JESSICA FRIEDMANN: So let’s just jump in, right in the middle: you’re not a medical doctor, and you’re not a clown. Where does the interest in medical clowning come from?

ATI CITRON: It’s a circumstantial thing. I was approached by a group of medical clowns in Israel called the Dream Doctors, in 2006. I was chair of the Department of Theatre at the University of Haifa, and they had a vision. It was to make medical clowning, or clown doctoring as it’s called here, a legitimate paramedical profession, which they compared to physical therapy or occupational therapy. In Israel you have to have a Master’s degree in order to practise one of those in a hospital. You don’t need that, right now, for medical clowning. And they wanted to have the academic training, and the professional training, that will eventually create it as a legitimate profession. And they turned to me. With the advice of my colleagues, I created a really interdisciplinary program. It had classes from everywhere, so it was getting to know the public health system in Israel, perceptions of the body in different cultures, perception of illness or wellness in different cultures, palliative care, introduction to developmental psychology, to sociology. In the studio, they had improvisation classes, movement and voice, music therapy and costume design. Of our first graduates, four of the twenty continued to a Masters program in drama therapy, and they’re going to be writing their thesis this year. So that’s how I got into it.

Now, there’s another little thing: they knew that I am a good person to do that in terms of my interests, because I was studying shamanism for so many years. And it just fell right into place. Shamanism, healing—I am a strong believer in performance as a healing agent.

It’s the song and the dance. If you believe in that, that the performance counts more than the agent, the chemical, because it changes the state of mind of the patient to having faith in the healing process, then he would be very receptive to the drug, to anything, because he has faith. And it’s true in our medicine as well.

When I started teaching, I realised that there’s a lot that I could learn from the clowns. I started doing that, and I started asking questions. I became involved, more and more, in the work they do. I’ve tried to see what techniques are being used, so it’s parody, it’s playfulness, it’s fantasy, it’s chaos, it’s all these things, and now I’m going back and looking at indigenous healing rituals to see if they use the same techniques, and what happens.

Those haven’t really been codified as healing techniques before, have they?

No, I don’t think so. I mean, they may have been codified in terms of routines that clowns do in cabaret, or circus, or something like that.

I’m really interested to hear you talk about cabaret, because one of the things I’ve found quite striking in the literature I’ve read about medical clowning is its links with shamanism, and burlesque, and the satirical figure, and, oh, ‘contrariness’? Is that the term?

Well, sometimes we call it ‘reversal’, or ‘anti-structure’ as my great teacher, the anthropologist Victor Turner, would call it, so that would mean that everything is upside down, people are standing on their heads as they do in Australia.

We’re an entire country of upside-down.

And it is associated with cabaret—I teach a course in cabaret, I love cabaret, studied it and have a lot of material about it, from the birth of cabaret in the 1880s in Paris, and then like a plague it went all over, to Germany, to Austria and Spain, and so on and so forth. I call it the anti-aesthetics, because in cabaret as in carnival, another field that I am interested in, everything is upside down. Now in order to do things upside down, you need to be intimately familiar with how they are. You need to know what the structure is in order to turn it upside down. For example, the only Jewish festival that is close to carnival is Purim. In the Yeshiva, in the high high education of the men who study the Torah, in Purim they have something similar to a carnival king, a carnival rex, who’s always a fool. They have in the Yeshiva a carnival Rabbi, the Purim Rebbe, and the Purim Rebbe has to be one of the best students, because he has to be so witty, he needs a sense of humour and wit and ability to satirise, but he can not be just a person with a good sense of humour because he needs to know the literature to turn it upside down.

So the reversal of structure is a magnificent thing that is really present in carnival, in cabaret—when I teach this course I go gradually until I get to the heart of the thing. The heart of the thing is that the most successful cabaret artist in the 1890s in Paris was Le Pétomane, who was farting music. And he was considered the greatest cabaret artist, he was at the Moulin Rouge and he could play any tune from his anus. He would be in a tuxedo, like totally neat and really artsy, and he would just fart the music. And people were astonished, amused, you can look him up on YouTube, there’s a documentary, there’s a feature film about him and I get gradually to the heart of this because I say this is leading students to a real understanding of what it means, “reversal of order”, what it means “anti-structure”.

