this realm. Therefore, when a
Dream Doctors have participated in special projects as part of inter-
clown appears, they instantly become the bridge that links us to the
national delegations sent to disaster zones, such as the earthquake
world of imagination: they have the immediate effect of reminding
in Haiti and the Tsunami in South Asia a few years ago (see Dream
us to use a tool that we naturally possess. Just by being there, the
Doctors Project, 2010, In the trauma zone).
clown guides us into the imaginary realm, thus helping us to acti-
Amnon Raviv has worked as a clown therapist for over seven
vate the innate resource of imagination, in a way that even when
years at Barzilai Medical Centre in the city of Ashkelon, on the
the clown has gone, the resource would still be working (Pendzik,
northern region of the Negev and southern coastal plain. In recent
in Dream Doctors Project, 2010). As Simonds (2001) puts it:
years, following the violent escalation of the conflict in Gaza, and
We need to remind people that they are human beings and to the rocket attacks on the western Negev settlements, Barzilai has
show children that they can go on being children despite the been receiving many wounded victims of the conflict, becoming a
nasty detail that they have cancer. We stay in their realm of frontline hospital for the region. Over the years, Amnon has worked
fantasy; we try to transport them to another world and give with a wide variety of people, ranging from injured and acute
them tools for the hospital voyage (p. 8). stress victims from both sides of the conflict, to children undergoing
weekly medical treatments, or one-time event surgical procedures.
An additional quality shared by medical clowns and drama
His clown therapist name is “Professor Doctor, Head of the Depart-
therapists is the ability to make therapeutic interventions from
ment.”
within dramatic reality. Unlike verbal psychotherapists (or even
psychodramatists) who remain at all times in the roles of listeners, Case one: “There will be no pain”
witnesses, or directors of their client’s scenes, drama therapists can Omer was a nine years old girl when Professor Doctor first met
chose to be performers and make interventions from within dra- her. She suffered from severe arthritis, and started to come to the
matic reality (Pendzik, 2008). In some working modes (for instance, hospital for treatment on a regular basis, once a week for over 3
in Johnson’s developmental transformations), drama therapists years. The treatment involved a long and complicated procedure:
spend most of the session within the playspace, from which they First, she had to go through blood-pressure tests, and then, get a
270 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275

very painful injection in her thigh. The procedure involved waiting her to allow herself to be surprised and open to the unexpected.
for a long time, and it brought up a lot of uncertainty: If the blood Chatting and laughing about the events of the week (from the
pressure was too high, she couldn’t get the injection. Omer perspective of Professor Doctor) also had a cathartic effect: here,
came mostly accompanied by her mother, and sometimes by her the ‘ritual’ elements were the known and familiar events, whereas
grandmother. the ‘risk’ was the clown’s point of view. She provided the contents;
Professor Doctor used three styles in the interaction with her: Professor Doctor shaped them into extraordinary occurrences by
(a) In the waiting time, while Omer’s blood tests were being made, looking at them from his astonishing angle. Yet, as she moved into
he used the classical clown approach: Gigs, jokes, absurdity, magic the second part of the procedure, this level of risk was no longer
tricks. They also talked and laughed about the things that Omer helpful for her. The ritual aspect needed to increase.
had experienced during the week – of course, looking at them Coincidently, the second approach used by Professor Doctor is
from the point of view of the clown. This was amusing for Omer: properly speaking a ritual – albeit a creative one which evolved out
Laughing enabled her to get the blood tests done while diminishing of their interaction over the years. A quick look at the four parts
her anxiety. that composed it reveals that it could be metaphorically regarded
(b) In the second part of the procedure, she had to go to the as a ‘preparation for battle’ ritual:
treatment room in order to get the injection. Usually, at this point
her anxiety went up again, and Professor Doctor discovered that (a) dancing and singing patterns (warming up physically and psy-
she was so frightened and disturbed, that she couldn’t listen to chologically, releasing fear through movement and song),
him anymore: He had to find a different way to reach her. So over (b) naming the characters involved (invoking the protectors or
the years, they developed together a ritual which they performed helpers),
before getting into the treatment room. It consisted of dancing (c) words of encouragement and eulogy for the heroine (stirring
funny steps to a funny song which they both sang. The song was up courage) and
about how brave and beautiful Omer was, and included details (d) a repetitive mantra: “there will be no pain” (inspiring fearless-
about all the other characters involved: the mother, the nurse, and ness).
