Abstract

Working with different forms of artistic and cultural expressions has been considered a form of health intervention to enhance the understanding and thinking about the needs in this field. A group of clown doctors conducted home visits for eight months to ten families located in micro areas of two family health teams. The practice aimed at expanding the solvability of the care given to people and to communities through the intense proximity established by the art of clownery. The idea consisted of making interventions in the homes of socially vulnerable families indicated by the family health teams using joy, humor, and laughter to stimulate reflections on the daily problems. The presence of “clown doctors” in the houses built strong and free bonds with the families and enhanced the humanized and comprehensive care within the context of family health strategy. Clowns and families found a special way to find possible solutions to the difficulties faced on a daily basis. Male and female clowns were able to manage new subjective constructions for each family to deal with everyday situations.

Clown; Clown doctors; Family health strategy; Bonding; Humanization; Completeness

Introduction

There is a big difference between being an actor and being a clown. The actor is able to interpret the body and soul of a character that has nothing to do with him (he can be a very good person and play the role of the cruelest tyrant). The clown does not interpret a character; he uses his body and soul to give life to someone who already exists within him¹1. Thebas C. O livro do palhaço. São Paulo: Schwarcz; 2005.. The clown always lives the present in connection with everything that happens around him and looks for creative solutions to the often-repetitive daily problems in human life. He does not simply act, he savors every move, every gesture, and everything connected with the authenticity achieved by the contact with his essence. Therefore, he is always open to innovative solutions to the problems he faces. This attitude causes strangeness and it can generate humor, surprise and astonishment²2. Mourão M. Doutores da Alegria. Vídeo Documentário Nacional; 2005.. Thus, he is able to address barriers imposed by diseases, pain, alienation and distress, with flexibility, and in a mood continuously adapted to the changing conditions and circumstances.

Additionally, the clown has the power of freedom. He is a free being who finds pleasure in everything he does, converts his personal weaknesses in theatrical force, works in reverse logic, puts the order in disorder and thus allows denouncing the existing order. The clown lies on the freedom of being able to be what he is, of being the maximum freedom, the freedom to take risks³3. Gaus A, Santos V. Centro de Pesquisa Teatral e Afins: escola de mímica do Brasil - Teatro Ativo [acessado 2012 fev 4] Disponível em: http://www.solardamimica.com.br/
http://www.solardamimica.com.br/... . Thus, working with this art so close to people means inviting them to take some risks together. The clown, by definition, threats the public order and, apparently, he has no place in the biomedical paradigm⁴4. Raviv A. The clown’s carnival in the hospital: a semiotic analysis of the medical clown’s performance. Social Semiotics 2014; 24(5):599-607..

As for the Brazilian health context, the clown is well known in hospital environments. The main example is the group known as the Doctors of Joy (Doutores da Alegria)²2. Mourão M. Doutores da Alegria. Vídeo Documentário Nacional; 2005., which is a project launched in 1988 by the Brazilian actor Wellington Nogueira. The Doctors of Joy began their activities with hospitalized children at the Hospital and Maternity Clinic Nossa Senhora de Lourdes, in São Paulo.

Recently, it is possible to identify the transposition of this technology to the Brazilian national territory⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516.^,66. Zoboli ELCP, Hohl KG. Tecnologia clown na saúde da família: a transposição de uma tecnologia de humanização hospitalar para o território. In: Anais do 21º Simpósio Internacional de Iniciação Científica da USP, 2013..

Since the Primary Care Policy provides for the construction of citizenship spaces as well as for health promotion actions⁷7. Backes DS, Backes MTS, Erdmann AL, Büscher A, Marchiori MT, Koerich, MS. Significado da atuação da equipe da Estratégia de Saúde da Família em uma comunidade socialmente vulnerável. Cien Saude Colet 2012; 17(5):1151-1157., the University created an extension project and suggested the insertion of clowns in the Family Health Strategy (FHS). Since the clown is able to see everything from a different angle, it is believed that he/she would offer new dimensions to the obviousness in the daily life of socially vulnerable families. Such a proposal is based on the possibility of establishing social technologies from the reality of these families, by promoting delight, gathering and joy⁸8. Matraca MVC, Wimmer G, Araujo-Jorge TC. Dialogia do riso: um novo conceito que introduz alegria para a promoção da saúde apoiando-se no diálogo, no riso, na alegria e na arte da palhaçaria. Cien Saude Colet 2011; 16(10):4127-4138.. The justification to insert the art of clownery in the households was based on the fact that it is a liberating, educational, creative and cultural instrument.

