Circus as Occupation in Individual, Community, and Socio-Political Contexts
Submitted by
Jill Maglio
Doctor of Philosophy, La Trobe University
A thesis submitted in total fulfilment
of the requirements for the degree of
Doctor of Philosophy
Department of Occupational Therapy
La Trobe University
Victoria, Australia
May 20th, 2024

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Table of Contents
List of Figures ………………………………………………………………………………………………………………. 11
List of Tables ………………………………………………………………………………………………………………… 12
Abstract ……………………………………………………………………………………………………………………….. 13
Statement of Authorship ……………………………………………………………………………………………….. 15
Acknowledgements ……………………………………………………………………………………………………….. 16
CHAPTER 1 INTRODUCTION ……………………………………………………………………………………. 17
Circus as Occupation in Individual, Community, and Socio-Political Contexts …………………. 17
Occupation Based and Focused Practice ………………………………………………………………………. 20
Understanding Historical Practice for Present Day Relevance ………………………………………… 21
Circus as Creative Arts Occupation ……………………………………………………………………………… 25
The Evolution of Circus Mirroring the Evolution of Occupational Therapy ……………………….. 26
Traditional Circus ………………………………………………………………………………………………………. 30
New Circus as a Socio-Political Occupation ………………………………………………………………….. 31
Social Circus as both Occupation-Based and Focused ……………………………………………………. 37
Social Circus Intersection with Health Professions and Occupational Therapy …………………. 42
Social Circus Through an Occupational Therapy Lens ……………………………………………………. 48
Social Circus and Occupational Therapy for Individual and Community Wellness …………….. 49
Circus and the Macro Context of Occupational Rights ……………………………………………………. 53
Summary and Overview of Next Chapters ……………………………………………………………………… 55

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CHAPTER 2 SCOPING REVIEW ………………………………………………………………………………… 57
Background ……………………………………………………………………………………………………………….. 60
Aim …………………………………………………………………………………………………………………………… 60
Methods …………………………………………………………………………………………………………………….. 61
Identifying the Research Question ………………………………………………………………………………… 61
Research Question ……………………………………………………………………………………………………… 62
Identifying the Relevant Studies ……………………………………………………………………………………. 62
Scoping Review Findings …………………………………………………………………………………………….. 66
Implications ……………………………………………………………………………………………………………….. 78
Limitations …………………………………………………………………………………………………………………. 80
Chapter Summary ……………………………………………………………………………………………………….. 82
CHAPTER 3 METHODS ……………………………………………………………………………………………… 84
Overarching Paradigm ……………………………………………………………………………………………….. 84
Collective Case Study ………………………………………………………………………………………………….. 89
Methods …………………………………………………………………………………………………………………….. 93
Aim, Objectives, and Research Question ……………………………………………………………………….. 94
Aim ………………………………………………………………………………………………………………………. 94
Objectives ……………………………………………………………………………………………………………… 95
Research Question ………………………………………………………………………………………………….. 95
Study Design ………………………………………………………………………………………………………………. 95
Participant Selection and Recruitment ………………………………………………………………………….. 97

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Data Collection ………………………………………………………………………………………………………….. 99
Ethical Approval ………………………………………………………………………………………………………. 101
Data Analysis …………………………………………………………………………………………………………… 101
Chapter Summary ……………………………………………………………………………………………………… 109
CHAPTER 4 FINDINGS …………………………………………………………………………………………….. 111
Beatrice …………………………………………………………………………………………………………………… 112
Vivienne …………………………………………………………………………………………………………………… 118
Emily ………………………………………………………………………………………………………………………. 121
Stephanie …………………………………………………………………………………………………………………. 125
Henry ………………………………………………………………………………………………………………………. 128
Julie ………………………………………………………………………………………………………………………… 130
Margaret …………………………………………………………………………………………………………………. 132
Sarah ………………………………………………………………………………………………………………………. 134
Occupational Therapists use of Circus in their Practice ………………………………………………… 139
Case One: Individual Focused Case ……………………………………………………………………………. 141
Case Two: Community Health Focused Case ……………………………………………………………….. 155
Chapter Summary ……………………………………………………………………………………………………… 166
CHAPTER 5 DISCUSSION ………………………………………………………………………………………… 168
Reflections and Interpretation of the Findings ……………………………………………………………… 168
Key Findings ……………………………………………………………………………………………………………. 169