of course, Professor-Doctor – Head of the Department. Another
core motif of the song was a recurring phrase repeated by Omer
The third part of the interaction involves turning the hospital
and the clown stating that “there will be no pain”. In the treatment
into an as if reality – and not just any as if, but an extraterrestrial
room Omer allowed only the presence of Professor Doctor.
space. Every aspect of the hospital’s daily landscape is transformed
She didn’t want even her mother to be there, and the clown kept
via dramatic imagination into an alien place. According to Duggan
singing and trying to make her laugh – or at least, to draw her
and Grainger (1997):
attention away from the treatment.
At the end of the treatment, Professor Doctor usually took Omer The use of here and now physical action and awareness are . . .
on his “spaceship” (a decorated wheelchair), and they travelled of inestimable importance therapeutically. Individuals who are
through the planets (the hospital), meeting with UFO’s and aliens. suffering may become so sunk in their own distress that they
Thus the last phase of their interaction involved a journey through develop a kind of numbness to other experiences. To re-enable
an imaginary world of their own creation, until they said good bye them to be aware of what is going on within and around them
to each other at the doorstep, on the way out. in terms of actual physical sensation is in itself healing. If they
For three years, Omer agreed to go through this medical procedure are then lifted out of themselves and onto the plane of dra-
only if the clown was there. In fact, the treatments were scheduled matic reality, they may thereby be sufficiently distanced from
keeping in mind the days in which Professor Doctor was available. their pains to be able to open themselves to other feelings and
experiences (p. 126).
In this description we can see clearly that therapeutic clown-
It is noteworthy that the hospital’s definition as ‘alien territory’
ing involves much more than traditional clown techniques, such as
– a distanced place that is very far away from ‘home’ – takes place
jokes or magic tricks. As Professor Doctor maintains, these were
only towards the end of the treatment, on the way home. Defining
only applicable at certain moments of the interaction, whereas
the painful procedure as a journey to outer space probably helped
at others, they were not useful at all. The clown’s switch in the
Omer to de-role from ‘patient’ role, to separate this experience from
approach employed may be considered in light of Jennings’ (1990)
the normal flow of life and put it in a different context. A way of
notion of ritual and risk. According to her, “every drama therapy ses-
saying: “Life goes on, home is elsewhere; this was just one of these
sion has a component of ritual and risk, and the balance of these two
crazy journeys to outer space.”
elements varies with the particular client group and may vary over
time as people change and develop” (p. 61). The ritual factor is the Case two: “This is not the right time”
familiar or structured aspect of dramatic reality: the structure of a “A merry heart doeth good like a medicine, but a broken spirit drieth
game, its rules, theatrical conventions, a known musical pattern, or the bones”
a song’s recurring refrain. The ritual acts as a container: it protects.
Book of Proverbs, verse 17:22
Its predictability makes the person feel in a recognizable, safe space.
The risk, by contrast, relates to the unforeseen part of dramatic real- On Monday, 3/9/2007, at 7:38 am, a Qassam rocket fell very close
ity: the unexpected twist of a game, the outburst of improvisation: to a school bus that was full of children on their way to school in
it implies a creative step into the unknown. In Chesner’s (1994) the city of Sderot. The kids were brought to Barzilai hospital in a
view, drama therapists need to be aware of the balance between state of shock. They were gathered in the dining room with the staff:
ritual and risk “at each phase of the session, and their task is to psychologists, psychiatrists, social workers, doctors, and nurses. The
find appropriate structures to provide tolerable challenges” to their medical clown was not included among them.