The “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. are considered life promoters in the dialogical encounter⁸8. Matraca MVC, Wimmer G, Araujo-Jorge TC. Dialogia do riso: um novo conceito que introduz alegria para a promoção da saúde apoiando-se no diálogo, no riso, na alegria e na arte da palhaçaria. Cien Saude Colet 2011; 16(10):4127-4138. with the families. The dialogue with the clowns is horizontally held; it is a human, loving and courageous activity able to raise freedom and mutual trust. The open dialogue construction favors the mediation of knowledge among agents⁸8. Matraca MVC, Wimmer G, Araujo-Jorge TC. Dialogia do riso: um novo conceito que introduz alegria para a promoção da saúde apoiando-se no diálogo, no riso, na alegria e na arte da palhaçaria. Cien Saude Colet 2011; 16(10):4127-4138., as it is cited in the literature. Therefore, the message the clown would take to people would not be passively received. The visited families would not be object and recipient, but authors and creators of the aesthetic value of the encounter⁹9. Cunhal A. A Arte, o Artista e a Sociedade. Lisboa: Editorial Caminho; 1996..

Thus, the current study raised the following questions: Does the clown, within the family context, enhance the families’ perception about their daily lives? Does the clown renew and innovate their understanding of their own living conditions, through joy, humor and laughter, thus optimizing the way they cope with the daily problems?

The herein presented study aims to report the experience of a group of “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. who visited the homes of socially vulnerable families identified by family health teams.

Method

This is an experience report about an intervention performed with adults in a community context. During eight months, a group of “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. visited the homes of families and index persons identified by two family health teams as socially vulnerable. This group was formed by university professors, health professionals, medical school residents, graduate students in health, music, other arts, and occupational therapy.

The practice of clownery in the FHS was structured from a university extension program associated with cultural and research activities in health care. It was funded by the Dean of Extension of the Federal University of São Carlos, and this is the reason why the project has not been previously submitted to the ethics committee.

The dialogical attitude⁸8. Matraca MVC, Wimmer G, Araujo-Jorge TC. Dialogia do riso: um novo conceito que introduz alegria para a promoção da saúde apoiando-se no diálogo, no riso, na alegria e na arte da palhaçaria. Cien Saude Colet 2011; 16(10):4127-4138. of the clown inserted in the family context was based on some principles such as truth, dignity, respect for human life, being always ready to the problems presented to him, the ability to dialogue through his essence and to always seek new challenges, among others. The intervention details are presented below.

a) Planning the intervention and training the staff in the art of clownery: the planning took place six months before the home visits started. Three women who suggested the project (a graduate student in Occupational Therapy, an Occupational Therapy professor and a resident physiotherapist of the Family and Community Health Program) attended an immersion clown course in the active theatre company Solar da Mímica & Cia³3. Gaus A, Santos V. Centro de Pesquisa Teatral e Afins: escola de mímica do Brasil - Teatro Ativo [acessado 2012 fev 4] Disponível em: http://www.solardamimica.com.br/
http://www.solardamimica.com.br/... .

After the course, they practiced body language exercises and scenic improvisations two hours a week to search for their individual inner clown. In addition, they established dialogues with two family health teams of the Family Health Unit (USF - Unidade de Saúde da Família) located at the peripheral region in the countryside of São Paulo. A physician, a nurse, a nursing technician and community workers formed the two family health teams and they counted on the collaboration of a multidisciplinary team of medical residents. The three women held meetings with both family health teams to define the criteria used to exclude or include certain families who experienced one or more of the following problems: social vulnerability, poor housing conditions, low income, alcoholism, drugs, disabled persons, or persons suffering from psychological distress, bedridden and users who have difficulty to attach and/or to adhere to the care provided by the family health teams. Based on these criteria, the teams asked for clown intervention in ten socially vulnerable families. An index person to whom the clown should visit and give attention was indicated in all families; however, the clown should always try to give attention and include all family members and those who were present at the time of the visit.