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Key Finding 1: Circus use by occupational therapists as remediation to improve capacities
…………………………………………………………………………………………………………………………… 170
Key Finding 2: Enhanced preparation and education of occupational therapy students and
professionals is required to enable them to contribute to community-centred practice using
circus …………………………………………………………………………………………………………………… 174
Key Finding 3: Collaboration between circus, occupational therapy and community
development professionals can progress the occupational therapy profession to promote
occupational rights ………………………………………………………………………………………………… 175
Micro, Meso and Macro Contexts ……………………………………………………………………………….. 178
Circus As Remediation of Individual Capacities: Valid, Limited, and the Result of Education
……………………………………………………………………………………………………………………………….. 181
Circus as a Play Activity and Occupation: Reconciling Mutual Exclusivity ……………………… 185
Towards Greater Wellness: Remediating a functional impairment focus alongside community
centred practice ………………………………………………………………………………………………………… 189
Circus as an Innovative Means for Occupational Therapists to Promote Engagement in
Meaningful Occupations ……………………………………………………………………………………………. 197
Circus as an Innovative Means for Occupational Therapists to Enable Community Wellbeing
Through Participation: Possibilities and Barriers ………………………………………………………… 201
Community Participation Through Circus as Occupation: Maximising Community
Development …………………………………………………………………………………………………………….. 203
Occupational Therapists’ Role in Addressing Social Determinants of Health for Occupational
Justice ……………………………………………………………………………………………………………………… 210
Occupational Therapy Challenges in Participating in Community Development Actions …… 214

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Envisioning a More Comprehensive Form of Circus as Occupation: Effective Actions in
Community Development Practice ………………………………………………………………………………. 219
Contemplating Education Opportunities Through Multi-Discipline Collaboration …………… 221
Kawa Model, Circus, And Community Development ……………………………………………………… 231
CanMOP, Circus, and Community Development ………………………………………………………….. 232
A Collectivist Approach for Circus use by Occupational Therapists ……………………………….. 236
An Explicit Focus on Occupational Therapy Participation …………………………………………. 237
Removal of Categorisation …………………………………………………………………………………….. 237
Explicit Consideration of Meaning ………………………………………………………………………….. 237
Advanced Consideration of Performance Components and Environment …………………….. 238
Explicit Consideration of History ……………………………………………………………………………. 238
Explicit Consideration of Occupational Possibilities …………………………………………………. 239
Social Circus as a Means of Community Development Education for Occupational Therapists
……………………………………………………………………………………………………………………………….. 239
Limitations ……………………………………………………………………………………………………………….. 243
CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS …………………………………….. 246
Circus Use Impacts …………………………………………………………………………………………………… 250
Collaboration: Occupational Therapy as Activism ……………………………………………………….. 257
Key Points for Further Research, Education, and Practice ……………………………………………. 259
References ………………………………………………………………………………………………………………….. 265
Appendix A …………………………………………………………………………………………………………………. 288
Ethics Approval ………………………………………………………………………………………………………… 288

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Appendix B …………………………………………………………………………………………………………………. 290
Methodological proposal guide ………………………………………………………………………………….. 290
Appendix C …………………………………………………………………………………………………………………. 291
Participant information statement ………………………………………………………………………………. 291
Appendix D …………………………………………………………………………………………………………………. 294
Withdrawal form ………………………………………………………………………………………………………. 294
Appendix E …………………………………………………………………………………………………………………. 296
Consent Form …………………………………………………………………………………………………………… 296
Appendix F …………………………………………………………………………………………………………………. 298
Participant demographics ………………………………………………………………………………………….. 298
Appendix G ………………………………………………………………………………………………………………… 300
Interview guide …………………………………………………………………………………………………………. 300
Appendix H ………………………………………………………………………………………………………………… 301
Preliminary finding WFOT poster ………………………………………………………………………………. 301
Appendix I ………………………………………………………………………………………………………………….. 303
Acrobalance …………………………………………………………………………………………………………….. 303
Appendix J …………………………………………………………………………………………………………………. 304
Acrobalance group ……………………………………………………………………………………………………. 304
Appendix K ………………………………………………………………………………………………………………… 305