It’s part of the cult. And you go to cabaret in order to explore that. That’s why cabaret singers, for example, usually have bad voices. And the Zuni clowns [of the Pueblo people of the Southwestern United States], when they’re invited to help the medicine man, he has to tell them “buzz off “, and they walk in reverse into the room and they talk in reverse. What an art form! I can’t imagine myself doing that.

So we’re talking about disruption, inversion, the toppling of hierarchies—how does this fit into the hospital—

[Dramatic groan]

—which is a place predicated on hierarchy, sterility, cleanliness…

It’s perfect for the hospital, because we’re talking about hospitals really the way we know them, that are hygienic, orderly, hierarchical, solemn… and until the clowns were there, and even sometimes still, because we don’t have enough of them and not in all the hospitals, the system tends to forget that the people with a kidney problem, heart problem, broken limb or cancer are people, not organs that have a disease. Hospitalisation is pretty traumatic and disenfranchising for the patients, because you lose your identity when you’re in hospital. You become a case. You wear a uniform. You obey orders. You have to comply with everything you’re told to do, even when you have no clue why you’re doing that or where it is that you’re being dragged by an orderly, along endless corridors. It’s really like an initiation ritual where you’re supposed to have your identity erased in order to become something new.

It’s become a myth already because it turned into a film and so on and so forth, but what we know is that when Patch Adams first tried it, he got a kick in the ass and was thrown out, because his professors thought that introducing humour or a red nose would just be totally out of place and that he should experiment somewhere else. Later on, just fifteen years later, the medical system was a bit more open to that, because it began cautiously to absorb alternative medicine, homeopathy, reflexology, what-have-you, acupuncture, things that some doctors still think are rubbish, just voodoo. But since there’s so much demand, all clinics subsidise it and you can do it and it’s considered legitimate.

When it began in the mid-eighties, the medical system was ready to get more humane-faced. More personal. The whole concept of holistic medicine became recognised by enough people to have it not be some type of voodoo. The changing world of circus allowed the clown to become more than just a marginal figure. I mean, sometimes they still were and sometimes they were very important, but there was space for the clown to develop into something more three-dimensional—of course not denying his most substantial traits.

I was about to say—a big part of the identity of the clown is that he exists on the margins of society, and that because of that he might have special powers or knowledge that the rest of society can’t access. His marginality is crucial.

Absolutely. It’s true, and it’s part of his power really, but this is a different kind of marginality. Just now, I was talking in terms of status, even in circus, and then circus was marginal, some people say liminal really, because in the twilight zone outside of the city, there’s risk involved in that. Queer show, you know, woman with a beard—to be associated with that is really to be associated with the underworld. When circuses did not have animal acts anymore, and freak shows, it became more theatrical so that the human aspect and the virtuoso qualities were more important than if there were dwarves.

The clown represents failure. Always. One of the things that works best is that the clown tries to enter a room in the ward, and he first bumps into the door or the window. And the kid inside says “Ah, silly!” and the clown sticks his head in the open door and says, “How do I enter?” And that is immediate empowerment of the patient, as the patient for the first time since hospitalised knows better than someone who is part of the system and at the same time not part of the system. And he’s called a doctor—Dr Achoo, Dr Doctor, Dr Cracker, whatever. And this doctor is funny – looking, and he doesn’t even know how to walk through the open door. He bumps into things. He asks you how old you are, and you say “Eight”, and he says “Eight thousand? That’s very old!” “No, eight!” So the clown doesn’t see well, doesn’t understand what’s going on, fails in almost everything. And that puts him in a lower status than the patient. And these are tricks that they took from the traditional clowns in the circus and the cabaret.

The clown, as well as being a marginal figure, is often quite a grotesque figure. We were talking about the public face of the hospital as being sterile, when in fact it’s a place you go when you’re in a very abject condition in your own body, and have to become un-abject to be allowed back into functional society. So does the clown mediate not just between patient and doctor, but also between states of illness and states of wellness?

I think so. I mean, the clowns I work with, put it this way, they said—actually one of the doctors said, let me quote him, it’s on a YouTube Dream Doctors video, he says, “The clowns heal just as much as we heal, only they use different methods.” And the clown said, the medical stuff deals with the unhealthy part of the patient. We deal with the part that is healthy. We can empower that part, and help the patient do proactive healing. This is by the way, called placebo. In traditional sciences, pharmacology, drug development, placebo is the enemy.

Placebo is mysticism?