After the families and index persons who would receive the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. were defined, a community agent and one of the three members of the clowns’ group visited the index persons to invite them to participate in the project. They also investigated some qualitative indicators related to: family composition and dynamics; the pleasures/hobbies, feelings of each index person; how their daily lives were structured; and what they knew about the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516.. The dialogue with the families allowed establishing indicators to be checked after eight months of intervention and they were all recorded by a “clown doctor”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516..

This first visit was used to establish contact with the families and to obtain their consent to participate in the study. An informed consent form was not required for the participants to be included in the project, since it has extension nature.

All interventions were recorded in a field diary by all “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. and some of them were photographed. This material was weekly discussed by the team of clowns. The visits were held once a week, thus totaling 32 visits in each family. The bond established with the team of “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. was immediate, since the first encounter. This bond was strengthened in each encounter and the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. became part of the visited persons’ routine, who waited for the weekly encounter.

b) The clown doctors visiting procedure: each home was weekly visited during 15 minutes. The time was marked by a rooster crowing sound in the cellphone of one of the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. and it indicated the end of the intervention time. This time could vary according to the actual need of the encounter. The clowns knocked at the door of the houses without any pre-established script. They were open to the encounter with the other. When the clowns were hosted by the family, they generally established a first greeting time through hugging, kissing, etc. However, it was not always the rule. The action of the clowns was determined by improvisation at the time of the encounter, and the theme was somehow given by the family and/or by the index person. The clowns’ attitude was marked by their intense presence toward the index person and/or family. The initial group of “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. was formed by the three aforementioned women and by community workers.

c) Team evolution throughout the project intervention time: as the team of clowns became known in the university and in the city, it increased due to the spontaneous emergence of other clowns who also established the weekly exercise routine including improvisation, search for the inner clown, and weekly visits to families. The team was then formed by a UFSCar professor, an occupational therapy student, a resident physiotherapist, community workers, a dentist (sporadically), and by students from other fields such as music, other arts, occupational therapy, engineering, and biological sciences, as well as by a university employee.

d) The “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. visited the families during eight months. After this period, they reestablished the contact with the families to investigate whether there was evolution in the qualitative indicators established before the art of clownery was introduced to the home visits.

Results

Features of the persons indicated to the study

Seven out of the ten index persons who were selected, visited and indicated to the study were women and three of them were men. Their characteristics are described as follows: 1) Visually impaired man. He was a widower and lived alone in a precarious situation. One of his children also lived in the same ground where he lived. His son used to spend the entire day out at work and leave his children (7-10 year-old children) for the grandfather to take care of. The children used to go out and play on the streets and the grandfather had no control on them. He did all the housework, including cooking for the children. However, his income was not always sufficient to feed him and the children.

