New Perspectives on Medical Clowning Clown Doctors in

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First published 2023
by Routledge
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and by Routledge
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Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2023 Amnon Raviv
The right of Amnon Raviv to be identified as author of this work has
been asserted in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library

ISBN: 978-1-032-42330-2 (hbk)

ISBN: 978-1-032-51544-1 (pbk)
ISBN: 978-1-003-36230-2 (ebk)
DOI: 10.4324/9781003362302
Typeset in Times New Roman
by codeMantra
Dedicated with love to my beloved children Toot and Yam
and my dear parents Esther and Tuvia.
Contents

List of figures ix
Preface – How I became a medical clown xi
Foreword xv

1 Humor, consciousness, and anxiety 1

2 The birth of a new profession 8

3 Medical clowning during Covid 13

4 Medical clowning in wartime 32

5 Qualitative research on clowning in pediatrics units 43

6 Clowning around with cancer online: the impact

of social media on the interaction between the
medical clown and oncology patients 57

7 Medical clowning and music in the wards for

chronic and serious illnesses 71

8 Rethinking the training of medical clowns and

the basics of the profession 83

Index 89
Figures

0.1 My mother and I are celebrating mother’s birthday xii

1.1 The scarecrow, “Sheba” hospital oncology, 2021 6
2.1 The International Healthcare Clowns’
conference, held in The Hague. April 2022 12
3.1 Before entering the Corona ward, the first step
is replacing the mask with a special one. Herzfeld, 2021 23
3.2 Second step before entering the corona ward is
to wear a head and neck covering 24
3.3 Third step before entering the corona ward
wearing a cloak and shoe cover, and hand sanitizing 25
3.4 Ready to enter the corona ward 26
3.5 Dancing with a patient in the oncology ward at
Sheba Hospital, 2021 27
3.6 A funny interaction with a patient in a
wheelchair. Herzfeld, 2020 28
3.7 A patient dances in a wheelchair and her short
clown partner. Herzfeld, 2020 29
4.1 The clowns’ car over a makeshift bridge. Taken
in August 2022 on the way from Rohan to Kharkiv 39
4.2 The refugee’s shelter, village Voloskye. Taken in March 2022 39
4.3 Jan in the Kharkiv metro station, April 2022 40
4.4 Hagar and Amnon entertaining children in a
shelter, under a rocket attack, Ashkelon 2012 40
4.5 Hagar with a toddler outside the shelter during
a lull in the rocket attack, Ashkelon 2012 41
5.1 A large soap bubble distracts a cute toddler.
Pediatrics Barzilai Hospital, 2007 53
5.2 Lively interaction with a teenage girl.
Sheba Hospital, 2011 54
5.3 Sponge sword interaction. Barzilai Hospital, 2009 54
x Figures
6.1 A patient who put her wig on the clown’s head.
Sheba Hospital, Oncology ward 2015 64
6.2 A stormy dance with a green flamenco dress.
Sheba Hospital, Oncology 2017 65
6.3 Rachel R.I.P. my family member. Soroka
Hospital, Oncology 2016 65
6.4 A comical encounter with two nurses.
Rabin Hospital, 2016 66
6.5 Dancing with a patient. Sheba Hospital, 2013 67
6.6 Riding on an infusion pole. Sheba Hospital, 2017 68
7.1 Singing in a trio. Rabin Hospital, 2015 79
7.2 Two elderly patients with handkerchiefs.
Herzfeld Hospital, 2013 79
7.3 Singing with a patient who is a medical clown
herself. Sheba Hospital, 2022 80
7.4 Singing to a patient who is doing an inhalation.
Herzfeld Hospital, 2015 80
7.5 Singing with a patient in a duet. Rabin Hospital, 2015 81
8.1 Medical clowning class. Tel Hai College, 2019 88

Note: All figures Courtesy of Amnon Raviv, beside 4.1, 4.2, 4.3 -
Courtesy of Jan Tomasz Rogala and 4.5 Courtesy of Hagar Hofesh.
Preface – How I became a
medical clown

It’s all due to my mother that I became a medical clown.

