Presence redefined: The reciprocal nature of engagement between elder-clowns and persons with dementia

Introduction

Arts-based approaches are among the most recent innovations in person-centred dementia care (de Medeiros & Basting, 2013). They most commonly include music (Raglio et al., 2008; Svansdottir & Snaedal, 2006), art-making (Rusted, Sheppard, & Waller, 2006), dance and movement (Coaten, 2001, 2002; Palo-Bengtsson & Ekman, 2002), story-telling (Basting, 2006; Fritsch et al., 2009), visual arts (Basting, 2009), and drama (Lepp, Ringsberg, Holm, & Sellersjö, 2003). A red-nosed clown who specializes in working with older adults is an important new development in long-term care settings (Hendriks, 2012; Warren & Spitzer, 2011). Referred to as elder-clowns, they utilize improvisation, humour, and empathy, as well as expressive tools such as song, musical instruments, and dance to individualize engagement with institutionalized elders (Hendriks, 2012; Warren, 2008a; Warren & Spitzer, 2011).

The efficacy of elder-clowning in dementia care, specifically positive effects on the psychosocial and cognitive functioning of residents, and/or a reduction in the severity and duration of agitation, has been demonstrated in a number of published observational studies (Warren, 2008b, 2009), a multi-site intervention study (Low et al., 2013), and in unpublished conference proceedings (Colobong et al., 2014). Given the prevalence of medical and psychological perspectives in research on elder-clowning (Hendriks, 2012), it is not surprising there has been little exploration of the aesthetic and relational components of elder-clown practice that account for its efficacy. We conducted a study to specifically examine the techniques and strategies that elder-clowns employ when interacting with long-term care residents with dementia.

This paper is organized as follows: first, we trace the development of clowns in health care, and the sub-specialty of elder-clowning; second, we describe an elder-clowning program conducted in a long-term care facility in Ontario, Canada; and third, we discuss findings drawn from qualitative interviews, video recorded observations, and practice reflections, which suggest elder-clown-resident interactive practice is founded upon what we have termed ‘relational presence.’ We conclude by noting the significant care implications of relational presence, specifically a rethinking of relationship and the unique capacities of residents to shape caring interactions.

Clowning in health care

Although Hippocrates (470 BC – 350 BC) was famously claimed to have used troupes of clowns and musicians to enhance healing (Warren, 2008b), and the use of clowns in children’s hospitals was noted as early as 1908 in England (Spitzer, 2007), the use of clowns in contemporary health care began in the United States in the 1970s (Roy, 2009). In 1990, clowns in health care gained increased legitimacy in North America following a feature cover article in Life Magazine that featured the Big Apple Circus Clown Care Unit (Christensen, 1999). Variously termed medical clowns, clown-doctors, or therapeutic clowns, they share the characteristics of working in

hospitals and other health care settings…to provide support for the sick and their families, promote their recovery process, and minimize stress in every possible way – including in the health care setting itself…through the use of clown’s skills, and by sensitively interacting with patients, families, and staff by means of humor and laughter, fantasy and empathy (Pendzik & Raviv, 2011, p. 268).

Preparation for clown work in health care settings often happens through organizations that recruit, train, and support artists to work with specific clinical populations (Big Apple Circus, 2012; Hearts & Minds, 2013; Jovia, 2012). Some clown programs in higher education or healthcare settings also exist (Couchman & Thomas, 2014; Estrin, 2012) although training length varies considerably (Couchman & Thomas, 2014). Continuing professional development in artistic, psychosocial, and clinical competencies, as well as regular participation in moderated reflective practice or clinical supervision are viewed as essential to best practice (Couchman & Thomas, 2014; Le Roux, 2010).

Children remain the primary target population for most clown programs in acute care settings (van Troostwijk, 2007). Less frequently, clowning has been utilized for adults receiving non-acute medical services in palliative care (Warren & Spitzer, 2011), rehabilitation (Gervais, Warren, & Twohig, 2007), and assisted reproduction (Friedler et al., 2011). Clowns have also participated in crisis projects for adult and child refugees in Croatia and Kosovo (Pendzik & Raviv, 2011).

The movement of clowns out of hospitals and into nursing homes began in the US with Clown Ministries (Kerman, 1992), which was focused on “social healing” in nursing homes and elder care in hospitals (Van Blerkom, 1995, p. 470). Since the late 1990s, elder-clowns have specifically adapted clown practice to the dementia population (Killick, 2003; Warren & Spitzer, 2011). Unlike a paediatric clown, the elder-clown eschews the doctor clown persona and the wearing of a white laboratory jacket and stethoscope because, unlike in a hospital, a physician is relatively uncommon in a nursing home (Warren, 2008b). Elder-clowns don a red nose, but avoid the traditional heavily made-up white face with the exaggerated smile (Warren & Spitzer, 2011). What further distinguishes them from costumed paediatric solo clowns is use of costuming that harkens back to a previous era, such as colourful 1950s swing dresses, and their work as duos, often with character storylines of loving but rival siblings (Gervais et al., 2007; Hearts & Minds, 2013; miMakkus).

Clown interactions, known as “plays,” (Warren & Spitzer, 2011, p. 563) utilize similar techniques regardless of setting or clinical population. Key elements include verbal, physical, and musical interactions that incorporate fantasy, surprise, inversion, physical comedy, and storytelling (Blain, Kingsnorth, Stephens, & McKeever, 2012; van Troostwijk, 2007). In the health care setting, plays additionally include “reminiscence techniques, music and song structures, and… bedside magic” (Warren & Spitzer, 2013, p. xiii). Clowns typically modify their plays so that the pitch, speed, and energy are appropriate for the clinical, developmental and attitudinal specificity of the target audience (Pradervand, 2003; Schamberger, 2012).