2) Woman with limited mobility due to severe pain in the leg. She lived with her son, but he worked all day long and she was alone at home without much chances of having external contact. She had diabetes; her diet was based on fried food and on food typical of the Brazilian Northeastern cuisine. She had difficulty to adhere to the care provided by the family health team. The son’s girlfriend also lived in the house in some periods. 3) Diabetic woman subjected to abdominal surgery a few months earlier, which left her bedridden with compromised healing process. Her husband was her primary caregiver and his depressive condition was recorded by the team. She had children and grandchildren who returned home in some moments of life due to marital separations. There was a fluctuating number of people living in the house. 4) Elderly woman with history of domestic violence inflicted by the first husband (deceased) and, at the time of the project, by a son diagnosed with psychosis, according to her account. She lived in a property with three houses that belonged to her children. Many people of all ages - adults, adolescents and children - lived there. This woman lived in her house with a grandson, a mentally ill son and a daughter. 5) Man with cerebrovascular accident sequelae, such as speech and mobility difficulties. He was the primary source of family income in his home. The family feared his death because it would represent the risk of losing the family income. There were many houses on the ground, which was restricted to a corridor with several houses next to each other. Despite his importance to the family income, he lived in a room at the back of the property. Many children, young people, unemployed men and women, sons, daughters, daughters and sons in law lived at the property. One of his daughters was his caregiver. 6) Depressed woman with history of suicide attempts. Her income was the main breadwinner in the family. Her children and grandchildren (kids) lived with her. 7) Elderly woman with severe breathing problems. There was suspicion of family negligence. Although her children and adult, young and little grandchildren lived in the house, this woman spent most of the time alone at home and without food. Sometimes she cooked for herself, which had already led to some domestic accidents. 8) Man, a former truck driver, who had CVA and lived alone. He had many difficulties to walk and to perform daily living activities alone. The house needed care. 9) Elderly woman with motor sequelae from CVA was bedridden for a long time or in a wheelchair. She had a community caregiver and her husband was absent all day long. 10) Woman subjected to domestic violence inflicted by her husband. She lived with their children and made every effort to keep them busy all day so they did not witnessed the aggressions she was subjected to. The husband’s working hours varied. Sometimes he stayed a few weeks at home and sometimes he spent several days traveling. The team reported her difficulty to adhere to the FHS proposals.

Characterizing the visited families

The number of people living in some households was not defined by their own choices, but by necessity due to the aging process, health problems and/or family economic changes, such as marital separations and unemployed children who returned to their parents’ home with their family due to financial difficulties. All families had low income.

Nine out of the ten index persons were not from the city where the project took place. They had moved from their place of origin to search for better living conditions. These data are consistent with the features of the area chosen for the intervention, since it is a district isolated from the city center and its occupation is characterized by the diversity of migrant and rural workers coming from Paraná, Minas Gerais, and Northeastern States, and from other cities of São Paulo State. This occupation process - by invasion and sale of lots at a lower price - resulted in the rapid and uncontrolled growth of the region, in the appropriation of lands unsuitable for residential use, in the concentration of poor people and in lack of urban equipment¹⁰10. Brasil. Secretaria Municipal de Saúde. Território, Comunidade e Atenção à Saúde no Bairro Cidade Aracy em São Carlos/SP: (Re)Conhecendo potencialidades e vulnerabilidades por intermédio da Estimativa Rápida Participativa. Administração Regional de Saúde do Bairro Cidade Aracy. São Carlos: Prefeitura Municipal de São Carlos; 2009..

The daily life reported by the index persons was restricted to domestic works such as cooking, washing the dishes, cleaning the house and looking after the children. There were also those who did not perform these activities due to mobility difficulties related to be bedridden, in pain or in wheelchairs. The typical routine of these persons consisted of waking up, having breakfast, having lunch, walking a little in the backyard, and waiting for the nurse, companion and/or caregiver to administer their medication and change their bandages.

Leisure was not part of the family life, and whenever it was mentioned, it was associated with religious practices and visits to friends. One family mentioned that cooking typical foods of their region of origin was a type of leisure, because it was not just the act of cooking, but going downtown in the company of neighbors and friends to buy ingredients in a typical Northern-food store, for example.

The described pleasures and hobbies were quite different. One interviewee said she liked walking on the highway and going to the cemetery; others said they liked watching television, listening to music and even playing with their grandchildren.

The following complaints related to the everyday life emerged in the reports: living with alcoholic children and husbands; difficulties in personal relationships, as in the case of mothers- and daughters-in-law living together; being restricted to bed; lack of sex due to surgical recovery; chronic cough generating physical pain; pain in the legs; discouragement to do anything; no prospects of changing the daily life.

At the initial contact, they said it was hard to change their daily lives. Loneliness was a feeling reported by the participants, even by those living with several people in the same house. They said they were not motivated to perform several activities in their daily routine because they did not see the sense in doing them and due to lack of company.

Reporting the exemplary situations of the relationships established due to the presence of clowns and their dialogical and transformational potential

The idea of having “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. performing home visits linked to family health teams generated some changes in the visited persons and these changes will be briefly reported.

