Abstract

Introduction

For a long time, masks have been used in rites and cure procedures. In tribal rituals and in the origins of the western medicine, the art associated to objects that represent divinities or human archetypes are present as support in the treatment of illnesses. In the contemporaneity, the clown's mask has acquired a great importance, mainly starting from 1986 when Michael Christensen, one of the founders of Big Apple Circus (one of the most important circuses in the world) was invited to a presentation in New York's Babies and Children's Hospital. Him and his collegue, Jeff Gordon, made a parody of the medical procedures, that constituted the base for the foundation of Big Apple Circus Clown Care Unit, one which today has eighty clowns visiting about two hundred and twenty-five thousand children a year.

Many groups around the world follow the model of Big Apple Circus, through professional clowns' work, as the Doctors of Joy (Brazil), the Humour Foundation (Australia) and the Le Rire Médecin (France), among others. Parallel, an expressive number of volunteers' groups have formed, that, in spite of motivated by good will, many times lack methodology and knowledge about the performance of this persona within the hospital environment, and could cause a series of damages, from the embarrassment and rejection by the professionals, patients and companions to the possible increase of the risk of hospital infection. Therefore it is necessary to establish a theoretical and technical field that subsidizes the clowns' practices within the hospital, favoring the outreach of benefits. The objective of this revision is to collect the available data in the scientific literature regarding the interventions based on clowns in the hospital and, to contemplate how this work can be better conducted by professionals as well as volunteers.

Methods

A bibliographical research with the collection of scientific articles in English, Portuguese and Spanish published until May 19, 2015 was carried out. For the search of these articles, we used the following data bases for academic researches: MedLine (PubMed) and Virtual Library in Health (BVS).

In the search accomplished through the PubMed base, the descriptors employed were clown and hospital. Of this research, we obtained 43 results of which 17 were available for access in the University of São Paulo (USP) and were adequate for the theme proposed: a recognition of the adopted paradigms and the respective effects of the clowns' performances within hospitals.

In the research accomplished through BVS, we made two independent searches: the first with the descriptor “palhaço” and the second with the despcritor “clown” to include the different terminology used in Brazil to describe this figure that, in this work, interests us. In both searches filters were applied that selected the journals Lilacs (Latin-American System and of Caribbean of Information in Sciences of the Health), BDENF (Base of Data of Nursing) and IBECS (Index Bibliographical Spanish of Sciences of the Health). With the first descriptor, we found 14 articles and with the second, 22. Removing the duplicated articles and the ones not available for access in USP, we obtained 16 results.

We proceeded with the integral reading of the original articles and selected the main categories and subthemes to be developed as follows.

Table 1 with the 33 articles read and considered in this revision.

Physiologic context

According to the meta-analysis carried out by Lamers et al.²2. Lamers SM, Bolier L, Westerhof GJ, Smit F, Bohlmeijer ET. The impact of emotional well-being on long-term recovery and survival in physical illness: a meta-analysis. J Behav Med. 2012; 35(5):538-47., we can find, in the scientific literature, evidences of the existence of a positive correlation among the emotional, well-being, the recovery and the survival facing a physical illness. In this perspective, the clowns, in general, have as objective the ressignification of the hospital environment with resulting improvment in the emotional wellbeing as much of the patients as of companions and staff³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.

4. Bertini M, Isola E, Paolone G, Curcio G. Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med. 2011; 2011:879125.

5. Barkmann C, Siem AK, Wessolowski N, Schulte-Markwort M. Clowning as a supportive measure in paediatrics - a survey of clowns, parents and nursing staff. [Internet] BMC Pediatr. 2013; [aceso 2015 Set 14] 13:166. Disponível em: http://www.biomedcentral.com/1471-2431/13/166
http://www.biomedcentral.com/1471-2431/1...

6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.

7. Kingsnorth S, Blain S, McKeever P. Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evid Based Complement Alternat Med. 2011; 2011:732394.-⁸8. Linge L. Magical attachment: children in magical relations with hospital clowns. [Internet] Int J Qual Stud Health Well-being. 2012; 7:10.3402/qhw.v7i0.11862. Published online 2012 Feb 24. [citado 2015 Set 14] Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286793/pdf/QHW-7-11862.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... .