clients (p. 125). Professor Doctor heard about the incident by chance, from a com-
In the case of Omer, although the first stage of the medical ment made by someone walking down the corridor. He hurried up
procedure was anxiety provoking (because of the uncertainty it to the dining-room, but as he was about to enter, one of the psy-
brought up), it was not physically painful, and the level of risk chologists signaled him with his hand, in a gesture that could only
she could tolerate was quite high: she was able to get warmed be interpreted as “don’t disturb us; this is not the right time for
up with jokes, gigs, and magic tricks – all of which required from clowns.” However, a clown is naturally a rebel, and is not bound to
 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275 271

do what he is told. As he believed that this was precisely the right of Professor Doctor to the dining-room gave the children not just
time, he therefore entered the room in utter disobedience. an opportunity to laugh, but also to feel that someone is more
The children were sitting in a circle, withdrawn and pale, quietly lis- ‘untogether’ than they are or that he can voice that part of them on
tening to the words of the psychologist. Professor Doctor sat among their behalf. As Linge (2008) states, medical clowns may position
them, dropping the weird contents of his bag – obviously, “not on themselves as the ‘bearers’ of a child’s affects, which enables
purpose”. He then apologized while making funny faces, and col- children to see themselves from the outside. This mirroring devise
lected the contents of the bag again. By then the children began in which a therapist portrays the vulnerability or fears of a client
to laugh, and in a few moments, the heavy atmosphere that sur- from within dramatic reality is known to drama therapists. It may
rounded them was softened: they looked less pale, and it seemed be compared to what playback theatre performers’ do when taking
as if they could free themselves a little from the tension. aspects of the teller upon themselves; or parallel some of Johnson
Afterwards, Professor Doctor accompanied the children through the (1992) interventions in the playspace, such as pre-emptying, in
different stations in the hospital where they had to undergo med- which the therapist appropriates the difficult attributes of a client’s
ical examinations and checkups. They played with him, moving role in order to induce the client to play a complementary one.
from one place to another, holding hands with him, and turning Moreover, according to Raviv (2012) the medical clown is a
the whole process into an adventure in which both the clown and revolutionary figure that challenges, shakes, and even changes con-
the kids travelled through a different reality: The medical examina- ventions at the hospital site, because it “brings a carnival spirit
tion became a journey into the jungle, where the ‘natives’ they met into this world, turning the hospital’s rigid social structure on its
(hospital staff), were so enchanted and fascinated with the visitors, head. . .” (p. 4). This attribute of the role provides an advantageous
that they kept asking lots of questions and examining them all the starting point for the clowns, enabling them to make the imaginary
time. world manifest right away. From the staff’s point of view, given the
At lunchtime, the meal became a potato chips-battle triggered by situation, the clown was viewed as a potentially disturbing factor
the clown, (much to the dissatisfaction of the dining-room man- that could upset the order, and it seemed a logical choice not to
ager.) The children were laughing really hard, and it seemed as allow him to come in. Yet the fact that he was signaled to stay out
if they had come back to themselves again. All the children were only made a stronger impact on the kids, who perceived him as a
discharged that day. liminal figure, coming from ‘another place.’ The clown’s defiance
and disobedience of the rules made it clear to them that he does
As in the previous case, the imaginary realm serves to con- not belong to the staff, which immediately opened them up to col-
textualize the experience of suddenly finding oneself in a foreign laborate with him. At some point, without the clown noticing it, the
territory: dramatic reality offers the possibility of translating a dif- deputies of the hospital’s director had entered the room and wit-
ficult situation into an encapsulated version of it, which helps to nessed the interaction between the kids and the Professor Doctor.
contain and process it (Pendzik, 2006). It also provides a measure of Realizing the immense help that a clown therapist can offer to the
aesthetic distance through which the contents can be approached medical staff, they decided to incorporate the clowns more closely
with a sense of safety and control (Landy, 1996, 2001). Professor in the work of the hospital team in mass crises interventions.
Doctor’s choice of the ‘jungle’ metaphor allowed the children to
Case three: A whole world of their own
define the situation in a way that they feel more control over it
“To you, I am just a fox like a hundred thousand other foxes. But if
(they control dramatic reality). As opposed to the de-rolling func-
you tame me, we shall need one another. To me, you will be unique.
tion of the ‘journey to outer space’ of the previous example (which
And I shall be unique to you.”
was made on the way out of the hospital), here the journey into
the jungle had the purpose of facilitating their stay at the hospital Antoine de Saint-Exupéry
by identifying the medical examinations with a pleasant metaphor: J. was a seven years old Palestinian child from Gaza, who was hos-
almost a vacation. Moreover, redefining the events in terms of a fic- pitalized in the orthopedic ward of the hospital, with both legs
tional genre the children are familiar with also helped them to make amputated. He was lying in an Israeli hospital for several months,
sense of it by providing the means for them to story their experi- without his family, without knowing the language, and removed
ence. As White and Epston (1990) claim, people are able to give from his surroundings. He was alone most of the time.
meaning to their experiences by plotting them into stories; expe- When Professor Doctor came to his room for the first time J.
riences which stay unstoried, are never told or properly expressed, was amazed and enchanted. They communicated through body
remain as amorphous and meaningless contents of the psyche. language, gibberish, fantasy, magic tricks, music, and puppets.