Right, it’s like—you give the patient a salt pill and you tell the patient this is a new drug, and the patient heals. There’s a recovery, and they say “Ugh! They just believe the bullshit we say.” And a recent experiment in placebo, by the way, and this is amazing, because they tell people this is placebo and they still recover. Which means that there’s something there that is deeply rooted in us and is necessary for the recovery, and that’s a kind of faith and get-our-act-together to get better. Now, people are starting to say with placebo, “What’s so bad about a patient who hears a doctor say ‘This is a new drug, take it’, and it’s not a new drug at all, and he recovers?” It’s cheaper, no side effects! [laughs]

It’s so much cheaper because to develop a new drug is so enormously expensive. So I’m not saying we should stop developing new drugs, but I’m saying we should recognise the importance of placebo. I just recently learned that placebo comes from the same root, verbally, as pleasure, and being pleased. So what is better than the clowns being a paradigm of placebo? The process needs something like that, and it’s true that clowns are sometimes grotesque. We try to minimise that aspect of the clown because the grotesque is also frightening.

I think the grotesque, although it’s not completely out of the repertoire, it’s not the strong thing, because grotesque has death in it, and you don’t want too much of that.

Still, we know that there’s clown phobia, so you need to approach them gently, to find detours. It’s not very common, it happens but it’s not very common.

Most people respond well—sometimes with subdued suspicion. Yesterday, for example I saw a mum who was not very cooperative. But her two boys were so joyous and loud in their interaction that even her suspicion or her detachment did not interfere with a good scene that was taking place. So it’s important not to be too brassy, not to be too loud, not to bring a big circus presence, because you’re not performing—you’re interacting.

For you personally and clown doctors more broadly, how does the experience of performing, of being a performative figure in such a strange space as a hospital, affect your own perceptions of illness or health, or your own experience of illness or health?

[pause]

For me personally, that’s a confession, it brings back memories, because I was badly injured in the 1973 war, in the abdomen. And I was going through another operation, another and another, for years. Early on, the thing is that when you have stitches in your abdomen…

You can’t laugh?

You can’t laugh. It’s hard to breathe, too, especially for a person who did acting before that, especially because many people don’t realise that they use their abdominal muscles to breathe and many use less than us actors, who learn to use the diaphragm, to get as much control as possible. I had to unlearn it, and use from the chest up. And I developed this weird-sounding laughter, because I laugh a lot. And they called me “Smiley” in the hospital, because I was an optimist and I knew I was going to get through it.

Shamans have to die first, before they even begin to learn anything. They have to have an intimate relationship with death before anything, either by illness or by a snake that bites you or serious injury or something like that.

At one point, early on, when I was after two or three, maybe four operations, I heard that the most popular entertainment group in Israel, a trio, was coming to the hospital. And of course immediately they let me know that I am not allowed in. And I said, “But I know how to manage this! I developed this chest kind of laughter which sounds horrible but I can laugh this way!” So they said okay. And surely, once they started, I forgot about this and I laughed and all the stitches popped out. And they asked them to stop, and I’ll never forget the face of one of them—it turned grey with guilt, because he felt so bad. He was there to make people happy, and all of a sudden he saw me in real pain. (laughs) And the nurses, really concerned, pushing me out. It was packed, it was a small room, it was packed with people, and manoeuvring a bed to the treatment room and later to the operating theatre… It was like, “What did you do?!”

So this is a very strong recollection that I have, that always comes back to me when I think of how you need to walk on eggs. You have to be fully yourself as a clown, and yet, you need each time anew to know not to overdo it, to use the right magnitude, because you look at illness and injuries all the time and you realise that none is similar to the other. The cases, to the doctors, sometimes look the same—I don’t think they look the same, but the approach is that a heart attack is a heart attack and we just mark where exactly in the heart it took place. But one boy with a broken leg could be totally depressed because he was supposed to participate in a match, and another would be a healthy boy with a broken leg. The clowns develop a certain kind of maturity, because you also see all sorts of deformed people, all kinds of people who are people, but have no limbs, or have no lower body, or all kinds of things that you don’t normally see because many of them stay in hospital most of their life.