It is considered that as much the illness as the internment configure stress generating situations, fear and anxiety, context on which the clowns interventions are based ⁴4. Bertini M, Isola E, Paolone G, Curcio G. Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med. 2011; 2011:879125.,⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.,⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.

10. Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010; 20(10):937-43.

11. Viggiano MP, Giganti F, Rossi A, Di Feo D, Vagnoli L, Calcagno G, et al. Impact of psychological interventions on reducing anxiety, fear and the need for sedation in children undergoing magnetic resonance imaging. Pediatr Reports. 2015; 7(1):5682. doi:10.4081/pr.2015.5682

12. Dionigi A, Sangiorgi D, Flangini R. Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol. 2014; 19(3):369-80. PubMed PMID: 23362335.-¹³13. Messina M, Molinaro F, Meucci D, Angotti R, Giuntini L, Cerchia E, et al. Preoperative distraction in children: hand-held videogames vs clown therapy. Pediatr Med Chir. 2014; 36(5-6):98. PubMed PMID: 25669889..Therefore, we propose a short discussion on the physiology of stress for understanding the effect of obtaining better responses to the patients' and companions treatments, the ones who were in contact with the clowns⁴4. Bertini M, Isola E, Paolone G, Curcio G. Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med. 2011; 2011:879125.,⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.,¹⁴14. Kingsnorth S, Blain S, McKeever P. Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evid Based Complement Alternat Med. 2011; 2011:732394.,¹⁵15. Lancheros García EA, Tovar Valle JF, Rojas Bermúdez CA. Risa y salud: abordajes terapéuticos: [revisión]. [Internet] MedUNAB. 2011 [acesso 2015 Set 14]; 14(1). Disponível em: http://revistas.unab.edu.co/index.php?journal=medunab&page=article&op=view&path%5B%5D=1380&path%5B%5D=1352
http://revistas.unab.edu.co/index.php?jo... .

When an individual is submitted to a stressful event, cortisol and cathecolamine liberation occurs. They provoke the necessary alterations for the body to be capable to react appropriately to the situation responsible for the stress. On the other hand, they can unchain anxiety, appetite loss, increase of allergic reaction and aggravation of conditions as hypertension and diabetes⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.. Common signs of these reactions to stress are alterations of the pulse, breathing frequency and skin temperature, that in some studies are used as parameters for evaluation of emotional well-being ⁴4. Bertini M, Isola E, Paolone G, Curcio G. Clowns benefit children hospitalized for respiratory pathologies. Evid Based Complement Alternat Med. 2011; 2011:879125.,⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.,¹⁴14. Kingsnorth S, Blain S, McKeever P. Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evid Based Complement Alternat Med. 2011; 2011:732394.. Like this, interventions that aim to reduce the stress levels provoked by the illness and by the internment, for clinical treatment, surgical procedure, anaesthetic¹³13. Messina M, Molinaro F, Meucci D, Angotti R, Giuntini L, Cerchia E, et al. Preoperative distraction in children: hand-held videogames vs clown therapy. Pediatr Med Chir. 2014; 36(5-6):98. PubMed PMID: 25669889. or sedative¹⁶16. Weintraub Y, Rabinowicz N, Hanuka P, Rothschild M, Kotzki S, Uziel Y. Medical clowns facilitate nitrous oxide sedation during intra-articular corticosteroid injection for juvenile idiopathic arthritis. Isr Med Assoc J. 2014;16(12):771-3. PubMed PMID: 25630207., can contribute to avoid the onset of complications and associated pathologies, promoting even the patients response to the treatment ¹⁰10. Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010; 20(10):937-43.,¹²12. Dionigi A, Sangiorgi D, Flangini R. Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol. 2014; 19(3):369-80. PubMed PMID: 23362335..

In general, this mechanism is thought of as the main hypothesis for the patients' best response than they receive the clowns' visit, who act as reducers of the stress associated to the illness and to the internment. It is worthwhile to highlight that the structuring and evaluation of these projects were accomplished starting from depositions and subjective visions of the participants³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,⁵5. Barkmann C, Siem AK, Wessolowski N, Schulte-Markwort M. Clowning as a supportive measure in paediatrics - a survey of clowns, parents and nursing staff. [Internet] BMC Pediatr. 2013; [aceso 2015 Set 14] 13:166. Disponível em: http://www.biomedcentral.com/1471-2431/13/166
http://www.biomedcentral.com/1471-2431/1... ,⁸8. Linge L. Magical attachment: children in magical relations with hospital clowns. [Internet] Int J Qual Stud Health Well-being. 2012; 7:10.3402/qhw.v7i0.11862. Published online 2012 Feb 24. [citado 2015 Set 14] Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286793/pdf/QHW-7-11862.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... ,⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113., so there is still a lack of quantitative scientific evidences that confirm the physiologic effect behind of the benefits generated by the interventions.This fact allows researches to be accomplished in this sense.