While clowns across the health care spectrum may practice “empty pockets clowning” (Warren, 2011, p. 184), whereby they utilize only those objects found in patients’ rooms, the use of props, “or properties…the gadgets the clown uses to enhance his act” (Litherland, 1990, p. 27) is fairly common. Elder-clowns carry a “personal clown kit” (Hendriks, 2012, p. 463) that contains such common props as mirrors and jewelry (Hendriks, 2012). Clown plays also foundationally rely upon “census information” (Gervais et al., 2007, p. 181) provided by health care staff. Census information includes the clinical, pharmaceutical, social, and familial details said to “facilitate the relationship between artist and the patient” (Achcar, 2007, p. 162), including guidance for the most helpful treatment adjunct (e.g. for elder-clowns to practice vocalization through song with an aphasic patient), and necessary contagion prevention instructions (Gervais et al., 2007).

The fundamental goal of clowning is to achieve a state known as “presence” (for a comprehensive history of clown presence see de Graan, 2012). In theatre, presence refers to making spontaneous fictional propositions real and immediate for the spectator, as well as an actor’s manipulation of engagement with physical space and the audience to create a heightened “‘now’ between actors and audience” (Power, 2006, p. 38). Presence is understood as “the ground of clowning” (de Graan, 2012, p. 61). For clowns, presence is defined as the action of being “in a sense fuller, more authentic, or more real than what we normally come across” (Davison, 2008). Presence is said to be successfully achieved when clowns are “fully in the present moment” (de Graan, 2012, p. 69), which requires that they suspend their personal judgment or urge to compare the unfolding moment with their own past personal experiences (de Graan, 2012). Clown presence is achieved via particular capacities and capabilities, such as “attentive listening” (de Graan, 2012, p. 70). Whilst necessarily requiring non-clown participants as spectator, foil, or partner in comedy, traditional clown conceptualizations of presence nevertheless generally fail to acknowledge the interactional aspects of presence.

An important recent advancement in the conceptualization of clown presence is found in the work of de Graan (2012). Drawing on the pedagogy of the dramatic arts wherein presence is conceptualized as an “‘energy’ generated through an actor-audience relationship” (Power, 2006, p. i), de Graan views clown presence as a “dialogic inter-action” (2012, p. 69). Thus, through the clown expressing “curiosity” (de Graan, 2012, p. 62) and “appreciation” (de Graan, 2012, p. 67) regarding the individual or group audience, the clown develops a special intimacy with them that results, ideally, in a mutuality or “communitas” (Turner cited in de Graan, 2012, p. 89). Clown communitas involve a blurring of self-other differentiation since “in communitas there are no separate identities, just self and other co-emerging undifferentiated as the performance of being” (Turner quoted in de Graan, 2012, p. 89). Mutuality and dialogical performance are thus conceived as end points of the clown performativity of presence, at which point the separation between self and audience is dissolved, and co-emergence (a sense of oneness or wholeness) results (de Graan, 2012).

Despite de Graan’s (2012) efforts to redress the one-sided nature of presence as it is traditionally conceptualized, his emphasis on mutuality and communitas effectively shifts the attention from the different agents in the interaction to the clown identity, which then becomes conflated with the outcome of the interaction. He thereby overlooks, as is typical in clown scholarship on presence, what the Other brings to the interaction in terms of their own a priori techniques of being, relating, performing, and provoking. The consequence is twofold. First, it diminishes the notion of presence since it becomes subsumed under co-emergence and consequently “dissolves” the uniqueness of Other. Second, it limits understandings of clown techniques because they are conceptualized only in terms of individualistic clown actions, rather than theorized in light of how they are utilized in situ, which would underscore their fundamentally relational nature.

The work of Hendriks (2012) on the “articulated” clown is instructive here. He notes that a significant component of clown training is learning to be affected by the experiences of the Other, that is, to be “moved, touched, and stirred to specific reactions” (2012, p. 469). While this offers an important corrective to the notion of co-emergence and acknowledges the contribution of the resident in clown plays, for Hendriks (2012), the capacity of the resident to contribute relies on the clown effectively triggering the resident’s “latent capacity to be moved” (2012, p. 472, original emphasis). This is akin to the “sleeping beauty syndrome” (Killick & Allan, 2012, p. 65) in cultural depictions of dementia, wherein residents must be “awakened by a word or gesture or pattern of movement (or a kiss),” (Killick & Allan, 2012, p. 65) or otherwise remain “fixed and unmoving” (Hendriks, 2012, p. 471). Contra the myth of the sleeping beauty, our evidence demonstrates an interactional state we term “relational presence.” This term captures the reciprocal nature of engagement during plays, and the capacity of residents to initiate as well as respond to verbal, embodied, emotive and creative engagement.

Methods

The study took place from 2012–2014 in Ontario, Canada, and was a mixed methods evaluation of a 12-week elder-clown program involving 23 residents of a dementia unit in a long-term care facility. The 4 elder-clowns hired for the study had been professionally trained at recognized Canadian clown organizations. For the purposes of the study, elder-clowns additionally received study-specific training in a specialized person-centred dementia care approach known as embodied selfhood (Kontos, 2004, 2012a; Kontos & Martin, 2013). Our analysis in this paper is restricted to elder-clown strategies and techniques not directly impacted by this additional training.