As the interventions took place, the visited persons approached and bonded with the clowns. All families freely expressed themselves in order to share experiences, difficulties, joys, as well as to make plans and complaints. They established a welcoming relationship with the clowns and considered them as close friends to whom they showed care and affection, according to the reports and to the described situations.

• The welcoming: in one of the encounters, the clowns were kindly welcomed with sesame tea and cookies typical of the Northeastern cuisine. The intervention context was very intimate, like the visit of good friends who sat at the table to talk and laugh together. One of the clowns asked for water and he was immediately told: “You are home, go get it in the fridge...”

• Playing for relaxation and disinhibition: as a free being, the clown allowed the other to feel free to play, to take the stage with him/her and to feel pleasure and joy. In one of the visits, the clowns entered the house and saw a belt on the table. One of them asked about the purpose of the belt. The woman replied that it was used to hit the dogs when they did not obey her and she added with laughter: “It can also be used to beat disobedient clowns”. Another clown immediately said that it was the case of Dr. Lucrécia (clown), and from that moment on, the scene naturally progressed with the woman pretending to hit Dr. Lucrécia. All other clowns encouraged the woman, who had limited mobility, to keep on playing. They spoke seriously and the woman laughed a lot of everything and showed pleasure with the encounter.

• Reviving affective memories: the clown is able to fluidly revive life stories and cultural practices that the person performed, such as playing an instrument. Interventions with sounds of objects were always prioritized in the house of the visually impaired man. There was a day in which the clowns entered the house of this man playing the violin and other instruments. This action generated empathy in the man and brought back memories of the time he used to play accordion. He told them part of his life story before he lost his vision and spoke about the death of his wife. The clowns listened to him carefully, since it was not the moment to laugh, but to take up the story. The clowns resumed the music when they were leaving, and they included the man in the group as musician. They encouraged him to seek the accordion, although it was old and not in good use condition. They all improvised and played together.

• Lightness in the routines: the clowns also stimulated routine change with lightness and humor. A couple reported that they had not had sex for almost a year because the wife had been subjected to abdominal surgery. This situation was distancing the couple. Dr. Tatá (clown) said that the clowns had a handbook able to solve the problem. Dr. Rosinha (clown) added that the handbook was practical, and that each encounter would teach them a different lesson. The first lesson involved smelling each other’s neck. The second lesson was dancing with wandering hands. The third lesson was setting the environment with candles and scents. Humor allowed the couple to get closer to each other at each encounter, while they waited for the next instructions. They reported that the affection, even without sex, became part of their routine.

• Thematic range: the themes that emerged during the interventions were diverse. The clowns generated intimacy, and the participants felt free to speak and act in a spontaneous and natural way. The clowns sought to establish dialogues and actions in the ongoing scene. They did not judge or recriminate, they just lived the moment intensely and enjoyed what the other brought to the scene. They accepted the proposition of the other; they played and improvised. It is possible to associate this aspect to the popular education ideas. According to them, the educators’ practice is not naïve; they do not intend to be knowledge keepers; they should position themselves as someone who does not know everything¹¹11. Gadotti M. Convite à leitura de Paulo Freire. São Paulo: Scipione; 1999.. The current study does not discuss the merits of whether the clown is an educator or not. However, the clown seeks the human essence, he seeks his own essence to dialogue with the essence of the other. Thus, he is open to everything that happens, he has fun with everything and respects everyone.

• Improvisation and surprise in unusual situations: the clowns were also able to create in risky situations and to dare suggesting new solutions. For instance, there was a woman who said she missed her father very much and that his death was heartbreaking. Since she had difficulty in accepting her loss, she put herself at risk by leaving home at dawn to go to the cemetery, which was located on a busy highway with bad lighting. One of the clowns immediately took an EVA-made heart out of his pocket, pointed to it and said: “Here’s your father, you can be with him all the time, every day, just keep him in your pocket and pick him up when you need to”. The following week she said she had not gone to the cemetery. She had followed the clown’s advice and it made her feel calmer, and she even slept better. The clown’s strength lies on his belief that her father can be therein represented and that touching the object can bring her some comfort. The woman’s transformation was instantaneous due to the clown’s action. The care given to the other became even more intense after this experience, because the group realized that something very important happened in this clown-person relationship. The bond established through the art of clownery was immediate.