The articles studied do not point out objectively which inherent aspects to the clown's performance are directly associated to reduction of the stress. Among the several possibilities, is considered that this answer is related to the humor³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.,¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31.. According to Freud¹⁸18. Freud S. Der humor almanach 1927 [Internet] [cited 2014 Nov 4]. Available from: http://www.freudonline.com.br/livros/volume-21/vol-xxi-4-o-humor-1927/
http://www.freudonline.com.br/livros/vol... , the pleasure mechanism that arises starting from the humor has origin in the deviation of the suffering, possibility that is done by the human mind through the jaking. This way, the suffering is diminished and becomes laughable,, at the same time as individual is elevated to a superiority status, as it is clear in the following passage: "the humor has something of liberating in its respect, but it also possesses any thing of greatness and elevation"¹⁸18. Freud S. Der humor almanach 1927 [Internet] [cited 2014 Nov 4]. Available from: http://www.freudonline.com.br/livros/volume-21/vol-xxi-4-o-humor-1927/
http://www.freudonline.com.br/livros/vol... . In other words, when elevating the individual and confront the possibility of suffering, "the humor it is not resigned, but rebellious"¹⁸18. Freud S. Der humor almanach 1927 [Internet] [cited 2014 Nov 4]. Available from: http://www.freudonline.com.br/livros/volume-21/vol-xxi-4-o-humor-1927/
http://www.freudonline.com.br/livros/vol... .

Artistic context

In different cultures around of the world we can find a comic figure based on the fool's logic, of the maladjusted, that can be associated to the clown¹⁹19. Espinosa BB, Gutiérrez TR. Lo esencial es invisible a los ojos: payasos que humanizan y promueven salud. Aletheia [Internet]. 2010 [acesso 2015 Set 14]; (31):4-15. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-03942010000100002&lng=pt
http://pepsic.bvsalud.org/scielo.php?scr... . However, the clown as we know today in the western cultures has its origin in the European circuses of the century XVIII, where traditionally perfomences of corporal abilities were presented in which the life risk was imminent. The audience of these circus shows was submitted, therefore, to situations capable to produce great tension. With the objective of breaking this tension, in the intervals of the acts, repeated performances and clowning were inserted.

The repeated performances are usually short and comic presentations that satirize the other numbers of the circus¹⁹19. Espinosa BB, Gutiérrez TR. Lo esencial es invisible a los ojos: payasos que humanizan y promueven salud. Aletheia [Internet]. 2010 [acesso 2015 Set 14]; (31):4-15. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-03942010000100002&lng=pt
http://pepsic.bvsalud.org/scielo.php?scr... . This way, the clown in the traditional circus is an individual who is ready to accomplish presentations equivalent to the one of the other circus artists, but it is physically unable to execute them. Like this, the relationship established between the clown and the public does not happen by recognition and equality, but by strangeness, executing like this one of the demands of the comicality and of the laughter, which is, the superiority condition of whom laughs over one or those that are object of the laughter"²⁰20. Bolognesi MF. Palhaços. São Paulo: Ed Unesp; 2003. (p. 105).

When inserted in the hospital context, in general, the clown persents him self as a doctor, following the tendency created by Michael Christensen in their first visits, in 1986²¹21. Doutores da alegria: música e pirueta nas enfermarias infantis. Dialogo Med. 1997; 12(1):10-2.. With this approach, the clown is disposed to accomplish the medical activities in the same way that traditionally was disposed to carry out the different numbers of the circus. Once again he shows himself maladjusted, subverts the pre-established logic and, the comic situation is created from there on.

To establish himself in the position of the maladjusted it is fundamental for a clown to accept failure and manifestation of their emotions in a sincere and true way²²22. Camuñas Palacín A. El teatro clown en el entorno sanitario. Index Enferm. 2009; 18(1):63-5.. However, this failure acts on the clown in an unexpected way. In an unusual logic, He is not unmotivated or strays of his intention of accomplishing a great show or, in the hospital clown's case, of being a great doctor, of promoting a great encounter. This attitude and the feeling associated to the mistake reinforce the clown's comic power and they place the patient in an empowered and trustful position³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96..