The elder-clown program consisted of twice weekly clown duo resident visits (approximately 10 minutes per visit) over a 12-week period. Each clown duo-resident visit was video recorded to facilitate subsequent analysis. During each visit, the clown duo was free to utilize any artistic modality (e.g. dance) or prop (e.g. miniature ukulele) that they believed appropriate given the resident’s mood, interactional style, or clinical condition. This decision-making was supported by the provision of census information, which enabled clowns to appropriately tailor interactions.

For the purpose of health care staff introductions, elder-clowns attended a 4-hour orientation at the facility. An additional 4-hour camera test shoot with the videographer served as an opportunity for staff and residents to acclimatize to the presence of the videographer and elder-clowns. Following the test shoot, researchers reviewed the test footage and provided feedback (e.g. camera angle modifications). Throughout the study, clowns were provided with support from researchers and an elder-clown trainer.

Participants

The study was approved by the research ethics boards of the participating facility and the research institute of the Principal Investigator. Recruitment was driven by the quantitative component of the study, specifically the interest in examining the impact of elder-clowning on severe behavioural and neuropsychiatric symptoms (e.g. apathy, depression) as defined by the Neuropsychiatric Inventory-Nursing Home version (Cummings, 1997). Recruitment of residents was further based on family members of potential study residents being asked whether the resident would enjoy interacting with the elder-clowns; all those approached agreed. Baseline scores of moderate to high symptoms were used to identify 23 eligible participants; the mean age was 87.8 years (SD = 8.0), 16 were female, and dementia diagnoses were predominantly Alzheimer’s dementia (73.9%), followed by mixed Alzheimer’s and vascular dementia (13.0%),Lewy body dementia (8.7%), and vascular dementia (4.4%). For the qualitative study, we sought to broaden the biomedical/psychological approaches to behaviour in the dementia context that assume behaviour is always symptomatic of dementia to include recognition of need-driven behaviours (Cohen-Mansfield, 2001) and other purposeful and meaningful communication (Dupuis, Wiersma, & Loiselle, 2012; Kontos, 2005; Kontos, 2012b). This is reflected in our analysis (e.g. sadness is interpreted as a natural expression of grief and not pathological).

All substitute decision makers who were approached consented by proxy (Karlawish, 2003). Resident assent (Slaughter, Cole, Jennings, & Reimer, 2007) was ascertained by elder-clowns on a per visit basis based on interpretation of residents’ verbal and gestural cues, for which they have specific training (Stirling-Twist & Le Roux, 2014). Elder-clowns consented to be video recorded during visits while in costume/character, and during reflections while out of character. Each elder-clown also consented to participate in an individual audio recorded semi-structured interview upon study completion. Pseudonyms have been assigned to all participants.

Data collection

Clown-resident visits

The elder-clown duo visited individually with resident participants. Four hundred and seventeen interactions occurred in residents’ rooms (approximately 66 hours) and were video recorded. An additional one hundred and five visits occurred in the hallway or other public areas where video recording was prohibited; clowns later verbally detailed these visits during video recorded reflections. Resident responses to the videocamera included only mild curiosity and indifference, and were interpreted as assent.

Video recorded reflections by the elder-clowns

At the end of each half-day of visits, the elder-clowns stepped out of clown character and assumed their “normal identities” (Van Blerkom, 1995, p. 467) to complete video recorded reflections. Together they discussed: visited residents; artistic modalities used (e.g. song); how the visit had been tailored with the use of census information; residents’ active or passive verbal and non-verbal responses; and factors that might have facilitated and constrained the visits. These non-moderated reflections were consistent with how elder-clowns are trained to reflect on the implications of their characters’ actions during plays (Stirling-Twist & Le Roux, 2014). Some video recorded reflections were moderated by (first author) as a means to explore with the elder-clowns the choices they had made in character/in situ. Clowns are identified by clown character pseudonym (Cherry, Aksom, Zazzie, Mitsy) during interactions when they are in clown, and by practitioner pseudonym/character pseudonym (Holly/Cherry, Camilla/Aksom, Kate/Zazzie, Ann/Mitsy) during video recorded reflections.

Interviews

Upon completion of the program, individual interviews with all four elder-clown practitioners were informed by our interim analysis of the video footage. This enabled us to explore the techniques and strategies as described by elder-clowns, and also our initial interpretations of their activities. As with reflections, each elder-clown is identified by practitioner and character pseudonyms.

Analysis

Interim and final analyses involved researchers analyzing video recordings, reflections, and interviews. First, the entire corpus of video footage of clown duo-resident visits was viewed several times by multiple researchers, as is recommended when working with this data type (see for example, Derry, 2007). Video recorded interactions were then transcribed as non-participant observer field notes by (first and second author) who are trained in ethnographic observation. (First and second author) detailed clown techniques (e.g. skit), residents’ nonverbal social and affective expressions (e.g. visual tracking), verbal exchanges, and emotive responses (e.g. enthusiasm). When required, (first and second author) also repeatedly reviewed interactions in slow motion in order to focus on non-verbal micro features of the interactions.

Transcriptions of the clowns’ video recorded reflections and in-person interviews, as well as ethnographic descriptions of video footage, were analyzed concurrently and recursively using standard thematic analysis techniques (Denzin & Lincoln, 1998). Text segments were assigned a descriptive code reflecting the original statement, which served as the basis for category formation. Through an inductive, iterative process, categories with similar content were investigated for interrelationships, and then refined by moving from lower-order to higher-order themes as analysis progressed. Finally, analytical categories were examined to illuminate strategies and techniques vis-à-vis reciprocal engagement and resident verbal and nonverbal communication.