An important point to consider in this vignette is the psychol- Together they created a whole world of their own. J. liked the magic
ogist’s initial refusal to allow the clown to come in. This kind of tricks very much – especially the one of the handkerchief that disap-
dismissal brings to mind similar instances encountered by drama peared in the air. Time and again he requested to watch the wonder,
therapists (particularly at the onset of the profession), in which psy- always trying to figure out how could this happen, and hoping that
chologists or other staff members minimized the potential of drama this time it will be revealed to him. Another trick that he liked was
therapy as an intervention tool, or render it as inadequate in order the magic book. This book was empty most of the time, but only
to deal with a ‘serious’ situation. Jennings (1987) referred to this when J. touched it with his finger (only him and no one else) the
issue as a fear of the Dionysian aspects of the field – a fear that can be magic book became filled with pictures.
certainly can be extended to therapeutic clowning. At first sight, it The clown became his friend: he waited for him impatiently and
seems that the situation is ‘too serious for a clown’. Yet, as it occurs was sad when he had to leave. Only once during his hospitalization
in many extreme situations where people are in a state of shock, it could be arranged for his mother and twin sister to come to visit
rather than being counterproductive, the presence of the clown him. On this occasion, J. was proud to introduce his new friend to
is perceived as something so completely out of the ordinary and them.
illogical that it expresses the absurdity of the circumstances and One of J.’s favorite acts was the play of the bubbles, in which the
legitimizes the feeling that ‘something is really out of order here’ clown created an underwater world full of strange creatures swim-
(Pendzik in Dream Doctors Project, 2010). Furthermore, as Citron ming and gazing with funny faces at him. J.’s role in the act was to
(2011) asserts, in the hierarchical context of a hospital the clown’s make the bubbles fly.
vulnerability empowers patients, who may feel comforted by the Professor Doctor often included members of the medical staff while
fact that there’s someone more vulnerable than them. The entrance playing with J. There were also other kids who stayed for a while
272 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275

in the same room, and took part in the interaction and the play- that the image somehow worked for him. On the other hand, it was
ing scene. They tried to help J. to find the missing handkerchief, the clown who connected him with the surroundings, by inventing
or participated in the bubbles play. In the play, they became part- games in which other kids and staff were also involved. The clown
ners. Though they couldn’t talk in the same language, they could then functioned both as mirror and as bridge, as interpreter and as
communicate well enough to collaborate and to have fun together. a guide between worlds.
The magic book and the disappearing handkerchief were also
Nonverbal communication is at the core of drama therapy. As important symbols in this relationship – not only because of the
Dokter (1998) states, role-play, voice work, myth, story-telling, sense of uniqueness (only J.’s finger filled the empty book) or the
and other forms regularly employed by drama therapists can be bond that they helped to create between the child and the clown.
used non-verbally – just as in the other arts therapies. The visual Professor Doctor was aware that J.’s requests to repeat over and
aspect of drama is emphasized whenever language barriers are over again these games, and his curiosity to understand how it
present. It is here that we realize that, although drama utilizes happened, were somehow emotionally charged: emptiness and
words, dramatic communication is not a purely verbal approach, fullness, just like appearance and vanishing, bring to mind an
but an embodied use of language. Theatrical language is visual, and attempt to make sense of inexplicable loss. Perhaps by repeatedly
clowns are definitely masters of body speech. In fact, a particular dealing with them in dramatic reality, J. was trying to understand
method of medical clowning, called the nonverbal or limited-verbal something about his own loss?