As we said previously, the clown of the traditional circus based great part of his performances on the satire of the circus show. For this reason, it was unnecessary that he had a great number of abilities as riding, juggling, trapeze and acrobatics²⁰20. Bolognesi MF. Palhaços. São Paulo: Ed Unesp; 2003.. When migrating to the hospital environment, the classic itineraries of the circus give place to a wider surprise, potentiating this capacity of traditional ad-libber. The hospital clown integrates different abilities as interpretation, music, dances, recreation techniques, among others⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.,¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31.. And, with this, he becomes "a skilled ad-libber with the capacity to answer to the authentic and immediate needs evoked by any patient in any situation"¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31..

Due to his own characteristics, the clown is a transformer of environments and the hospital environment is no exception. When the mask of the clown enters the scene it brings with itself a world in that the logic can be subverted and, starting from the problem, the possibility of amusement emerges, in what the mistake becomes comic and the maladjustment is common. The clown's mask, therefore, has the power to generate the pleasure of the humor. He is foolish and allows his speaker to be uplifted and enjoy the laughable potential of being unresigned in relation to the hospital environment, independent who this speaker is, of his status or condition²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... .

The clowns in the hospital resignify structures, functions, people and objects so that they transform the whole hospital environment, benefitting not only the patients, but all those involved in this condition momentarily or definitively subverted: patient, companion and even the own team of the healthcare³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.,²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles...

24. Gadamer HG. Verdade e método: traços fundamentais de uma hermenêutica filosófica. Petrópolis: Vozes; 2006.-²⁵25. Finlay F, Baverstock A, Lenton S. Therapeutic clowning in paediatric practice. Clin Child Psychol Psychiatry. 2013; 19(4):596-605.. This breakdown of the traditional environment of the hospital and its ressignification are the base of most of the projects that act with the clown's language in the hospital, and they bring with themselves the humor besides the laughter through the creation of a "world between the real and the imaginary" that allows showing imagination and creativity ²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... .

As per the contemporary philosopher Gadamer²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... , the artistic existence doesn't become exhausted in a moment of pleasure capable to provoke the escape of the lived reality. The art is not detached, but layered upon the lived reality, promoting the experimentation of a cascade of memories, sensations and feelings that, mediated by the cognitive elaboration, they allow another symbolic construction, a renewed interpretation of life.

Target of the interventions

Who benefits from the clown's visit?

Some of the interventions reported in the literature⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.,²⁶26. Mussa C, Malerbi FEK. O efeito do palhaço no estado emocional e nas queixas de dor de adultos hospitalizados. Psicol Rev. 2012; 21(1):77-97. are based on this wide reach of the clown and they include activities that integrate not only the patients of the ward, but nursing teams, doctors and companions. The visits promote: joy⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.,²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... ,²⁷27. Aquino RG, Bortolucci RZ, Marta IER. Clowns doctors: the child talk… [Internet] Online Braz J Nurs. 2004 [acesso 2015 set 14]; 3(2). Available from: www.uff.br/nepae/objn302aquinoetal.htm
www.uff.br/nepae/objn302aquinoetal.htm...

28. Araújo TCCF, Guimarães TB. Interações entre voluntários e usuários em onco-hematologia pediátrica: um estudo sobre os “palhaços-doutores”. Estud Pesqui Psicol. 2009; 9(3):632-47.

29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93.-³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6.; release of tension²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... ,²⁴24. Gadamer HG. Verdade e método: traços fundamentais de uma hermenêutica filosófica. Petrópolis: Vozes; 2006.,²⁶26. Mussa C, Malerbi FEK. O efeito do palhaço no estado emocional e nas queixas de dor de adultos hospitalizados. Psicol Rev. 2012; 21(1):77-97.; improvement of the hospital environment ²³23. Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts [Internet]. Int J Qual Stud Health Well-being. 2013 [acesso 2015 Set 14]; 8:10.3402/qhw.v8i0.18907. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538281/pdf/QHW-8-18907.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles... ,²⁸28. Araújo TCCF, Guimarães TB. Interações entre voluntários e usuários em onco-hematologia pediátrica: um estudo sobre os “palhaços-doutores”. Estud Pesqui Psicol. 2009; 9(3):632-47.

