Laughter is the best therapy

The Shaare Zedek Medical Center in Jerusalem was smiling and laughing as a colorful group of clowns, led by "Nurse Nice" (aka Hilary Chaplain), a medical clown from New York, walked through the corridors of the Pediatric Ward and entertained sick children in the dialysis room. With her visit supported by the U.S. Embassy, Tel Aviv, Hilary gave several workshops to Israeli medical clowns and worked with the "Dream Doctor," the largest medical clowns' organization in the country, to apply new methods taught at the workshop. Ambassador Daniel Shapiro was the guest of honor at this special event and took an active role by talking to the children and dancing with the clowns. As one mother put it after seeing a real smile on her sick daughter's face: "It's about time she started laughing after such a long period of tears ..."

The Dream Doctors Project

There are special clowns you won’t find in the circus, or in the theater, or at children’s birthday parties, but instead in children’s hospitals, standing next to the doctor or nurse, trying to make patients laugh.

Dream Doctors in Israel is building a nationwide professional community of medical clowns who learn a combination of nursing and comedy skills to make hospital experience less traumatic and more pleasant for children.

The project started 10 years ago, with only three clowns in one hospital. Today Dream Doctors has 72 professional clowns active in various pediatric wards and clinics at 20 hospitals across the country.

While hospitals around the world invite clowns as visiting entertainers, at Dream Doctors the clowns are a full-time part of the medical staff. This project turns “clown therapy” into a standardized, research-backed healthcare profession. In this model, the clown therapist is not an outsider but a member of staff, with regular hours and responsibilities.

Part of the medical staff

Daniel Shriqui, director of the Dream Doctors Project, tells NoCamels: “In other places clowns come into hospitals in the afternoon, after rounds are over. Here, we work integrally together during rounds. I don’t see the medical clowns differently than any other part of the team. It’s not entertainment, it’s not just a performance; it’s therapy.”

But what does medical clowning have to offer? Shriqui explains that “medical clowning is about taking a reality that can be horrible, and putting it in another way, so the child will experience it from another place.” He adds that “if you want to understand a child, you have to go inside his world and play his game. The best way to work with children is with the imagination of their world. This way you empower them. This is what we do. And if the child is more positive, the whole atmosphere is better.”

According to Shriqui, “there are many children that come back to visit the clown. There are children who won’t go through the procedure without the clown. Once the doctor starts with a clown, he won’t finish it without one.”

The criteria to become a medical clown are demanding and Dream Doctors requires academic training. “In our organization in Israel, we try to pick mature people with families, who have experience in the theater arts and a rich world from which they can relate to the children and they have to go through a difficult training,” says Karin Schneid, program coordinator for the Magi Foundation that funds Dream Doctors.

“We also encourage them to get a degree from Haifa University, where we have a one-of-a-kind accredited BA program in clown therapy. We are also planning a master’s program. But mostly, you have to have a great heart.”

Clowning therapy requires therapeutic, medical, artistic, psychological and nursing skills. Shriqui mentions that “the clown makes a show where the hero is the patient.” As a Dream Doctor clown put it: “Laughter and pain, and happiness and sadness are all mixed up in our work.”

Pain relief, stress reduction

Research on medical clowning was conducted in Israel and results suggest that putting trained clowns on the medical team leads to measurable benefits in pain relief, stress reduction and stronger immunity. “Even before research was conducted you could tell it was successful because of the growing demand from children, parents and doctors to bring in clowns,” says Shriqui.

Dr. Amos Etzioni, director at one of the participating hospitals, adds: “I have no doubts that since Dream Doctors came to us four years ago, we have seen incredible changes in everything that is happening in the hospital.”

To date, only ten Israeli hospitals are not employing Dream Doctors and the waiting list is growing larger from clinics in demand of clowns.

Nearly one hundred thousand patients, mainly children, are annually exposed to medical clowns in Israel.

Dream Doctors is now planning to turn to elderly patients, particularly those with Alzheimer’s disease and Dementia.