approach, defines “the essence of Therapeutic Clowning as a non-
verbal Question-and-Answer Dance that proceeds at the pace set Case four: The adventures of Miss Esther (from Professor
by the patient” (Thompson, 1998, p. 1). Doctor’s diary)
In J.’s case, language was only one kind of barrier in a long “Stories are medicine”
series of barriers. Professor Doctor’s use of nonverbal communi- Clarissa Pinkola Estés
cation in an attempt to find a common language between them It was a Monday morning and the pediatric ward was full. I entered
was perhaps one of the ingredients for the success of the relation- room number three and I saw four little kids lying on their beds with
ship. A journey into dramatic reality is always an intimate one, forlorn faces. Their parents were sitting next to them. One mother
requiring and building intimacy at the same time. Playing, creat- was so tired that she hardly opened her eyes.
ing fantastic worlds, journeying together to dramatic reality, were “Listen,” I said quietly and in a mysterious voice. “Did you happen
an international language that helped the clown to reach J., and to see Miss Esther, by any chance?” The kids looked at each other,
to establish a metaphorical ‘bubble of sanity’ inside an otherwise and then again at me, and said nothing. “Listen,” I insisted, “I know
untenable situation. As Lahad claims (in Dream Doctors Project, she must be here, somewhere in the room. . .”
2010), medical clowns working in disaster zones can manage to One of the mothers said that they didn’t see anyone entering the
create around them an ‘island of resilience.’ Indeed, this was also room. “Well,” I said, “it’s hard to see her because she is so small. . .”
generated through the clown’s efforts to integrate other hospital Now the kids became very attentive.
staff and children in their games, thus expanding the island of “Listen,” I said for the third time, “I need someone with magic pow-
dramatic reality to include other members of the hospital’s com- ers to look for Miss Esther.”
munity. I took out my magic book from my bag and checked everyone in the
As Seymour (1998/1999) maintains, drama therapists should be room, to see if he or she had the magic power. Pictures appeared
aware of the political dimensions of their work, and in this context, on the empty pages when the kids touched the book. Their parents,
it is clear that the attribute of marginality gave Professor Doctor though, didn’t have the magic powers: The pages remained blank
an advantage in establishing a bond with J. As the quintessential at their touch. It was of course an amazing coincidence that all of
representative of the limen, the clown is always an outsider, act- the kids had the magic powers; but there was not enough time to
ing from the border, blurring hierarchies and challenging authority. comment on it, because by then, the kids were out of their beds, all
This ability to operate from the margins allows them to help where looking for Miss Esther.
others fail. Perhaps a well-intentioned staff member may not have Miss Esther (a finger puppet) was found through a joint effort. As
reached as far or as fast as the clown. Their liminality allows clowns soon as she was revived on my fingers, she began narrating, mostly
to move across boundaries of class, ethnic, political, or religious through my lips, her unbelievable story: She told of her adventures
sides in a conflict, transcending borders and nationalities: they in strange lands, where she had to stand on her nose, walk with
don’t belong anywhere. J. may not have responded to Amnon Raviv her hands, put her legs on her head, and perform all sorts of bodily
with the same openness as he did to his clown character, even if tasks in order to overcome dangers of all kinds: She had to swim
Amnon would have been as friendly and funny as Professor Doctor in stormy waters, walk in the depth of the forest, and fly up to
was: it is primarily the role that facilitated the contact. the sky, so as to rise above insurmountable perils and obstacles.
Citron (2011) asserts that clown doctors are in a paradoxical Eventually, she switched to someone else’s fingers (the kids’ and
position: on the one hand, they are part of the hospital’s system parents’), continuing her account through their lips.
(they are authorized to enter into restricted areas, staff mem- At some point Miss Esther had to fly away (out of the room, to the
bers may collaborate with them, etc.); on the other, they conspire ward’s corridor), and all four kids followed her, flying along with
against the system, exposing its flaws, revealing its power structure. her, side by side. We all flew over the world for some time, and then
Like the traditional court jester, medical clowns are all-licensed headed back home again (to the room).