Here’s the story …
In my early twenties I landed in Amsterdam. I had a plan: I would
buy a van, take out the back seats, put a mattress in (so I could sleep
in it), and travel around Europe as a street performer. The plan suc-
ceeded: I performed with my partner during that summer and quickly
discovered that the audience loved the show and was very generous. I
had a lot of fun, the audience made sure that the hat was full of money
at the end of the show, I met a lot of interesting people and had great
experiences around the continent. There was no reason to go home at
the end of the summer. The original plan of a two-month adventure
turned into a four-year journey.
In those years of the mid-1980s there were no computers or mobile
phones – yet, every two or three weeks I would call from the central
post office of the city where I was staying (or from friends’ homes) to let
my parents know that I was fine, and to hear how they were doing. One
day, after four years of performing, my father picked up the phone and
told me in a worried voice that my mother had cancer, was operated on
and was hospitalized at the Hadassah Medical Center, Ein Karem, in
Jerusalem. I felt as if an arrow pierced my heart, and I boarded a flight
to Israel the next day. I landed at Ben Gurion International Airport in
the evening and immediately took a taxi to the hospital in Jerusalem,
arriving late in the evening. Visiting hours were over, so I had to argue
with the guard who was not willing to let me in. Only after examining
my passport and verifying that I had indeed arrived that day from
abroad did he let me in. I entered the room where my mother was ly-
ing, surprised to the core. She had no idea I was returning to see her,
and barely recognized the guy who looked like a vagabond with long
hair and an overgrown, bushy beard. On one shoulder was the guitar I
bought from gypsies in Seville, and on the other a tall red unicycle that
xii Preface – How I became a medical clown
I soldered together in Amsterdam from bicycle parts. On my back was
a pack with some clothes and juggling equipment.
A pale and weak mother watched in disbelief. This was undoubtedly
one of the most touching moments experienced by mother and son.
In the weeks and months that followed, I stayed close to her, accom-
panying mother to the treatments, and then through a rehabilitation
process, until she recovered.
The cancer “visited” her one more time, twenty years later. She also
recovered from the second round, after doctors had to amputate part
of her foot. We would sit before, after, and during the treatments, fill-
ing in the gaps of my four years in Europe. We mostly laughed the
whole time – laughing about everything, about life, cancer, memories,
and even farts. Mom and I always shared a common sense of humor
and now the situation summoned the humor and laughter even more. I
was her private clown and she was my first patient. The year was 1987,
and, in fact, it was there under these most personal circumstances that
I began my journey as a medical clown.
In the long weeks and months of accompanying my mother through
the difficult oncology wards suffused with sadness, I made a decision

Figure 0.1 My mother and I are celebrating mother’s birthday.

 Preface – How I became a medical clown xiii
to enter these wards as a clown, after my mother recovered. I felt the
need to enter the wards of the most seriously ill patients as a clown and
musician, to bring some light and humor to patients facing the most
difficult challenge of their lives.
The year before I returned to Israel to take care of my mother, a
pioneering medical clown project began in New York. Clowns began
visiting a children’s hospital. The year was 1986, the beginning of med-
ical clowning as a profession. I had already heard about this project
from street artists who came from the USA to perform on the streets of
Europe, and knew some of the clowns of the Big Apple in New York.
The project sounded important to me, but the oncology wards seemed
the farthest thing from the bustling streets of the European cities in
which I performed. I could not guess how close they were, and could
not imagine the circumstances which were about to become extremely
personal (Figure 0.1).
Foreword

Dr. Amnon Raviv was the first, and so far, the only medical clown,
to have earned a PhD (from the University of Haifa). His dissertation
was titled “Medical Clowning with Patients with Life Threatening and
Incurable Diseases.” Raviv’s first book, Medical Clowning: The Healing
Performance (2018), combined autoethnographic descriptions of his
work with children and adult patients; interviews with other clowns,
patients, and hospital staff; and a discussion of medical clowning in
the context of healing rituals and carnival theories. It was a tremen-
dous contribution to what I once referred to as the “emerging profes-
sion of Healthcare Clowning.”
In the current book, New Perspectives on Medical Clowning: Clown
Doctors in Covid-19, Wartime, and the Everyday, Amnon now updates,
expands, and offers insights on topics facing medical clowns: What
are the challenges of achieving direct, joyous, human contact during
Covid-19 or wartime? Music speaks all languages. How does it impact
serious and chronic illness and what type of music has positive ef-
fects on what type of illness? How does one train to become a medical
clown? How do you train to become friends with the unknown? How
do smart phones and social media impact the work of medical clowns.
Quite often, people ask me: “How do you see the future of medical
clowning?” My response: “We must deepen our relationship with our
medical partners and in the spirit of co-creation, the future of medical
clowning will unfold.” We need people like Amnon very much. We need
his heart, which is always available and his ability to clearly articulate
the successes and challenges of our emerging profession. Emerging pro-
fession? Hmmm. Although the activity of bringing joy to various vulner-
able populations will certainly continue to evolve, his current book New
Perspectives on Medical Clowning: Clown Doctors in Covid-19, Wartime,
and the Everyday is a clear indication that it has arrived. Joy finds its way.

Michael Christensen
1 Humor, consciousness,
and anxiety

Many philosophers and intellectuals throughout history have tried to

define, describe, and characterize humor, including Plato, Aristotle,
Descartes, Hobbes, Kant, Schopenhauer, Kierkegaard, Nietzsche,
Bergson, and Freud. Contemporary humor researchers tend to divide
theories of humor into three main theoretical traditions based on in-
congruity, superiority, and release (Lippitt 1994, 1995a, 1995b, 1996).
Incongruity – Kant analyzes laughter as an incongruity of expecta-
tions, as an expectation that suddenly disappears in surprise. Incon-
gruity can occur at the meeting between different content worlds, at
the encounter between cultures with different social, conceptual, and
behavioral conventions. Basically, anything that creates incongruity
with our conceptual logical concepts and social conventions has a hu-
moristic potential.
Superiority – Plato considers laughter as a flaw and an expression
of ignorance, and sees laugher and mockery as negative, especially
humor that results from opposition and disapproval. Nowadays, hu-
mor is seen as a positive virtue, but the humor that humiliates others
(for reasons of race and skin color, for example) is negative and il-
legitimate. Humor and laughter have an anarchic and critical basis.
Another example is satire, which mocks and criticizes political and so-
cial phenomena and has an important critical role in the sociopolitical
culture of every community and society. The question is whether criti-
cal humor has been used order to oppress the individual, or whether its
purpose is to vent feelings and challenge conventions to free the indi-
vidual and the community from any fixed ideas and oppression. Berg-
son claimed that people are afraid of being mocked, and that laughter
makes them perceived as ridiculed and inferior. He argues that society
or government can make cynical use of the human fear of being the
target of ridicule and laughter in order to impose their desires and
goals on the “rebellious” individual (Lippitt 1995a).