Bridging the gap

The success of this paramedical model is also apparent in the growing global interest, especially from the United States, Canada and Australia. In an international congress that took place in Jerusalem last October, over 250 representatives from 20 countries came to inquire about the medical clowning approach.

In the meantime, the Dream Doctors project is also reaching out to third-world countries. In January 2010, they contributed to the humanitarian mission to hospitals and orphanages in Haiti following the earthquake.

Additionally, Dream Doctors says they are a tool to bridge the gap between different cultures in Israel. Hospitals in in the country are multicultural meeting grounds for immigrants from the former Soviet Union and Ethiopia, ultra-Orthodox and secular Jews, Bedouin, Druse and Israeli Arabs.

“Clowns facilitate interactions across religious, ethnic and national lines. Their expressive abilities enable them to bridge between opposites, elicit smiles and inspire trust in the medical team and the treatment process,” says Shriqui.

When a clown is better than aspirin; Israel leads the way in professionalizing the field of medical clowning and providing scientific evidence for its effectiveness.

Photo courtesy of Shaare Zedek Medical Center

“Dr. Sababa” clowning with kids at Shaare Zedek Medical Center in Jerusalem.

Groucho Marx once said: "A clown is like an aspirin, only it works twice as fast."

Can that notion be proven scientifically? The question was among those pondered at an October conference in Israel that drew participants from many countries.

Coinciding with the 10th anniversary of Israel's internationally renowned Dream Doctors therapeutic clowning program, the congress gave visitors a chance to watch clowns in action at Jerusalem hospitals and learn about efforts to promote medical clowning as a standardized, research-backed healthcare discipline.

Israel leads the world in this regard, says Michael Christensen, founder of New York's Big Apple Circus and its Clown Care Unit. He was among presenters at the conference, where 100 Israelis met 100 counterparts from abroad.

"I am totally and utterly inspired by the way Dream Doctors have integrated themselves into the medical profession in Israel," says Christensen. He trained theater students at Tel Aviv University to be medical clowns at Schneider Children's Hospital in Tel Aviv 22 years ago.

Photo courtesy of Shaare Zedek Medical Center

“Bishko” entertaining at Shaare Zedek, the site of several studies showing the effectiveness of clown therapy.

Today, Israel is the only country that offers a bachelor's degree in clown therapy as a paramedical profession, at the University of Haifa's Graduate School of Creative Arts Therapies. A master's program is also planned.

"In the States, our clowns are called upon from time to time to assist in various [medical] procedures, but nothing compared to the depth, consistency and wonderful partnership that I see in Israeli hospitals," Christenson tells ISRAEL21c.

Dream Doctors founder and chairman Yaacov Shriqui said that 90 Dream Doctors are now working in 22 Israeli healthcare facilities, mainly with children.

"We visit 176,000 children per year, spending an average of 12 minutes per child," said Shriqui, speaking to an audience that included North Americans, Australians, Portuguese, Danes, Brazilians, Palestinians, Scots, Germans, Dutch, Swiss, Peruvians, French and Russians, among others.

Less stress = less pain medication

Presenters described how medical clowns make a qualitative difference in their hospitals.

Photo courtesy of Emek Medical Center

Dr. Herzyl Gavrieli, left, head of pediatric oncology, and “Professor Sancho” team up to do serious funny work at Emek Medical Center.

Dr. Yaacov Gozal, associate professor of anesthesiology at Jerusalem's Shaare Zedek Medical Center, launched a study to see if professional clowns could calm children before outpatient surgical procedures as effectively as bitter-tasting oral sedative syrup. "With less stress, children need less pain medication and can be discharged sooner," he said.

Gozal's staff divided the 40 subjects -- healthy Israeli kids ages two to 11 -- into two groups. Children in the first group each interacted with a Dream Doctor for 15 minutes prior to being anesthetized, while the second group got the sedative. They found that the children's levels of blood cortisol (a stress-induced hormone) just before surgery were equal in both groups, and that parents felt greater satisfaction with the experience when their child had received clown therapy.

At the same medical center, Dream Doctors have started aiding young cerebral palsy victims during painful botox treatments to relax spastic muscles. Dr. Hilla Ben Pazi said this is sometimes done under general anesthesia because the children are so distressed.