• Freedom of language: the clown’s language is mobile and adaptable to different situations. When the clowns visited a visually impaired man who could not see the clown’s nose with his own eyes, the nose was introduced through other sound and textual sources and in various formats. The clown’s nose is his guide; it is the mask revealing the person, his inside out, and it brings out the depth not yet accessed¹²12. Dorneles JL. Clown, o avesso de si: uma análise do clownesco na pós-modernidade [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2003.. The nose gives the clown the power to subvert the order. However, when it comes to those who cannot physically see it, how to communicate its existence and the permission it gives us to be and to play? The exercise took place through sound and tactile games, which allowed the joint construction of living scenes. The tone of the voice indicated the possible way to go. Touching the body and the objects delimited and widened the intervention. Intimacy gradually became part of the bond, and the life story was rebuilt and re-signified in every encounter. The visited person shared with the clown his joys and sorrows before and after the disability. The man’s care for the clowns stood out in this relationship. He was able to perceive when some clown had a cold and when a clown was missing. Whenever it happened, in the following encounter, he always expressed how he had missed that clown the week earlier. His complicity with the clowns was the keynote of this encounter.

• Presence in absence: whenever no one was in the residence, the clowns always left some object in the house gate, such as a balloon, a flower, and EVA objects with a message directed to the person and/or family. Thus, they knew the clowns had been there. This gesture of leaving something in the gate of the houses generated meanings to the participants, who always mentioned the fact in the following encounter and even directed the motto of the intervention with games based on the left objects. A woman reported in the second interview after eight months that the messages were important to her, because they made her feel that there were people who cared about her. According to her, the clowns accepted her more reserved way of being and she felt welcomed by the objects left at her gate even without the physical presence of the clowns. This woman actually received fewer visits from the clowns, because she was never at home. Thus, the visits took place through these gestures and through the humorous dialogue established by means of objects and messages.

• Care and tenderness toward human pain: there must be tenderness and humor to deal with the pain of the other. When the clowns came to the house of a woman, she told them about the deliria and hallucinations she had one night after she took 40 pills to die, two days earlier. She reported that she slept until the clowns arrived. Faced with such a tense and tragic situation, the clown was able to gently bring humor by inviting her to dance a “forró” (folk dance) because she was surely more relaxed after ingesting 40 pills. The woman, with laughter, accepted the clown’s invitation. She could strongly embrace the clown in this dance and feel warmth in such a difficult time. This attitude allowed keeping a body and affective dialogue with reports of what happened. There was no disapproval or any feeling of compassion and no guidance. The clowns only sought to connect with the other via tenderness. In a simple way, she told them part of her life story until the suicide attempt. After this fact involving the extreme case of a suicide attempt and the reception of the clowns, the woman showed new desire to live in the other encounters. She developed the desire to change the way she dressed herself. She wanted to use clothes that expressed her female figure, clothes that could set her free from the religious patterns her son required her to use as a mother’s behavior. She wanted to be a woman rather than just a mother. She started new dialogue possibilities with the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. and shared the desire to leave her solitude and to have a companion in her life. The clown took this idea of having a new companion with the desire to change the way of dressing and used it to explore this new developing image. During the following encounters, they all dressed with humor, laughter and sensuality. The pleasure of being a woman was recovered and, after a few days, she started dating her neighbor.

• Being open to all types of problems, from the simplest to the most complex ones: the clown is open to any problem, from the simplest to the most complex one; there is no hierarchy. One day, another woman opened the door to the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. saying that her house was very untidy. She did not have time to clean the kitchen before our arrival and it seemed to disturb her. One of the clowns entered the house and went straight to the kitchen in order to clean it. The others realized the proposal, took the broom and started sweeping the kitchen, wiping the pots and dishes and making coffee, all very fast and with good humor. The woman sat in the chair and stood laughing. She said that we were really crazy. After everything was done, we sat down to drink the coffee together and someone said: “Problem solved. What is the next one?” Strangeness, laughter and joy were surely the keynote of the encounter, as well as the certainty that, during those 15 minutes, she could actually rely on the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516.. As a free being, the clown acted with spontaneity and improvised the daily life itself.”