Findings

Our examination of clown duo-resident engagement found that successful, meaningful plays were predicated on a practice and state that we have termed “relational presence.” Relational presence was achieved and experienced through a combination of the use of one or more of three primary strategies between the clowns and the resident: a) affective relationality; b) reciprocal playfulness; and c) co-constructed imagination.

Affective relationality refers to the elder-clowns’ sensitivity to, compassion for, and in some cases their susceptibility to becoming affected by, the joyful and sad emotions of residents. Reciprocal playfulness included resident responses to clown-driven physical games, pranks, verbal jousting or jokes, and importantly included residents’ own initiation of such activities. Co-constructed imagination is defined as the co-creation of oral stories by clowns and residents. In some cases, co-constructed imagination presented with positively experienced delusionary or unverified reminiscence by residents.

Affective relationality

Central to the training of elder-clowns is the facilitation of the acute perception of, or responsiveness towards, the emotions of another person (Hendriks, 2012). The clown learns to distinguish “with increasing subtlety…how the other person relates to the world, attentively, physically, and sensorily” (Hendriks, 2012, p. 469). In this study, affective relationality included elder-clowns’ responsiveness to residents’ expressions of joy as well as sadness as expressed verbally and non-verbally either independent of clown activities or in response to them.

Joy

The majority of research involving clowns in health care focuses on the presence and curative potential of laughter (for a critique see Hendriks, 2012), what is deemed the purpose/aim of clowning (Geiger, 2007; Glasper, Prudhoe, & Weaver, 2007; Pendzik & Raviv, 2011; Weaver, Prudhoe, Battrick, & Glasper, 2007). While laughter was certainly far from uncommon during clown duo-resident visits in this study, the expression and communication of joy by residents with dementia was often additionally displayed inaudibly or through non-verbal means such as bright eyes and engaged looks, and intense smiles known as Duchenne smiles (Ekman & Davidson, 1990; Parvulescu, 2010). This is aptly captured in the following example:

Lana is sitting in an arm chair with her eyes closed. Zazzie and Cherry crouch low to the floor in front of her. Zazzie sings a quiet lullaby as she strums a few accompanying notes on her ukulele. Cherry hums in harmony as she looks at Lana, and then very gently extends her hand and touches Lana’s arm. Lana immediately opens her eyes, which startles both clowns who voice an involuntary, simultaneous ‘Oh!’ Lana smiles. At first, her smile appears as friendly but reservedly polite as she maintains strong eye contact with Cherry who is gently stroking her arm. But the longer she holds the clown’s gaze, the warmer and broader her smile becomes. In response to Lana’s increasing engagement, Zazzie begins to stroke Cherry’s cheeks and her long blonde hair, which invites Cherry into the play. Then, after carefully watching Lana’s increasing engagement and facial animation, she ups the interaction to a clown duo game where she tweaks, teases and pretends to slap Cherry’s face, while Cherry responds with slapstick jolts. Lana’s face is in a clear Duchenne smile that appears to radiate delight and joy.

In this example, affective relationality is furthered by the elder-clowns’ improvisational technique of “more.” During a researcher-moderated reflection, Holly/Cherry elaborated,

…In an ideal clown scenario, you build what’s called “more.” “More and more,” and you keep going with the play and ideas which can result in humour or incredible emotional states one way or the other [like] sadness, joy, excitement.

In another moderated reflection, Kate/Zazzie also explained that clowns used the improvisation technique of “yes, and” in order to further facilitate affective relationality between themselves and residents:

There are [clown] principles…that are …in line with improv principles, “Yes, and-ing.” So if someone makes an offer, you “yes-and” it, so you accept the offer, and you add to it. So when [residents] would say a word, we would delight in it, take it on board, and then repeat it and give [them] back that same thing or add to it, or do something musical to support it.

In the following video observation, clowns used “yes-and” in a musical way in order to build on Betty’s non-verbal expressions of joyfulness and engagement:

As Aksom and Mitsy walk down the hallway, Mitsy strums an improvised folk tune on her ukulele while singing the phrase, “it doesn’t get more real than this,” with increasing volume as they approach Betty’s room. Standing in the doorway with a broad smile, and to the beat of the music, Betty is moving her hands up and down, and tapping her right foot. Upon seeing Betty, Mitsy changes the phrase of her impromptu song to, “it doesn’t get more real than Betty.” Betty focuses her gaze on Aksom, and while keeping with the tempo of the music, she changes the rhythm of her movements so she is bobbing in double time. Betty’s foot tapping evolves into a stomping of her right foot, akin to a hoedown [a lively American Western country and music square or line dance], coordinated with shoulder lifts. In response, Mitsy changes the phrase to “let’s all stomp our feet.” Aksom follows Betty’s lead and mirrors her foot stomping. Betty then takes steps towards the clown while stretching her mouth with exaggerated “ohh”s and “ahh”s to the beat of the music. Aksom responds by playfully biting the air and puffing her cheeks in synchronicity with Betty’s facial expressions.

Sadness

Contrary to the predominant focus on clowns giving and receiving of happiness (Warren, 2011; Warren & Spitzer, 2013), elder-clowns have also embraced a recognition and acceptance of sadness. As Symons has noted (2012, p. 13), “when there is [resident and elder-clown] contact it is possible there are tears…People are in the last stage of life, so why be afraid of tears?” The clowns’ affective relationality skills enabled them to perceive resident sadness in the subtlest of movements and gestures. At times, they could perceive sadness even beneath the guise of happiness. During a video recorded reflection, the clowns commented on their perceptions of Frank’s underlying sadness even though he was, as was usual for him during clown visits, willingly partaking in song and dance:

Ann/Mitsy: It felt like he was acting joyful to me, rather than feeling joyful.