29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93.-³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6.; decrease of the patients' stress and of companions, even when stressful extra-illness factors as financial concerns or family are concerned²⁶26. Mussa C, Malerbi FEK. O efeito do palhaço no estado emocional e nas queixas de dor de adultos hospitalizados. Psicol Rev. 2012; 21(1):77-97.; aid in recovery¹⁰10. Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010; 20(10):937-43.,¹²12. Dionigi A, Sangiorgi D, Flangini R. Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol. 2014; 19(3):369-80. PubMed PMID: 23362335.,²⁸28. Araújo TCCF, Guimarães TB. Interações entre voluntários e usuários em onco-hematologia pediátrica: um estudo sobre os “palhaços-doutores”. Estud Pesqui Psicol. 2009; 9(3):632-47.,²⁹29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93.,³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6.; peacefulness to the mothers in the pediatric patients' case; improvement of the professionals' and students relationship with the pacients³¹31. Mota GM, Mota DMC, Machado MMT, Arrais RH, Oliveira CPV, Salgado MS, et al. A percepção dos estudantes de graduação sobre a atuação do “Doutor Palhaço” em um Hospital Universitário. Rev Bras Promoç Saude. 2012; 25 Supl 2:25-32., ³²32. Rosevics L, Aguiar DA, Borges CR, Hasegawa Filho R, Yamashita TS, Manchak AC, et al. ProCura - a arte da vida: um projeto pela humanização na saúde. Rev Bras Educ Med. 2014; 38(4):486-92. and even of the patients with one another²⁶26. Mussa C, Malerbi FEK. O efeito do palhaço no estado emocional e nas queixas de dor de adultos hospitalizados. Psicol Rev. 2012; 21(1):77-97..

In the interventions focused on the companions, we can observe a phenomenon of reflective reduction of stress and anxiety of the pacient⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601.. In other words, a companion with high anxiety levels and stress can unchain these conditions in the patient, so that when the clown acts addressed to the companion, it also reaches, consequently, the patient. This same phenomenon can occur regarding the health team,who when satisfied in the work environment, tends to improve the wellbeing of those whom they attend.

Besides, there are also benefits for the individuals who act as clowns, whether profissional artists ³³33. Masetti M. Doutores da ética da alegria. Interface (Botucatu). 2005; 9(17):453-8. or voluntaries²⁶26. Mussa C, Malerbi FEK. O efeito do palhaço no estado emocional e nas queixas de dor de adultos hospitalizados. Psicol Rev. 2012; 21(1):77-97.,²⁸28. Araújo TCCF, Guimarães TB. Interações entre voluntários e usuários em onco-hematologia pediátrica: um estudo sobre os “palhaços-doutores”. Estud Pesqui Psicol. 2009; 9(3):632-47.,³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6.

31. Mota GM, Mota DMC, Machado MMT, Arrais RH, Oliveira CPV, Salgado MS, et al. A percepção dos estudantes de graduação sobre a atuação do “Doutor Palhaço” em um Hospital Universitário. Rev Bras Promoç Saude. 2012; 25 Supl 2:25-32.-³²32. Rosevics L, Aguiar DA, Borges CR, Hasegawa Filho R, Yamashita TS, Manchak AC, et al. ProCura - a arte da vida: um projeto pela humanização na saúde. Rev Bras Educ Med. 2014; 38(4):486-92.: the use of the mask allows the establishment of unique communicative abilities³²32. Rosevics L, Aguiar DA, Borges CR, Hasegawa Filho R, Yamashita TS, Manchak AC, et al. ProCura - a arte da vida: um projeto pela humanização na saúde. Rev Bras Educ Med. 2014; 38(4):486-92., that contribute to the establishment of an integral vision of the individuals within the health service and, sometimes, they serve as relationship model for the team that works in this service³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113..

Although there is no age group predilection for the stress inherent to the hospital enviroment, the clowns' work has been associated mainly to children¹⁰10. Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010; 20(10):937-43.,¹²12. Dionigi A, Sangiorgi D, Flangini R. Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. J Health Psychol. 2014; 19(3):369-80. PubMed PMID: 23362335.,¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31.,²⁷27. Aquino RG, Bortolucci RZ, Marta IER. Clowns doctors: the child talk… [Internet] Online Braz J Nurs. 2004 [acesso 2015 set 14]; 3(2). Available from: www.uff.br/nepae/objn302aquinoetal.htm
www.uff.br/nepae/objn302aquinoetal.htm...