One very anxious eight-year-old girl was about to be treated when the anesthetist was called away for an emergency. With the mother's consent, Ben Pazi substituted a staff clown for anesthesia. "The child received five recurrent injections, and by the fifth she not only did not cry but even laughed throughout the procedure," Ben Pazi reported. "This gave us a big push toward research."

There are many studies on how to alleviate and manage pain during needle procedures in children, she added, but none looked at clown care. Her study, done in conjunction with medical clown Avraham Cohen, showed that although kids didn't believe they'd experience less pain because of the clown's carefully orchestrated antics, most were surprised to find it helped.

Photo courtesy of Emek Medical Center

“Professor Sancho” with kids at Emek Medical Center in Afula.

"In the control group, all the kids said they felt severe pain, but only less than a third with clown care said they had severe pain. That's a big difference," she pointed out.

At Beersheva's Soroka Medical Center, six doctors and 17 nurses did a six-month study examining the impact of medical clowning on anxiety levels of hospitalized children. "The clown's work is most critical when no family is around and before invasive procedures," Pediatric Hematology-Oncology Head Nurse Liat Maimon reported.

Soroka, which serves a large Bedouin and immigrant population, is also interested in studying how therapeutic clowns lessen stress for caregivers, parents and siblings of patients. "Humor is an ancient secret weapon to distract patients from pain, helps remove barriers and lessen anxiety, and empowers children to deal with pain and fears," Maimon said.

Clowning during intimate procedures

Dr. Nessia Lang, an ob/gyn at Poriya Medical Center in Tiberias, reported that clown therapy alleviates feelings of pain and fear during pelvic examinations of children who've been sexually abused.

"The medical clown has a crucial role in allowing for a thorough exam without retraumatizing the patient," she said. Kids who've been molested have trouble trusting adults, especially adults asking them to spread their legs.

A clown called Shoshi described how she helps the kids feel empowered, such as "arming" them with a syringe of water to squirt or a whoopee cushion to activate in the presence of the physician. She may engage little girls in funny hairstyling competitions to redirect their attention to the upper part of their bodies from lower part where the doctor is working.

"Sometimes in the hardest cases the clown allows us not to use anesthesia in order to do the exam," said Lang. "And children accompanied by the clown show fewer post-traumatic stress symptoms than children without the clown."

Dr. Shevach Friedler, head of Assaf Harofeh Medical Center's Infertility and IVF Unit, ran a study involving more than 200 women lying prone to aid implantation after embryos were introduced into their wombs.

"They are full of anxiety after this procedure and have nothing to take their minds off it," said Friedler, who studied mime in Paris.

He and Dream Doctors devised a 15-minute routine specifically for these patients, and found that pregnancy occurred much more often in women humored by the clowns. The results were published last January in the medical journal Fertility and Sterility.

"We recommend further investigation in our field and in other fields of medicine," said Friedler. "We already know that laughter stabilizes blood pressure, facilitates digestion, enhances the immune system, improves circulation, and may produce the release of neuropeptides called beta-endorphins, which are pain reducers."

Dr. Yaron Lang, head of pediatrics at Emek Medical Center in Afula, headed a study involving 142 babies and children undergoing radionuclide scanning for urinary tract infections, a procedure where the child must lie perfectly still.

Over 14 months, only five percent of the kids undergoing this scan with the help of a clown needed sedation, as opposed to 100% under control conditions. "And some of those 5% should have been excluded because they had mental retardation or other conditions precluding cooperation," he added.

"Dream Doctors are an integral part of our medical staff, and we're always looking for more ways to integrate them," said Lang.

Clowning for worldwide recognition

Shriqui said many countries, including 14 African nations, are eager to adopt Dream Doctors' methodologies. "Our focus for the next 10 years is getting official recognition so we can bring happiness to as many children as possible in the world," he said.

Dream Doctors, which has been supported by the Magi Foundation since 2004, is working with the Israel Ministry of Health to build a legal status for the profession and push for worldwide standards.