Camilla/Aksom: It’s true…it was heavier…I felt his sadness.

Ann/Mitsy: ‘Cause I’ve experienced him, same subject, same topic, same words, same everything, but there’s a different intent behind it. And today, I really felt like he was acting happy, rather than being happy…It just seemed a little bit more effortful…He had to work harder to feel happy today…Like, we didn’t leave him in a sustainable state of joy.

Although the elder-clowns appeared disappointed that they were unable to leave Frank in a “sustainable state of joy,” which suggests a desire to change or transcend his dark emotion, this was not always their intention. In some instances, clowns’ affective relationality meant bearing witness to the sadness of residents, and not attempting to change the emotional timbre. In a video recorded reflection, Ann/Mitsy recalled,

I was singing a quiet song, and just at the end Betty started singing a song. And this is where I felt like I was watching a great performance. She would emote tremendously, like almost a sobbing cry through her song…It was a very moving song. She was moved by her own song…that yawny note, it triggered the tears…The emotion brought her to a…place which turned out to be lovely. Even though there was sadness in it, it didn’t have to be negative…It wasn’t necessary to take away that emotion…It’s not wrong to feel sadness. It’s not wrong to feel teary. It’s not wrong to cry.

In other instances, as Linge (2008) explains, clowns move from simply bearing witness to sadness to the sharing of an inner emotional state or affect attunement. During a researcher-moderated video recorded reflection, Kate/Zazzie explained:

With Ginger, there were some days where she had so much sadness in her body… Just the way she was breathing, you could feel her sadness…She expressed [her sadness]…in the way that she would sort of touch our hands, and touch our faces...We recognized this sadness and held it in a way, allowed that sadness to be in the room… We mirrored the energy with her so we felt like [we were with], or we were trying to sort of accompany her in, that state.

In moving towards and incorporating the sadness of the Other, the clown “sets off from where the other person is,” going along with “the rhythm, intensity, emotional mood, and specific form of their physical presence,” (Hendriks, 2012, p. 467) and becomes affected by the emotions of the residents. At this point, the shared emotional state becomes a relational effect (Hendriks, 2012) where it is unclear who is the performer, and who is the audience regarding the articulation of sadness. The following observation of a clown duo visit with Frank illustrates shared relational affect:

Zazzie and Cherry discover Frank laying in his bed with the lights off. As they quietly approach his bedside, they see that he is awake. Zazzie crouches to the side of his bed. She gently strokes his arm while the other clown stands at her side, softly strumming her ukulele. Frank covers the top of her hand with small rapid kisses, and says in a plaintive melancholic voice, “I live ‘til now. It’s okay…Thank you very much. You come to see me one last time.” Zazzie continues to gently stroke his arm and begins singing in a contemplative tone, “You have had a beautiful life. You have had much love. You have had a big family.” Frank again gently kisses the top of her hand. He says, “I have to go now. Live healthy and happy. You can do nothing about time goes by. It’s time to go, I have to go. Life pass by.” Zazzie responds with evident sadness, “We can’t change time. Time does what it wants to do.”

Reciprocal play

Carina Bonan, a clown teacher, explains that the purpose of the clown is to “bring a moment of excess, fantasy, offset, love, brotherhood, availability, laugh ... a moment of carelessness” (Red Noses: Clown Doctors International). In this study, the clowns certainly brought these moments of excess to the residents. But perhaps of greater significance is how the residents offered their own moments of fantasy, availability, and laughter through reciprocal play. In the following reflection, Kate/Zazzie and Holly/Cherry discussed how Joseph, a non-verbal resident who was generally described by the staff as unengaged and aloof, used a playful overture by Zazzie to engage in reciprocal teasing:

Kate/Zazzie: In the lounge, we were chatting with Betty, and we had our backs to Joseph. And then I turned around, and he was watching us…He uncrossed his leg, and [with my gaze] I followed his foot [she mimics conveying a playful and exaggerated curiosity]. And I looked at him. I looked at his foot again. I looked at him, and I pointed to his foot [she mimics wonderment]. And he lifted his foot up. And that’s where I went [she mimics gasps of surprise and delight]. And then I looked at his foot again. And he lifted it up, and I’m, like, [she mimics gasp of increased delight]. So that’s how the game started. And then [she turns, speaking to Cherry] …I wanted to see if really he was playing with us. So that’s why I was like, “Oh, you dropped the thing,” and you totally went with it [by picking up an imaginary dropped object]. Love you for that! That was great. And he totally kicked your derriere.

Holly/Cherry: He kicked me! In funness…And [when he kicked me], I would go flying across the room to play with it [to exaggerate the impact of his kick]. And he laughed again. How many times did we [repeat] it? We did it a number of times.