28. Araújo TCCF, Guimarães TB. Interações entre voluntários e usuários em onco-hematologia pediátrica: um estudo sobre os “palhaços-doutores”. Estud Pesqui Psicol. 2009; 9(3):632-47.-²⁹29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93.,³⁴34. Armfield NR, Bradford N, White MM, Spitzer P, Smith AC. Humour sans frontieres: the feasibility of providing clown care at a distance. Telemed J E Health. 2011; 17(4):316-8., reaching only in a secondary way the adults, companions or professionals who work in the hospital³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,⁹9. Sánchez Naranjo JC, Gutiérrez Segura JC, Santacruz Ibarra JJ, Romero Leguizamón CR, Ospina Ríos JP. El humor como estrategia terapéutica en niños hospitalizados en unidades pediátricas en Pereira (Colombia): reporte de una experiencia. Rev Colomb Psiquiatr. 2009; 38(1):99-113.,²⁵25. Finlay F, Baverstock A, Lenton S. Therapeutic clowning in paediatric practice. Clin Child Psychol Psychiatry. 2013; 19(4):596-605.,³⁵35. Wolyniez I, Rimon A, Scolnik D, Gruber A, Tavor O, Haviv E, et al. The effect of a medical clown on pain during intravenous access in the pediatric emergency department: a randomized prospective pilot study. Clin Pediatr (Phila). 2013; 52(12):1168-72..

In a study carried out by Agostini et al.⁶6. Agostini F, Monti F, Neri E, Dellabartola S, de Pascalis L, Bozicevic L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014; 19(5):587-601., there are evidences that influence exercised by the clowns' action is sensitive to the age group. In other words, patient of different ages respond in different ways. This study further suggests that younger children's response, in some cases, is smaller due to the immaturity of their cognitive development.

There are moments and situations in that the laughter doesn't change anything, but the humor is essential for the survival in these situations, so much for the patients as for the relatives and profissionais²²22. Camuñas Palacín A. El teatro clown en el entorno sanitario. Index Enferm. 2009; 18(1):63-5.. The existence of an illnes is a stressful phenomenon by itself and worse in situations of hospital internment, when the individual can be reduced to the condition of patient.

Considering the stress inherent to illness and the internment the potential of the clown's action, there are no evidences that justify the limitation of the interventions to the pediatric age group. Therefore these interventions can be directed to aimed at children, youths, adults³⁴34. Armfield NR, Bradford N, White MM, Spitzer P, Smith AC. Humour sans frontieres: the feasibility of providing clown care at a distance. Telemed J E Health. 2011; 17(4):316-8. and seniors, bearing in mind specific needs and the benefits that the humor can bring to all²²22. Camuñas Palacín A. El teatro clown en el entorno sanitario. Index Enferm. 2009; 18(1):63-5..

The clowns' relationship with the health professionals team

Health professionals teams acting in hospitals are frequently submitted to long and stressful work days, besides, they have an intense contact with illnes, suffering, anguishes and death, taking on heavy responsibilities. Its evidenced from the reports, that the possibility to participate in the clowns' artistic performance in the hospital environment provides happiness, casualness and relief of the stress not only to the patients, but also to the members of the health team. The professionals can establish a durable relationship with the clowns that a lot of times are seen as a relationship model with the patients³3. Ford K, Courtney-Pratt H, Tesch L, Johnson C. More than just clowns - clown doctor rounds and their impact for children, families and staff. J Child Health Care. 2013; 18(3):286-96.,³²32. Rosevics L, Aguiar DA, Borges CR, Hasegawa Filho R, Yamashita TS, Manchak AC, et al. ProCura - a arte da vida: um projeto pela humanização na saúde. Rev Bras Educ Med. 2014; 38(4):486-92.. This relationship that includes clowns, patient, companions and health professionals contributes to changes in the conducts adopted by the care team³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6. and like this it potentiates the effects of the clowns' performance beyond the moment of the visits.