critics, allowed to tell the truth (Welsford, 1968). In this regard, it
is meaningful to point out that one of the dramatic worlds that J. Stories and storytelling are regularly used as intervention in
and Professor Doctor constructed together (which J. enjoyed very drama therapy for a variety of reasons. First of all, they provide con-
much) was the underwater world, “full of strange creatures, gazing sistent structures that allow us to integrate parts of our lives that
with funny faces at him.” This metaphoric image of reality which we do not know how to make sense of or explain to ourselves. Sto-
mirrors, encapsulates, and conveys the difficult aspects of the situa- ries embrace our experiences by offering a framework of belonging
tion in playful, yet accurate ways, can only be put forth successfully – particularly for the most inexpressible and inconceivable ones –,
by someone who is also an outsider – the recipient of strange gazes so that we are not ‘left alone’ with them. Moreover, as Gersie and
from funny faces as well. J.’s participation in the scene as the keeper King (1990) assert, storytelling is always a shared experience that
of the quality of dramatic reality (making the bubbles fly) shows creates an immediate sense of bonding between people. Regardless
 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275 273

of whether a person likes a story or not, listening to stories together experience of medical procedures at the hospital and Miss Esther
has the general effect of connecting individuals by virtue of inviting ‘unbelievable’ account, which included having to perform all kinds
them to share a journey into the world of imagination. According of awkward physical extravaganzas and tasks – such as ‘walking
to Gersie (1997): on her nose’ – in order to escape from something more danger-
ous (which isn’t even mentioned in the story). The heroine goes
Since time immemorial, storytellers have familiarized adults
through water, earth and air – coinciding with the shamanic cos-
and children with vivid story images which are pertinent to the
mic regions: lower, middle, and upper worlds (Eliade, 1972); and is
listener’s character and to their specific situation. . . Through
subsequently passed onto the hands of other tellers – the children
the careful creation of a believable illusion, tellers weave an
– in an attempt to enable their experiences to be integrated in her
associative thread between the listener’s world and the story
account. Finally, she takes everyone on a trip flying over the world,
of characters adventures. The story’s apparently incidental rel-
and returns them home safely. It seems that not only Miss Esther,
evance enables the teller to elicit and to sustain the listener’s
but almost everyone in room three have been ‘revived’ by Professor
agreement to attend to the tale (p. 8).
Doctor.
Furthermore, stories provide a safe aesthetic distance from
which we can gather the courage we need in order to confront even
the most painful aspects of life. Through aesthetic means (such as Conclusion: the difference that emphasizes resemblance
form, conciseness, structure, loveliness, humor), stories manage to
tackle charged issues in oblique or indirect ways, thus bypassing Recently the authors presented separate papers at an Interna-
psychological resistances. Finally, stories are helpful therapeutic tional Conference on Richard Schechner and Performance Studies at
tools because they offer perspective and guidance without being the University of Haifa: Amnon Raviv on medical clowning; Susana
invasive. Pendzik on drama therapy. We were pleasantly surprised that we
were both assigned to the same panel: therapy and performance.
The known world is the starting point, the connection with
Given the strong performative aspects it involves, it may seem
a reality which we can identify and recognize. In the process
appropriate at first glance to locate therapeutic clowning within
of its unfolding, the tale develops a story which contains and
the specific rubric of drama therapy called therapeutic theatre. How-
explores the unknown. A story is a guide because it takes us
ever, a deeper look into it reveals that actually it does not qualify
from resting place to adventure, through misfortune to culmi-
as such – particularly if we subscribe to the definition of this pre-
nation and the end. (. . .) When the journey is completed, we
cise area of drama therapy that is proposed by Snow, D’Amico,
the listeners, emerge revitalized. The imagination has nourished
and Tanguay (2003). According to it, therapeutic theatre entails the
and inspired our motivation which in turn contributes to real-
development of a play with therapeutic intentions, in a process that
ization and solution. We gain strength by identification with a
is facilitated by a drama therapist (or a therapist with theatre skills),
story character who initially had the will to persist and who
which is “brought to culmination in a performance for a commu-
found the courage and strength to prevail (Gersie & King, 1990,
nity beyond the social sphere of the therapeutic group itself“(p. 75).
p. 35).
In our view, it is more accurate to consider therapeutic clowning
In the example from the clown’s diary presented above, Pro- within the wider spectrum of applied or social theatre – a branch
fessor Doctor finds a way to ‘revive’ and generate a playful bond of theatre that is concerned with its application in social contexts,
between the disconnected individuals in room three (both chil- which differentiates itself from the purely aesthetic experience, or
dren and parents), who were too exhausted, distressed, or sad, to as Thompson and Schechner (2004) claim “where aesthetics is not
use their healthy coping mechanism of imagination by themselves. the ruling objective” of the performance (p. 12). Even within this
The storytelling structure he used is brilliantly simple – especially framework, and as Seymour (2009) points out concerning other
as a means to engage little kids: The word ‘listen’ is pronounced in applied theatre forms, it is necessary to define its connection with
a mysterious tone three (magic) times – each one supplying a more drama therapy, also in terms of its differences in order to have a
intriguing piece of information: productive dialogue between these fields.