The clowns’ red nose itself signals a visual game (Linge, 2011). Clowns are trained to believe in the transformative power of the red nose – to see it as a “magical object, one that allows [the clown] to enter into another realm of experience” (Butler, 2012, p. 67). This transformative, playful power of the red nose appeared also accessible to some residents, what Butler (2012, p. 67) has referred to as the “empathetic function” of the nose for non-clowns who encounter it, that is, “a sort of permission to behave in a way that conventional social and cultural codes might not sanction.” The ability and desire to be deliberately playful with others is typically not a capacity ascribed to institutionalized individuals with dementia, who are more commonly characterized as the “living dead” (for a critique see Behuniak, 2011). Yet as this video observation reveals, the empathetic function of the red nose fully enabled Doris to be an active participant in the giving, not just the receiving of, humour:

At the doorway to her room, Doris is standing upright, leaning on her rollator walker. Before she permits Zazzie and Cherry to enter her room, as if charging an admission fee, she jokes, “I would like half from your nose,” commenting on the plastic cherry red ball that each clown has attached to their noses by a thin white elastic band that runs over their ears and under their hair. Zazzie dramatically gasps, “half from our nose?” while Cherry looks excitedly at her partner and says, “you first!”… Zazzie and Cherry face each other, and each pretends to wrench away half of their plastic red noses. They join the imaginary halves together, and in a synchronized movement pretend to transfer their combined clown nose to Doris. When their fingers touch her face, they simultaneously mimic the sound of an explosion. Doris’ face animates, and she says, “Ah!” as if having received a magical gift. She looks at them directly, and says of her imaginary clown nose, “now I can go to get marriage!” Reacting with surprise and delight, Cherry loudly echoes, “you can get married now!” Doris leans in, as if sharing confidential information, and jokingly replies, “with this kind of nose.”

As Doris’ actions demonstrate, persons with dementia “can still see a humourous side of things, and they themselves can present that humour” (Hearts & Minds, 2013). Indeed, when the clowns later chose to make the red nose a continued focus of play by providing her with her own red ball nose, Doris expanded and honed the play through her own initiative, improvisation, and wit. During a vide recorded reflection the clown practitioners commented:

Holly/Cherry: I gave [the red nose] to Doris, and she was so excited to receive it and wear it. She kept adjusting it into different positions and saying, “Now my nose is long,” and -

Kate/Zazzie [interrupting]: - And, “I want to wear it on my head.” …Doris was very playful with the nose. …It fell off at one point, and disappeared, and Doris [joked], “Oh! Somebody’s stolen my nose! They’re going to go to jail!”

Clown duo-resident reciprocal playfulness was also facilitated by the improvisation technique, “yes, and,” described earlier. For Frank, a resident who had been a delicatessen owner for his entire working life, his recounting to the elder-clowns of the meats he had once sliced and sold in his shop was spontaneously transformed by them into a joint lyrical storying through “yes, and” that joyfully reminisced another place and time. What began with Frank slowly and rhythmically repeating, “corned beef, pastrami, baby beef, smoked meat, tongue sandwiches,” was first mirrored in tempo, gesture, and affect by Cherry and Zazzie. Upon sensing Frank’s increasing delight when they did so, each clown then began to clamour with higher pitched shouts of “pastrami!” and “baby beef!” Responding to their enthusiasm, and upping the excitement of the play, Frank then began to holler “smoked meat!” as he wildly waved his arms and waited for the clown duo to shout back their response, “tongue sandwiches!”.

Co-constructed imagination

Davison (2006, p. 8) notes that a “mix of literal reality and pretense is so quintessentially clown…Clowns have always played with breaking up reality, and have no problem with existing in both worlds at once: real and pretense.” Imaginative possibility is particularly valuable in the context of dementia where boundaries shift between time, place, and person, and become more fluid and less defined (Mitchell, Dupuis, & Kontos, 2013), and where speech patterns may be slow, broken, or incoherent (Larner, 2012; Östberg, Bogdanović, & Wahlund, 2009).

Clowns often fully embraced the imaginary as a means to counteract barriers to communication such as residents’ incoherent or nonsensical speech in the presence of reminiscence or delusion. This stands in stark contrast to the common response by care staff and family members who “try to bring someone with dementia back to ‘normal’ reality” (Symons, 2012, p. 7). Instead, elder-clowns “surrender to the participant’s reality,” (Symons, 2012, p. 7) and draw on the performative coherence (Hydén, 2013) of residents’ storytelling to co-construct imaginative scenarios. This is demonstrated in the following video observation:

Jean spontaneously says to Aksom in a reassuring tone, “…I'm going to call and see. You can get down, now. Right now it's too late for him. But I'll catch it.” She pauses, and appears to reconsider, “And if that doesn't do it, I don't know.” Aksom responds as if he is following the instructions of an older sibling, and makes to leave. He says to Jean,...“You catch up.” Jean shakes her head sideways to signal ‘no,’ and says quietly, “I'm a breeze of an ant.” Aksom asks in disbelief, “Really?” He leans heavily on the arm of the wheelchair as he coaxes, “We'll do it together. Can you do that?” Jean answers uncertainly, “I think so.” Aksom replies, “You are strong,” and smiles reassuringly. Jean says in a decided tone, “You go out.” He is agreeable, and says, “Okay, I'll go out first.” Aksom then asks, “Do you have your toy? I have mine. You know we have to hide it. Should I bring it?” Jean smiles and says, “I will.” The clown asks excitedly, “Do you remember when we were running and you lost it? And we were looking [for it] and it was dark? We were so young. You were faster than me!” Jean laughs as if humouring him, “let's see what Father has to say.” Jean appears to pull an imaginary scarf from around her neck. She hands it to Aksom. Aksom queries, “should I take it?” Then he hands the imaginary scarf back to her and says, “You take it. You have it. You are strong.” Jean shakes her head and says in a rueful tone, “No, I wasn't.” Aksom responds softly, “I always thought you were strong.” Jean takes Aksom’s hand in hers, and says gently, “Thanks for waiting.” She and Aksom are silent for a few moments as they hold each other’s gaze.

In a researcher-moderated reflection concerning this interaction, the elder-clown duo explained that imaginative play does not require the presence of sensical language in order to meaningfully communicate with, and connect to, residents:

Ann/Mitsy: There was nothing [Aksom] was saying that made sense, but [Aksom’s] response satisfied Jean so deeply... Jean was just like [physically mimics engagement] "yeah".