"Right now, hospitals can just hand out red noses and say ‘go do it.' Of course we're not happy with that. But we have to get a thick file of research to achieve official status," Shriqui said.

Israel is showing the way in both research and practice.

"I find it fascinating that Israel has succeeded in legitimizing medical clowning as a profession while America has failed to do that," says Amy Korenvaes. She and her husband, Harlan, run a foundation that funds the fledgling Funnyatrics Clown Program at Children's Medical Center in Dallas, Texas.

"I am hoping to take a lesson home from the model the Israelis created. We have to convince doctors that [clown therapy] is time efficient, financially efficient and healing."

"We haven't taken the leap to evidence-based medicine that they have here," agrees Funnyatrics team leader Tiffany Riley. "Now we can go back and say, ‘Look at how far ahead this country is.' In this field, we have some things to learn."

Shaare Zedek Hosts Delegation to International Conference on Medical Clowning

This week, Jerusalem’s Shaare Zedek Medical Center hosted a delegation attending the International Conference on Medical Clowning.  The three day conference being held in Jerusalem attracted over 250 participants from around the world.  Largely recognized as an international leader in the field of medical clowning, Israeli physicians are increasingly acknowledging that clowns offer a direct contribution towards enhancing the prognosis of a patient.  In recent years, several scientific studies have been published on the topic, leading to a quick increase in the number of clowns seen in hospital wards.
Shaare Zedek’s Director General, Professor Jonathan Halevy saluted the conference which was being held in conjuction with the tenth anniversary of the founding of the Dream Doctors organization, which helps support much of the medical clowning activity around Israel. “I believe we can take great pride in our medical clowning program,” Professor Halevy said. “Our mission as a medical provider is to provide all our patients with the best and most comprehensive care possible and we sincerely believe that medical clowning enhances that level of care.”  Professor Halevy also singled out the generosity of Helen Abraham, who was visiting the hospital, for her establishment of the Lincoln David Abraham Paediatric Educational Institute. The Institute serves as the home for much of the clowning interaction with younger patients.

Professor Francis Mimouni, Director of Pediatrics at Shaare Zedek, held an impromptu jam session with the clowns, utilizing his talents on the guitar to express his appreciation.  “When a child is in the presence of a medical clown, he or she can completely forget the pain they are in – even if it’s momentary,” Professor Mimouni said.  “I therefore view it as a great privilege to be able to work hand in hand with the clowns.”
During their time at Shaare Zedek, the clown delegates who hailed from countries all over the globe including France, Scotland and Spain among others, visited the various medical departments around the hospital where medical clowning is most often practiced.  While children are the most common recipients of the “clowning treatment,” their work is often as appreciated by far older patients.  Scientific research has proven that the techniques employed by clowns can dramatically reduce tension in patients which can in turn provide better chances at healing that much more quickly.
In a round-table discussion amongst the clowns and Shaare Zedek pediatric neurologist Dr. Hila Pen Pazi, the clowns talked about the cultural differences that defined their particular experiences in clowning but said that the common denominator is their commitment to becoming partners in healing with the medical staff.
Professor Arthur Eidelman, previous Director of Pediatrics at Shaare Zedek who today volunteers with Dream Doctors as the Chairman of the Scientific Committee, stressed that clowns are an increasingly respected aspect of patient care, “There is a growing recognition that the work of clowns should be viewed as a real and proven specialty,” he said.  “It’s not just an issue of making a kid happy or laugh for a moment but the clowns play a critical role in the physicians provision of therapeutic care.”

Medical clowns from all over the world are heading to Israel for a congress to learn more about the country's unique model of clown therapy.

Israel didn't invent the notion of entertainers cheering hospitalized children. In many countries, volunteers decked out in crazy hats, jumbo shoes and red foam noses regularly bring their bags of tricks to pediatric wards.

But the Israeli program Dream Doctors did blaze the trail for professionalizing "clown therapy" as a standardized, research-backed healthcare discipline. In late October, the organization will host an international congress of medical clowning associations to share the theories and practices of this unusual approach.