The clowns' performance also provides for professionals the recognition that certain reactions by the children, such as, apathy, exhaustion, depression and resistance - usually attributed to the illnes - can be linked to the circumstances of the internment and of the relationships within the hospital itself.

It is observed, still, that the relationship between the clowns and the nursing team propitiates motivation and an invitation for intervention²⁹29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93..

Formation and action

Looking and listening as tools in the construction of a relationship

We mentioned so far that the clown possesses very peculiar abilities of communication that allow him to establish intersubjetive relationships with the patients, mediated by sensorial and affectionate experiences that, starting from the cognitive elaboration, propitiate a renewed interpretation of the reality.

This relationship is built starting from the language. The clown's figure constitutes the expression of the artistic language, because it is through the mask that encounters are estabilished, that breakdown the logic of the relationships in hospital environment, allowing other interpretative possibilities of the surrounding.

This artistic dimension stands out even more when we observe that the clown's comicality resides exactly in his extremely human character. The clown lives the sensations to extreme; when he laughs, cries, has fun and relates to, the clown makes its always in a very intense way. It is for this that in his own essence and, particularly, when he migrates to the hospital, the clown - through the artistic expression - contemplates what there is of human in each individual's subjectivity.

When inserted in the hospital environment, the person becomes patient (one that receives the action, the passive) and, frequently, the illness in itself. His interactions start to be restricted to the medical team and nursing, in some cases also to his companion. The relationships start to be built with base in paradigms and biomedical procedures that guide the professionals' conduct, creating an encounter in which some aspects of the subjectivity are occult. When receiving the clown, the patient does not see him as member of the medical team¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31. and this already allows the configuration of a new encounter type, in which elements of the subjectivity latent in the interned individual usually emerge.

In an improviser condition, starting from the tools given by his speaker, the clown should have a very sharpened perception of the other³³33. Masetti M. Doutores da ética da alegria. Interface (Botucatu). 2005; 9(17):453-8.. In other words, the base of the formation and of a hospital clown's action should be this ability to notice and to act with view to the establishment of a relationship that makes possible the appearance of the game and of the intersubjetivity. Starting from this interaction, aspects of the individuality emerge as much of the clown as of his speaker and, by the altered logic of the art of clowning, the intersubjetivity evades that of the daily hospital routine. This way, in contact with the clown, the patient adopts another role.

For this game to established itself in an appropriate way, it is fundamental that the clown be capable to recognize the ephemeral character of the intersubjetivity. Instead of looking for the establishment of the dialogue, flow with the dialogue established starting from the first instant of the encounter, be it verbal or no, to conduct it and let himself be conducted by it. This ability for the dialogue will be established, therefore, starting from looking and listening whole and incessant towards the other. In other words, looking and listening to the speaker, the clown can adequately build with him a relationship that alters as much one as the other and allows that both are affected by the presence of the otherness. This relationship with the otherness then can lead or not to the laughter and its simple establishment breaks the logic of the hospital relationships.

The clown is an multidisciplinary artist

As we said, since his performance in the traditional circus, the clown is characterized by his multiple abilities. With his task of satirizing the other circus numbers, he is frequently the one that knows more the abilities presented in the circus shows. Besides, to establish a close relationship with the audience, the clown needs to have a great improvisation ability to play with the information that come from of the spectators during their presentations.

When inserted in the hospital environment, the clown takes with himself multiplicity abilities and becomes, then, an ad-libber with a great supply of resources that can be evoked when necessary, starting from situations brought by the patients with whom they are working. Any resource that the clown possesses can be useful at a given moment when subsidizing the accomplishment of this work. The gags – short sentences, jokes or gestures that do not need a previous understanding to be funny - besides toys for the accomplishment of the scenic game, juggling techniques, magics, music played live and balloon sculpture³³33. Masetti M. Doutores da ética da alegria. Interface (Botucatu). 2005; 9(17):453-8. are the more commom resources²⁷27. Aquino RG, Bortolucci RZ, Marta IER. Clowns doctors: the child talk… [Internet] Online Braz J Nurs. 2004 [acesso 2015 set 14]; 3(2). Available from: www.uff.br/nepae/objn302aquinoetal.htm
www.uff.br/nepae/objn302aquinoetal.htm... . In some cases, the necessary training for the acquisition of the abilities used in the interventions can take up to three years³⁶36. Koller D, Gryski C. The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. Evid Based Complement Alternat Med. 2008; 5(1):17-25..