In that interaction, one clown is strictly an observer of an imaginative narrative that is co-constructed between the resident and the second clown. However, in the following observation, the narrative is a triadic co-construction between the clown duo and resident:

Claire picks up a folded white paper dinner napkin on her night table and slides her finger along the folded layers of the napkin as if opening the flap of a sealed envelope. She squints as she jabs her finger at the napkin as if she is trying to point out an unreadable passage. Aksom leans in closer to Claire and of the completely blank napkin he enquires, “What does it say?” Then he exclaims, “It’s a note! It’s only for you, Claire,” as he lifts his eyebrows in a suggestive manner. Claire replies, “That’s impossible,” but then, after peering again at the blank napkin, appears struck, and says excitedly, “Yeah! Yeah!”Claire pulls the napkin away from her body as if to adjust for bifocals or distance reading while she continues to read from it. Aksom resumes his imaginary reading, “When I saw you, myyyy…world…” His voice trails off uncertainly as if the invisible handwriting is so messy that it is indecipherable. Claire nods her head in agreement, points at invisible words, and continues to read aloud, “was full of gorgeous.” She shows the napkin to Aksom to see if he agrees with what she’s read. Aksom re-reads the invisible passage, “When I saw you…” and Cherry contributes, “My world was full of gorgeous flowers.” In an affirming tone Claire says, “He’s writing it.” and then murmurs something to Cherry who queries, “He’s making a what?” Claire replies, “A diamond.” Cherry gasps. She loudly repeats, “A diamond!” Aksom widens his eyes in surprise, and says, “He’s going to propose. Like me!” and pulls from his side pocket a large plastic purple solitaire engagement ring. Cherry exclaims, “Congratulations!” Aksom continues to read the napkin and adds, “Please meet me at…”. Claire appears to be reading along with him and finishes the sentence, “At the pub at Somerset.” The two clowns simultaneously squeal with surprise, “Oh!” Claire grins and asks, “Is that right?” as if questioning whether she is correct on the location. Aksom grabs Claire’s arm with excitement, peers again at the paper napkin, and replies, “I think so.” Cherry says “Oh my!” Claire gives what looks like an embarrassed yet thrilled smile, shakes her head in disbelief as if relaying great but unexpected news to close friends, and says in a gushing tone, “Oh God!”

Discussion

Our findings highlight the reciprocal nature of clown-resident engagement and the capacity of residents to initiate as well as respond to verbal and embodied engagement. Often with only embodied self-expression and/or nonsensical speech, residents would initiate, modify, and co-construct exquisite moments of engagement with the elder-clowns through affective relationality, reciprocal playfulness, and co-constructed imagination.

Our understanding of affective relationality begins first with an acknowledgment that in this study, emotions such as grief and sadness were found to be a central component of the experiences of residents. This stands in contrast to most of the existing research on grief in relation to dementia, which focuses on caregiving spouses, troublingly termed “crypto-widows” (Doka, 2010, p. 17) due to the losses of intimacy and companionship that renders them “married in name but not in fact” (2010, p. 17). Poor staff support persists for active grieving among persons with dementia (Gataric, Kinsel, Currie, & Lawhorne, 2010). Yet encouragement to express grief and sadness has long been advocated for dementia care to support persons with dementia in their ability to deal with loss (Cheston, 1998). Practice interventions most commonly aim to minimize grief expressions in persons with moderate to severe dementia (Mosher-Ashley & Witkowski, 1999) rather than validate and support such expressions as a natural process. In contrast, elder-clowns in our study showed unique facility in acknowledging and validating resident grief and, as such, are well positioned to improve the quality of the ‘therapeutic landscape’ (Kontos, Miller, Cott, & Colantonio, 2015; Williams, 2010) of dementia care.

A tension persists in clown practice between those who maintain the focus of red nosed clowns should be on the giving and receiving of happiness (Warren & Spitzer, 2011, 2013), and those who posit a role for “dark clowns” to enable the “witnessing [of] tiny moments of humanity” including vulnerability, stripped dignity, and tragedy (Davison, 2013, p. 300). We found elder-clowns transcended this tension since their affective relationality skills were inclusive of both joy and sadness. Similar to Symons (2012, p. 4), who noted that elder-clown interactions result in “dementia sufferers laughing, singing, dancing, joking, playing,” we did at times find that clowns articulated disappointment when they were not able to cheer up sad residents. However, our findings highlighted a variability in clown responses since they also evidenced an adeptness at ‘being with’ the sorrow of residents. In this regard, the clowns accorded greater legitimacy to a range of emotions, including sadness, than other therapeutic approaches that aim to temporally divert the attention of persons with dementia in order to minimize expressions of acute grief (Lewis & Trzinski, 2006). Clown responses to grief are generally consistent with frameworks of presence in nursing theory (Bunkers, 2012; Liehr, 1989; Mitchell & Bunkers, 2003; Parse, 1998, 2007), which promote bearing witness to a patient’s authentic self-expression, including harrowing grief (Melnechenko, 2003), profound fear, suffering, and struggle (Mitchell & Bunkers, 2003). The means by which nursing scholarship on presence eschews “taking away the hurting” (Melnechenko, 2003, p. 23) while remaining fully committed as a healing practice, could well inform the clown impulse, when it emerges, to shift a resident’s emotional timbre from darkness to a state of joy.