Daily transformations

The visited persons reported improvement in several indicators, after eight months of intervention: d.1 Routines: they acquired greater ability to exercise domestic activities, even with physical limitations. d.2 Loneliness: the previously reported loneliness was transformed into joy and confidence in themselves on a daily basis. There was change of heart; they did not feel lonely after the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. interventions. d.3 Leisure: leisure has expanded beyond religion; they were able to walk around in public spaces, such as parks and squares, and build new friendships at these sites. Old hobbies were resumed and new ones were developed, such as growing plants, playing accordion, listening to music and self-care, including the search for sensuality, body care, and customization of clothes. d.4 Family Dynamics: the family dynamics gained new contours; they did not feel alone anymore because they could talk better with family members, more clearly and objectively, they were able to talk about their feelings and nuisances without being criticized and with affection. They said they learned ways to express themselves with greater spontaneity, truth and simplicity. d.5 Self-Care: the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. were also able to stimulate the self-care in the caregivers as well as their pursuit for pleasure.

The clown insertion in the FHS enabled the person to recover his/her place in the world, his/her autonomy and self-esteem, to recognize of his/her own essence, his/her social being¹³13. Lazarte L. Sociología y terapia comunitária integrativa. Revista Uruguaya de Enfermería 2012; 7(1):67-76.. The home visits performed by the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. stimulated the release of historically constructed social roles and social conditions through creative solutions in which humor and laughter were always present. The clowns brought the power of the living work through the act¹⁴14. Franco TB, Merhy EE. Atenção domiciliar na saúde suplementar: dispositivo da reestruturação produtiva. Cien Saude Colet 2008; 13(5):1511-1520..

Discussion

The art of clownery was a resource able to make people think and make imaginative and intelligent associations about their own living conditions. Thus, it helped them being more resilient than vulnerable, using joy, humor and laughter as the main resources. The idea consisted of incorporating the clown and, with joy and humor, take him/her to the households in order to create spaces to deal with the everyday problems in an important human dimension, namely: the imaginative dimension.

The imagination is able to reveal secrets, revivify desires and to make the human reality clearer. Providing laughter to people at risk, vulnerable and struggling with difficulties means leading them to make imaginative and intelligent associations. As it was discussed in the literature, in order to provoke laughter in dramatic human situations, we have to distance ourselves from them and perform association of ideas. Therefore, using the intelligence requires us to momentarily anesthetize our hearts¹⁵15. Bergson H. O riso: ensaio sobre a significação da comicidade. São Paulo: Martins Fontes; 2001..

Being a clown requires an effort towards self-knowledge, self-acceptance and body language. The current study aimed to direct the art of clownery to the families and their aspirations. This practice is in line with the FHS and it expands the solvability of the care provided to people and to communities through close proximity. The “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. were able to insert themselves in the lives of the persons in a relationship in which constituting the bond was essential to effectively respond to the complex health needs of individuals and communities. These recent health care humanization and comprehensiveness proposals have become powerful and disseminated strategies used to creatively cope with the crisis and to develop alternatives to organize the health care practices in Brazil¹⁶16. Ayres JRCM. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde Soc 2004; 13(3):16-29.. Health promotion activities should be part of the local teams’ strategy. In addition, health promotion activities require the analysis of social and health reality, since they are expected to operate in the territory, to focus on family and community, and to approach psychosocial problems¹⁷17. Tesser CD, Garcia AV, Vendruscolo C, Argenta CE. Estratégia Saúde da Família e análise da realidade social: subsídios para políticas de promoção da saúde e educação permanente. Cien Saude Colet 2011; 16(11):4295-4306.. The home care takes into account the possibility of detecting the support needs and expanding the social support networks⁷7. Backes DS, Backes MTS, Erdmann AL, Büscher A, Marchiori MT, Koerich, MS. Significado da atuação da equipe da Estratégia de Saúde da Família em uma comunidade socialmente vulnerável. Cien Saude Colet 2012; 17(5):1151-1157.. It is not about investigating people’s lives in their intimacy, but talking to the families so they can be the authors of their own story. The clown insertion in the FHS through home visits was intense and the “clown doctors”⁵5. Pekelman R, Ferrugem D, Minuzzo FAO, Melz G. A arte de acolher através da visita da alegria. Rev APS 2009; 12(4):510-516. were able to free themselves to allow the encounter with the other¹⁸18. Sacchet POF. Da discussão: “clown ou palhaço” às permeabilidades do Clownear-palhaçar [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2009..