A work of Lima et al.²⁹29. Lima RAG, Azevedo EF, Nascimento LC, Rocha SMM. A arte do teatro Clown no cuidado às crianças hospitalizadas. Rev Esc Enferm USP. 2009; 43(1):186-93., shows that music accompanied by instruments, gestures and representations stimulate the patients to move. The clown, as ad-libber artist, is capable to count histories according to every specific moment. The use of the fictional and symbolic language can establish a form of appropriate communication to some situations in which logical and rational argument can not be the best approach¹⁷17. Raviv A. Humor in the “Twilight Zone”: my work as a medical clown with patients with dementia. J Holist Nurs. 2013 4; 32(3):226-31..

The continuity as key for integrality

As explained, one of the main points identified as root of the improvements observed in the patients that were in contact with the clowns is the ressignification of the hospital environment. This phenomenon unleashed by the clowning interactions happens in a period of larger time than proper time of the encounter itself, in other words, the patients antecipate the clowns' visits before the arrive and they carry within themselves memories after the departure.

Therefore, the patients expectations for the clowns' return, can also be appraised as positive attitudes in the internment³⁰30. Oliveira RR, Oliveira ICS. Os Doutores da Alegria na unidade de internação pediátrica: experiências de equipe de enfermagem. Esc Anna Nery Rev Enferm. 2008; 12(2):230-6. process as they collaborate for the hospital to earn a new meaning. For Masetti³⁷, antecipating the clowns' visits, the patients would be formulating an objective, and patient that maintain a life objective present better indices for their recovery.

In this sense, the telemedicine can contribute with the continuity of the clowns' visits when the distance or the demand for visits becomes a difficulty in the process. Although it sounds impersonal, a study accomplished with 92 children in Australia³⁴34. Armfield NR, Bradford N, White MM, Spitzer P, Smith AC. Humour sans frontieres: the feasibility of providing clown care at a distance. Telemed J E Health. 2011; 17(4):316-8., revealed the children's positive feedback when received virtual visits. According to their parents, who also benefitted by the encounters, these are the most awaited moments of the week for the children.

The continuity of the actions, with some periodicity, can then be considered as one of the keys for the success of the clowns visits in the hospitals. After all, besides stimulating anticipation factors and associated memory, the continuity promotes closer relationships, allowing potent elements of intersubjectivity to consolidate and the empowerment becomes more intense and clearer. Together, these factors can contribute to the best recovery of the hospitalized patient's health.

Conclusion

Generally, the visits accomplished by clowns, professional artists or voluntary , have showing positive results so much in the quality of life of the interned patients, as in their response to treatments, in spite of the lack of quantitative evidences that allows to check this improvement, what opens space for future investigations.

The factors that explain this association are not still fully clear, but we know that the clown's performance is extremely flexible and occurs mainly through the establishment of a relationship that reinforces the human character so much of the patient who receives the visit, as of the clown himself, of the patients' companions and of the health team.

The clown, with his many artistic abilities and flexibility, when confronted with complex, dense or unusual situation, is capable to establish another interaction quality, in which human aspects, latent during the internment, are evidenced. The clowning art legitimates the configuration of a game, placed upon the hospital, reality in which the clown - starting from the reactions noticed in the other - suffers too much, laughs too much, is emotionally involved too much and moves quickly among several emotions, but above all has fun and mobilizes in the other elements as humor, fright and enchantment, that take him to rebuild simbolically the moment lived.

From this reflection, we observed that the clown that acts in hospital transforms the artist, the human's expression. He should be capable to look the other in depth, to overcome the stigma of the patient in situation of hospital internment, to use the resources that eventually can have, whether based on the humor or not, to establish intersubjetive interactions potent in generating health.

They are many horizons open to the investigation on the sense and impacts of the clown's activities for the patients and others involved, looking for answers in the physiopathology, the neuroscience, in immunological, endocrine,processes etc. However, for the above exposed, it seems clear also that it is fundamental to give voice the other fields of knowledge, such as the philosophy, anthropology and the aesthetics, that help us especially to find the questions that are worthwhile to ask to understand the wealth and depth of this human experience.

Acknowledgment

We thank Prof. José Ricardo Carvalho Mesquita Ayres for the revision and suggestions in the final revision of this article.

References

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