And all of a sudden you’re there, and you realise that they can laugh, they can participate, they can be empowered… So this maturity that they require or develop gradually, is to realise… The Dream Doctors call this magic word, “the entrance”. You cannot miss the entrance. It’s all in a capsule, in one split second, that you need to be in touch with the entire environment. You don’t even have time to think and there’s no gap between getting the picture and responding, it’s at the same time. So your intuition, your realisation, not only of the patient but of how many people are in the room—do we have people at our back, so we interact with them and then we turn, or do we interact with all of them? Parents, siblings?

All kinds of things. What’s amazing to me is the brain, how fast it can work at so many different levels. Because once you make your entrance, you’re committed to something, and it better be right—you can’t stop.

In the space of the hospital—I was going to say the performance space—

It is a performance space, definitely!

—you were talking about how intuitively a clown needs to be able to react to patients, or read a room, in a way that does seem to parallel shamanic trances.

What I described as the best clown performance that I saw, here in Australia, one of the best I’ve seen ever, and when I was asked what was so good about his performance, I said it was totally relaxed, he did not produce anything, it just came out of him. We define it in performance studies as ‘flow’. This is something that was beautifully described by a psychologist, an American psychologist, his name is Mihaly Csikszentmihalyi, who wrote a book called Beyond Boredom and Anxiety. He says that when the requirements of a given task are higher than your capabilities, anxiety is experienced. When it’s the opposite, when it’s lower than your abilities, boredom is experienced. Flow is beyond that, and that’s where there’s a perfect match between what you can do and what you feel that you can do and the requirements and the challenges. The term ‘flow’, we all understand intuitively but when it’s defined so precisely it’s beautiful because there’s no reward outside of the action, that’s where the reward is. You feel privileged to be doing it, and when you are in flow, you don’t think, you don’t reflect.

To watch this clown in flow was to watch a clown—this was in the burns clinic—interact with a child who had a bad burn in his hand. It was very painful, and the most painful moment is when they have to take the bandages off, and to clean and to take a picture of the wound. The pain is not ignored, because the child experienced pain, and he screamed, and tears came down his cheeks, but in an instant he was back to his total engagement with the clown. The clown, wisely enough, was already there before the procedure began. So you can use the clowns so beautifully.

We’ve been talking mainly about the clown doctors working with paediatric patients, who are strongly encouraged to develop dream worlds and to have a playful attitude towards what is possible and what is impossible. Adult patients and the elderly are strongly discouraged from entering those phases, or I guess pathologised when they begin to exhibit behaviour that veers too far from a literal engagement with the world as-is. Does clown doctoring work well with the adult patient, or is it something that is better suited to children?

It works extremely well. At this phase, most of the clown doctors in the world work more with kids than with adults, but there’s so many exceptions that I think in the near future it will no longer be true. For example, in Israel they started working with adults in the dialysis room. Dialysis being probably the most depressive, because it has no hope, except for transplant, it’s a routine maintenance thing that is very painful, absolutely necessary because without it you die, and yet it’s not like you’re there for a week and you’ll be well—you’re there forever, and you’ll never be well. So the staff is also depressed. So they started there and found that the response was amazing. Anything to break the routine, just to chat, because usually they’re put on the dialysis and they’re left, they’re there, what do you do? You can’t read, it’s really terrible. So to have a clown there, it changes their lives all of a sudden. And for the staff that’s also depressed, to be able to joke… that’s one thing.

The other thing they do, the same team of clowns did work with ambulatory oncology patients who came through chemo. You’re talking about one large room of about twenty people, with their accompaniment, daughter, son, husband, wife, whatever, sitting in armchairs and having their chemo in IV. They were having lunch, when all of a sudden in come two clowns, with a horn, with this and that and lots of noise,

and the patients were like—wow, we didn’t know you could do that! Amazing! Amazing!

So yes, it can work miracles. I watched a beautiful piece of video from Scotland, where it was just a woman with dementia and a female clown, and the clown would take a hat and put it on and say, “I wonder, what hat should I be wearing today? Do you think this agrees with me?” And the woman was blank. “Okay, so you don’t like this one. How about this one? Do you like it? Ah… I don’t think you like it.” And I think it’s on the seventh or ninth hat, she puts it on and all of a sudden this woman, the lights come up and she says,“Yes…” and that’s it.

I still have goose pimples when I talk about this because this was one of the most moving moments in watching and dealing with clown doctors, because as a clown doctor you need so much faith and persistence and patience not to despair. How do we know that it’s going to happen on the ninth hat, and not on the twenty-seventh hat? You need to keep trying. And yet the reward, as little as it is, is so precious and so significant all of a sudden. No one can tell us, because we still know so little about dementia and about Alzheimer’s, if this can have a real effect on the ability to communicate, on the ability to function. Who knows? Maybe this is a way to follow in the future. So that was a revelation for me.