The clown in the household talks about real situations occurring with the person, in the family and in society. He uses possible and real resources to freely speak of what happens around him. Behind the nose, there is a human being who is inserted in society and perceives its contradictions, difficulties and joys, and acts in a spontaneous and challenging way. He contests himself, the collectivity, the life situations, and does the opposite of what a common human being would do. He is free to encounter the other. The clown seeks to dislodge things to the extreme; he breaks the rules, including those built by himself¹⁸18. Sacchet POF. Da discussão: “clown ou palhaço” às permeabilidades do Clownear-palhaçar [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2009.. He is not a model of social and cultural patterns, but he is able to manage new subjective constructions¹²12. Dorneles JL. Clown, o avesso de si: uma análise do clownesco na pós-modernidade [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2003., i.e., to naturally develop new ways of feeling, thinking, existing and communicating.

The clown visits in the current study have become a powerful care practice since they allowed establishing strong and free bonds between the clown and the families. The bonds were built due to the effective presence of the clowns in the house, due to their ability to respectfully and spontaneously act in any situation. The entire context was used as a theme for the intervention. The bond was formed as a care strategy and enabled freedom practices¹⁹19. Bernardes AG, Pelliccioli EC, Marques CF. Vínculo e práticas de cuidado: correlações entre políticas de saúde e formas de subjetivação. Cien Saude Colet 2013; 18(8):2339-2346..

The clown was able to engage in polemics and get in touch with the seriousness from the laughter, the lightness, and from his intense presence in the encounter with the other. Thus, he questioned accepted languages, and dehumanized daily lives automated by social injustice, violence and oppression. Laughter unmasked this everyday language, withdrew crystalized ideas⁸8. Matraca MVC, Wimmer G, Araujo-Jorge TC. Dialogia do riso: um novo conceito que introduz alegria para a promoção da saúde apoiando-se no diálogo, no riso, na alegria e na arte da palhaçaria. Cien Saude Colet 2011; 16(10):4127-4138. and, in an improvised and creative way, it exposed the power of the humanized encounter as a force capable of changing peoples’ life.

The clowns and the users understood the time relation as a tool they used to be strongly connected in a qualified manner. The 15-minute time generated care and attention to the encounter. The intensity was related to the language used by the clown and to the intervention time. Thus, it is possible to consider a social care technology established in the practice.

These home visits performed by the clowns assumed a localized dimension in peoples’ lives and in the complexities of family ties, since family members, friends, neighbors²⁰20. Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu) 2011; 15(37):589-599. and even animals were actors. The simple way the clown sees life was able to find new care logics in the complex relationships of the everyday life.

These new care logics comprise different types of knowledge able to transform the art of clownery into a living work through the act ¹⁴14. Franco TB, Merhy EE. Atenção domiciliar na saúde suplementar: dispositivo da reestruturação produtiva. Cien Saude Colet 2008; 13(5):1511-1520. and to provide health. Within the residential space, the clown’s living work through the act may be a team-built strategy to strengthen the relational flows between these professionals and the family members as well as several possibilities, including the symbolic level, of a broad space to fulfill their high degree of freedom. This innovative form of household teamwork enables the professionals to use light technologies and to connect themselves with their inventiveness in order to solve problems and to better interact with the knowledge of how to provide care to the family¹⁴14. Franco TB, Merhy EE. Atenção domiciliar na saúde suplementar: dispositivo da reestruturação produtiva. Cien Saude Colet 2008; 13(5):1511-1520..

References

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