DOI: 10.4324/9781003362302-1
2 Humor, consciousness, and anxiety
Release – Freud is the main formulator of the theory. Freud claims
that aggression as well as conscious and unconscious tension, breaks
down in the interaction between the one who tells a joke and the one
who hears the joke. The format called a “joke” allows the release of
tension that naturally exists between people by converting it into
shared enjoyment and interpersonal empathy. The possibility of the
teller and the listener of the joke being part of each other’s thought
process enables an experience of shared pleasure and the release of
unconscious aggression (Christoff & Dauphin 2017).
These three central theories and others shed light on certain char-
acteristics and aspects of humor but cannot holistically present this
unique phenomenon. This is similar to several people watching a
huge animal with each one characterizing it from his narrow angle
of vision, dictating as much as he can see. Moreover, humor changes,
thus changing its meaning and function according to the increasing
needs of the individual and of the community. For example, for cancer
patients, humor is an internal command to fight the disease and its
consequences, a weapon in the battle to live. But for the terminally
ill whose fate is determined and the battle is over, humor changes its
meaning and function. Instead of a weapon in the war for life, humor
becomes a means by which one can arrive at acceptance, completion,
and parting with the world with a smile. Humor enables embracing
closure with family, friends, and the self, becoming the possibility of
personal redemption.
I would like to propose a new theory of humor. I see humor as a
type of alternative existential consciousness. To explain it, I need to
describe how I observe the process from an evolutionary perspective.
“Language revolution” is the name commonly given by many
scholars to an important evolution that took place 70,000 years ago
among Homo sapiens (Harari 2013). Perhaps the term “revolution of
consciousness” is more appropriate. Most contemporary theories see
consciousness as a form of information processing (Attardo 1997).
Language is probably just one of the manifestations of the revolution
of consciousness, which involved the development of the brain and its
ability to create a high self- and social consciousness among humans.
Gervais and Sloan Wilson (Gervais & Wilson 2005) claim that humor
and laughter integrated together and are intertwined in biological and
social evolution. Belief, narrative, anxiety, imagination, and humor
are abilities derived from a high self (and social) consciousness. As I
see it, humor is an aspect of human consciousness that mediates real-
ity in a softer and more tolerable, more entertaining way.
 Humor, consciousness, and anxiety 3
Human consciousness might lead to an understanding that our lives
are meaningless in the perspective of eternity and cosmic space. We
live on a planet that probably has no meaning in such a context and if
it disappears it probably will have no consequence to the cosmos. The
length of our lives and our actions as an individual and as a species
seems to be negligible. This is the incongruity at the base of human
consciousness. The gap between the importance of our lives in our
eyes (our desire to live and leave behind something significant) and the
insight of what appears to be the lack of meaning in our cosmic exist-
ence, can cause existential anxiety (among other things).
This existential anxiety must receive a mental-emotional response.
One of the ways of dealing with existential anxiety is through the
mechanism of humor, which enables a change of consciousness (Berk
et al. 2014). Humor offers a different point of view of human existence,
as well as an alternative perspective in observing reality, which allows
for the reduction of anxiety and stress.
In the twilight of his life, the students of Democritus asked the
Greek philosopher to summarize life from the height of his age. His
response was that he could summarize life in three syllables: ha ha ha.
Humor allows us to look at life in an amused way and thereby reduce
our existential anxiety and the fear of death (Raviv 2018).
Another way to deal with existential anxiety is religious belief and
various practices derived from the various beliefs (Malhotra & Thapa
2015). The difference between the different ways to deal with existen-
tial anxiety is that humor offers a different point of view of reality,
while religious belief offers an alternative interpretation for under-
standing the reality. In any case, both ways offer sort of salvation from
existential anxiety.
It is difficult (or impossible) to detect humor in animal behavior and
certainly not in religious practice. Both humor and religion are related
to the higher consciousness that is unique to humanity.
Animals think and have a simple language. Animals can commu-
nicate with different voices that warn of dangers or have a social and
personal message of grief, estrus, empathy, anger, or territoriality.
Voices and sounds that connect to a basic language that enables a
hunter’s strategy (Harari 2013). Human consciousness deals (among
other things) with ontological and epistemological questions, such as
the meaning of life, how we were created, the meaning of death, and
the purpose of living. Man tried to understand and interpret natural
phenomena. What is lightning and the sudden storm? What are the
stars?