You know, you open with, “You’re not a doctor, you’re not a clown”—I realise that looking back on what interests me is always one thing, theatre that is effective. Because in our life, most theatre is totally insignificant. You go, you like it, you like it very much, you talk about it over dinner post-show, and you forget about it. You send friends, but it didn’t change your life a bit.

And yet, theatre, when it was born, it meant to change your life. It meant to be effective, to have some impact. So you see shamanism—you know when I went to South Korea and I documented this initiation rite, twelve-hour rite, someone asked me, “What brings you here, are you a doctor?” I said, “No, I’m a theatre person” and they said, “This is no theatre, you know.” And I said, “Of course.” But in my heart I thought, “Oh, you’re completely wrong, this is the theatre. This is the only theatre!” Because this is something that changes reality. That by the stupidest thing of pretence… of course, they don’t think it’s character acting. When I say, “She portrays a spirit”, it’s nothing like that.

“She channels a spirit”?

She channels a spirit, she summons the spirit, and when she is in trance, the spirit possesses her. They explained the physicality of it as that her own soul gives way, and that the body is just a vessel, and the spirit gets in the body. The conceptualisation of this is completely different, but I insist: it’s theatre. I saw, for example, that all these shaman disciples can get in trance—there were four of them, I think—and with two I could say within a second that they would be a failure. How, I don’t know anything about shamanism? Well, I know, I read. But I’m a director. I’m a theatre director. And I know an actor. And I know the concentration, the focus, and that’s what I teach. I teach directing I teach acting, that’s my specialty.

My specialty is to be able to discern this, and say, “this is not honest” or “this is not truthful” or “she is not focussed, she is focussing on whether we videotape her.” She was the only one throughout the twelve-hour session who said “no photography please”. And I said, okay, if the big shaman did not mind, the initiate did not mind, only she—she must be very vulnerable, and even defensive. She was a bit aggressive about asking not to take photographs—everybody was videotaping. The minute she said that, I said, “Oh, she’s not focussing on the right thing. She’s focussing on how she’s going to be perceived by others.” Photography or otherwise, we still had our eyes open and looked at her, and she failed.

Often when actors get in the part, they never get out for a long time. It depends on the actor. And we talk about versatility, it’s that you still bring all the souls you have inside, and yet discover another one. And with the shamans it’s the same thing. They know they have a repertoire of spirits, and costumes and everything, but a student of mine who went and recently did her PhD on shamanism in Korea focussed on the stores that sell them the costumes and the props, and she said the owner of one store decided to develop a new spirit. It’s not like she made it up completely, but it was a marginal spirit that was not part of the repertoire. She wanted to sell more costumes and props, so it became the fashion. Now all shamans do this new spirit, which was not in the repertoire.

So many things influence the dynamics, and the shamans too need to explore new terrains, in the repertoire. So it’s very similar to theatre, and my guide in that for a large part was Antonin Artaud, a French poet-actor-director, who wrote The Theatre and its Double, and there he says there’s no reason to do theatre if it’s theatre that doesn’t change reality.

And he calls it cruelty, because he says you need not to be flexible in the sense of flexibility of your standards, of your ethos, of your desires, because both performer and audience, which he calls participant, should be transformed, as he saw in Balinese theatre. But I call him a prophet, because he was hospitalised for most of his adult life in a mental institution, was brought back from Ireland in straight-jacket, identified with the Indians who did peyote and did it with them.

So he was a marginal character, in a way. But the writing he produced—he never managed to do the theatre that he wanted to do—that’s why I call it prophecy, because it’s not to be materialised, it’s just to be like a compass saying “Go there! Go there! This is the right road! Don’t stray, don’t go other ways because they’ll bring you easier success, because it’s entertainment”. This, for me, is really the essence of theatre that can change life.

The nice thing about medical clowning is that it’s the same, not that it’s not a job, but it’s there to change people’s lives, just like shamanism, just like other rituals. And that’s the glory of it, the beauty of it. It comes from the inner faith that theatre was born of, that by making faces and gestures and telling weird stories all together, you can change people’s lives. And that’s beautiful.