The family resemblance between drama therapists and medical
clowns is great. However, one of the main aspects in which these
“Listen, have you seen Miss Esther?”
two siblings differ is the way in which they perceive and are per-
“Listen. . . It’s hard to see her because she’s so small. . .”
ceived by the people whom they try to help – whether audience
“Listen. . . I need someone with magic powers to look for Miss
or clients. In this semantic distinction there is already a world of
Esther.”
difference: drama therapists would only occasionally perform for
their clients or consider them as audience (Pendzik, 2008); and they
The plot evolves according to Campbell’s (1972) description of would be generally be perceived by their clients as someone who
the Hero’s Quest: in order to become eligible ‘seekers,’ most uni- belongs to ordinary reality, who may lead them or join them in
versal stories and myths would include at this point a ‘test’ that all a round trip into an imaginary world, but whose starting point is
potential candidates need to pass. In this case, they need to prove everyday reality. Medical clowns, by contrast, are more likely to
they possess ‘magic powers’ by touching a magic prop (the book). conceive the people they work with as audience, and are generally
The fact that only the kids passed the test facilitates their quick con- perceived by their audience as belonging to the imaginary world.
stitution into a working team: They now belong together as a group; Throughout their interaction, the clown is seen, not as a therapist,
they not only have in common their role as patients, the random but as a character from the imaginary realm (a fact that also creates
sharing of the same room at the hospital; they are also connected some confusion among many medical clowns as to whether to see
through some magical bond: Their joint efforts make it possible to themselves as therapists or as ‘just clowns’).
create an island of imagination, to establish a good enough dramatic This paper attempts to bring medical clowning and drama ther-
reality in which therapeutic interventions can be made (Pendzik, apy together by applying drama therapy concepts and theory as a
2006). method to analyze medical clowning practices. It shows that the
Their success in finding missing Miss Esther is readily rewarded clown’s methods can be conceptualized using drama therapeutic
by her willingness to share of her story. Incidentally, some imper- models and theory. As stated above, even if very successful and
ceptible parallels can be traced between the children’s presumed growing, medical clowning is a relatively new profession, and in
274 S. Pendzik, A. Raviv / The Arts in Psychotherapy 38 (2011) 267–275

that sense, it lacks the body of knowledge, and the theoretical foun- Jennings, S. (1990). Dramatherapy with families, groups and individuals. London: Jes-
dations which the field of drama therapy has built in the past three sica Kingsley.
Jennings, S. (Ed.). (2009). Dramatherapy and social theatre: Necessary dialogues. Lon-
or four decades. Most of the work of medical clowns is intuitive; the don: Routledge.
field still lacks its own theoretical models of assessment and inter- Johnson, D. R. (1992). The dramatherapist in role. In S. Jennings (Ed.), Dramatherapy:
vention, as well as independent means for evaluating the clowns’ Theory and practice (pp. 112–136). London: Routledge.
Johnson, D. (2009). Developmental transformations: Towards the body as presence.
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research pointing at the effectiveness of therapeutic clowns – pre- 2, pp. 89–116). Springfield, IL: Charles C. Thomas.
cisely the kind of data which in drama therapy is hard to generate, Johnson, D., & Emunah, R. (Eds.). (2009). Current approaches in drama therapy. Spring-
field, IL: Charles C. Thomas.
possibly, among other reasons, because the processes are longer,
Jones, Ph. (Ed.). (2010). Drama as therapy: Clinical work and research into practice.
less observable on an immediate basis, and the follow up is more London: Routledge.
difficult. Karpelowsky, B., & Edwards, D. (2005). Trauma, imagery and the therapeutic rela-
tionship: Langu’s story. Journal of Psychology in Africa, 15(2), 185–195.
Kaplansky, N. (2009). Dissociating from death: An investigation into the resilience
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