"My vision is that the same way hospitals hire any therapist, they'll hire medical clowns," says Dr. Arthur Eidelman, the recently retired chief of pediatrics at Jerusalem's Shaare Zedek Medical Center and professor of pediatrics at the Hebrew University's Faculty of Medicine.

A gathering of Israel’s medical clowns.

As chairman of the scientific committee for the upcoming conference, he's eager to share Israeli research showing that putting trained clowns on the medical team leads to measurable benefits in pain relief, stress reduction and boosting immunity. Pre-surgical and post-surgical patients "treated" by medical clowns need less anesthesia before and less pain medication after the operation. In-vitro fertilization patients who are exposed to clown therapy right after implantation are more likely to become pregnant.

At least 200 medical clowns from North America, Australia, Portugal, Denmark, Germany, The Netherlands, Switzerland and France -- maybe even one from Peru - are expected at the October 23-26 congress at the Ma'aleh Hachamisha Kibbutz convention center near Jerusalem, says Karin Schneid, program coordinator for the Magi Foundation, which has funded Dream Doctors since 2004.

Clowning is serious business

The foundation helped set up the world's only undergraduate degree program in clown therapy as a paramedical profession, available at the University of Haifa's Graduate School of Creative Arts Therapies. A master's program will soon follow.

Pre-surgical and post-surgical patients “treated” by medical clowns need less anesthesia before and less pain medication after the operation.

"We are the center of the world with this model," Eidelman tells ISRAEL21c. "I didn't fully appreciate this till six months ago, when I started planning a convention with medical clowning associations in Europe. They sent representatives here to see what was going on in Israel, and they decided after seeing what we do that we should have the congress here."

In many countries, he explains, "clowns come into hospitals in the afternoon, after rounds are over. Here, we work integrally together during rounds. I don't see the medical clowns differently than any other part of the team. It's not entertainment; it's therapy."

About 80 Dream Doctors work in 18 Israeli hospitals, making a unique contribution to treatment, recovery and rehabilitation - mostly for children, but also for adults in virtually every inpatient and outpatient department. They help make assessments and devise treatment plans, just like music, drama, art or occupational and physical therapists do, and they use their paramedical training to assist with various bedside procedures.

The Magi Foundation foots the bill for each clown therapist's first year on the job. "We try to sign an agreement with every hospital that each year our share will decrease and their share will increase," says Schneid. "In the hospitals we've worked at the longest, the programs are now fully funded by those hospitals."

Medical clowns on the job at Rambam Health Care Campus.

That means the clown therapist isn't an outsider but a regular staffer with regular hours and responsibilities. "Physicians don't usually relate to this model," says Eidelman, but he's hoping the convention will start changing minds.

On the schedule are plenary sessions on the history and theory of medical clowning; practical workshops; and field trips to see clowns in action at Jerusalem-area hospitals. "The fact that physicians will be chairing sessions, and it's not just clowns talking to clowns, is symbolic," says Eidelman.

‘You have to have a great heart'

"In our organization in Israel, we try to pick mature people with families, who have experience in the theater arts and a rich world from which they can relate to the children," says Schneid. "We encourage them to get the degree from Haifa University, and we want them to go on to a master's as well, but it's not a requirement. Mostly, you have to have a great heart."

"We look for people with theater-arts skills, not just do-gooders," adds Eidelman. "Volunteers from the community come to entertain in the hospitals around hanukah and Purim, and that's wonderful, but they don't understand the [medical] issues as well as people who are trained. Professionals in theater arts are very flexible and adjustable, sensitive to the dynamics of the situation and know how to have appropriate interactions."

In Israel, where hospital roommates may often be of different ethnicities, the clown therapists not only inspire trust and calm fears, but also use their expressive abilities to bridge cultural gaps and facilitate communication across religious, ethnic and national lines.

Though the result is often giggles, it's pretty sober stuff, notes Eidelman, who is a scientist at core. "My research has been in basic clinical care, but in a pediatric department you really see that the needs of the child and family are just as important as what's going on in the test tube," he says.

Dream Doctors Medical clowns in Israeli hospitals are making a real difference.