Despite that the communicative ability of people living with dementia is regarded as limited when assessed by neurologists and psychiatrists in clinical examinations and tests, self-denigrating humour has been identified as an important, intentional linguistic device successfully used by persons with dementia (Moos, 2011). Nonetheless, this misses other important humour processes and effects that we have identified such as teasing, wit, gaiety, and jubilation, whether expressed non-verbally or verbally. For example, Joseph’s playful kicking was an example of slapstick style physical spontaneity designed to evoke laughter and to initiate a game with no reliance on linguistic engagement. Doris’ articulate jokes of the powers of her clown nose provides further example. There, language was a key driver of interaction through witty, playful scenarios involving the red nose, a toll booth, marriage, and jail. In these instances as in others, the humour was reciprocal in that the elder-clowns added to what the residents offered through exaggerated pratfalls, sound explosions, slapstick jolts, and facial animations either directed at the residents or their clown partner.

Humour alone did not define reciprocal play. As Killick importantly notes (2012, p. 27), “playfulness and humour are not the same thing: the former encompasses the latter.” In our study reciprocal play encompassed both playfulness and humour. This was apparent with Frank whose reminiscent lyrical storying of deli meats met with the clowns’ increasingly excited, higher pitched shouts of “pastrami!” as well as grins and the wild waving of arms. In this regard, the clowns moved away from a focus on explicit humour to what they themselves described as the “funness” of playful engagement (see also Dunn et al., 2013).

Even amongst arts-based approaches to dementia care, rarely are residents’ creative and imaginary capabilities supported. Notable examples include active story-telling (Basting, 2006; Fritsch et al., 2009) and song-writing (Basting, 2009). In those imagination-supportive approaches there is a suspension of the need to determine the fact-based accuracy of details (Basting, 2003), which is a significant shift from the clinical tendency towards the imperative of remembering. Instead, residents are supported in their ability to create (Fritsch et al., 2009). In our study, co-imaginative engagements between clown duos and residents shared many of the key themes identified in other creative expressive approaches. For example, the narratives of intimacy with lovers or families that were frequently told in story-telling workshops (Basting, 2001) were echoed in Claire’s telling of a letter from a lover, and Jean’s narration of comparison of herself to a younger sibling. As Basting (2001, p. 88) notes, “for those who feel simultaneously isolated and fully dependent, dreams…and intimacy are hardly surprising.” However, in this study, an important difference is that the narratives developed synchronously with the interactions, and emerged from organic, spontaneous imaginary co-constructions. Such spontaneity removes the normative, artificial strictures of structured therapeutic programming (Genoe & Dupuis, 2014), which may inadvertently thwart the creative expression it is intended to support. Further, the focus of story-telling on fictionalization, and the removal of all remnants of personal or historical mattering, unintentionally forecloses the possibility of the story-teller being implicated in their own story. In the context of our study, the centrality of the resident in the narrative proved indispensable to the achievement of relational presence, yet without any concern of the elder-clowns to distinguish reminiscence from delusion. This is suggestive that the mattering of ‘who’ must not be disregarded in the creative expressive approaches to dementia care that sidestep the troubling mattering of ‘when.’

In academic research, video data have been used in a range of ways, from capturing in situ practices to modelling practice change (Iedema, Forsyth, Georgiou, Braithwaite, & Westbrook, 2006). This study deployed video to record live clown duo-resident visits in order to enable the researchers to act, asynchronously, as non-participant observers of those visits. The social sciences have seen increasing enthusiasm for the use of video to record social phenomena including interpersonal relations (Rosenstein, 2002). The video camera is believed to afford a unique epistemological perspective which provides not only unparalleled asynchronous access to the “sparkle and character’’ of an event (Rosenstein, 2002, p. 6) but allows researchers, through slow-motion and freeze frames, to “[put] the various dimensions of social conduct into special relief” and thereby untangle “the substantive, normative, affective and temporal facets of situated practice” (Iedema et al., 2006, p. 24). In our case, video footage was repeatedly viewed and studied in progressively greater depth in order to understand the micro relational practices between elder-clowns and residents. This proved indispensable to our analysis and description of the reciprocal nature of engagement, and the capacity of residents to initiate as well as respond to verbal, embodied, emotive, and creative engagement.

Some authors note criticisms that use of the video camera “entrains the ‘Hawthorne Effect,” (Iedema, Long, & Carroll, 2010, p. 76) such that those being filmed are so affected by the experience that they radically modify their conduct. Others however note that, in practice “people are incapable of instant dis- and re- habituation” (Dewey quoted in Iedema et al., 2010, p. 76). Our efforts at acclimatizing residents and elder-clowns to the video camera over a prolonged period effectively minimized elder-clown and resident practices diverging from what one would observe, sans camera, during an elder-clown visit. Indeed, the ability of video to capture everyday clown practice is what made it an ideal investigative tool.

Our analysis of elder-clowning identified intrinsic capacities in persons with dementia – even persons with severe dementia – to initiate affective, creative, and playful engagement using verbal and nonverbal communication. Because this capacity exists a priori, it is critical that it be supported and nurtured in all aspects of institutional life, and not simply through elder-clowning specifically or even arts-based programming more generally. Recognition of this capacity would further the development of the nascent human rights and citizenship culture in long-term care, which holds as a basic tenet our collective responsibility to ensure persons with dementia are afforded every opportunity for self-fulfillment (Kelly & Innes, 2013). Relational presence is an important corrective to the hierarchical positioning of persons with dementia as passive recipients of services. In this sense, relational presence offers an important perspective with which to rethink care relationships between persons with dementia and interdisciplinary care staff. Whether or how relational presence can be taken up by non-clown practitioners, and inform the practice of presence in the therapeutic professions common in long-term care and community-based older persons care, is an important direction for future inquiry.