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Acrobatics ……………………………………………………………………………………………………………….. 305
Appendix L …………………………………………………………………………………………………………………. 306
Balance-based activities 1 ………………………………………………………………………………………….. 306
Appendix M ………………………………………………………………………………………………………………… 306
Balance-based activities 2 ………………………………………………………………………………………….. 306
Appendix N …………………………………………………………………………………………………………………. 308
Clowning …………………………………………………………………………………………………………………. 308
Appendix O ………………………………………………………………………………………………………………… 309
Hula hoop ………………………………………………………………………………………………………………… 309
Appendix P …………………………………………………………………………………………………………………. 310
Juggling …………………………………………………………………………………………………………………… 310
Appendix Q ………………………………………………………………………………………………………………… 311
Object manipulation ………………………………………………………………………………………………….. 311
Appendix R …………………………………………………………………………………………………………………. 312
Performance 1 …………………………………………………………………………………………………………….. 312
Appendix S …………………………………………………………………………………………………………………. 313
Performance 2 ………………………………………………………………………………………………………….. 313
Appendix T …………………………………………………………………………………………………………………. 314
Social and professional circus ……………………………………………………………………………………. 314

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Appendix U …………………………………………………………………………………………………………………. 315
Various circus disciplines ………………………………………………………………………………………….. 315

THIS PAGE IS INTENTIONALLY LEFT BLANK
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List Of Figures
Figure 1 The Kawa Model ………………………………………………………………………………………………. 52
Figure 2 Scoping Review Prisma Flow Diagram ……………………………………………………………….. 65
Figure 3 Practice Trends Among Case Study Participants …………………………………………………. 172
Figure 4 Occupation- Based And Occupationally-Focused Practice Model …………………………. 178
Figure 5 Evolution Of Occupational Therapy And Circus …………………………………………………. 181
Figure 6 Csikszentmihalyi’s Flow Chart ………………………………………………………………………….. 200
Figure 7 Aerial Double Lyra Social Circus Focus-Social Capacities ………………………………….. 225
Figure 8 Aerial Double Lyra: Social Circus Focus-Emotional Capacities ……………………………. 226
Figure 9 Aerial Double Lyra: Occupational Therapy Circus Focus-Physical Capacities ……….. 227
Figure 10 Aerial Double Lyra: Occupational Therapy: Circus-Cognitive Capacities ……………. 228
Figure 11 Occupational Therapy And Circus Collaborative Model …………………………………….. 235
Figure 12 Key Points For Further Research, Education And Practice …………………………………. 262

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List of Tables
Table 1 Inclusion And Exclusion Criteria …………………………………………………………………………. 63
Table 2 Summary Of Studies Selected ……………………………………………………………………………… 67
Table 3 Semi-Structured Interview Guide …………………………………………………………………………. 99
Table 4 Coding Strategy Example As Applied To Interview Transcripts …………………………….. 106
Table 5 Additional Interview Questions ………………………………………………………………………….. 108
Table 6 Case Study Participants …………………………………………………………………………………….. 112

Abstract
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Circus use by occupational therapists is an emerging area of practice. Circus can
be described as an occupational form of the creative arts that has potential use for
occupational therapists working in individual, community, and socio-political contexts.
This study explored how occupational therapists use circus in practice and the potential
implications of broader applications that address the needs of communities on a global
level. Background literature on circus related to community health is included in this
study to highlight parallels, differences, and potential opportunities that exist between
occupational therapy-informed circus and non-health-related circus practices.
A collective case study design was used to increase understanding of how
occupational therapists are using circus in their practice. Purposive sampling ensured that
cases selected were practicing occupational therapists currently utilising circus in
individual, community, or socio-political-focused contexts. Semi-structured interviews
captured a detailed account of participants’ use and rationale for using circus. The data
collected were analysed using interpretive/thematic analysis to gain an in-depth
understanding of each individual case before eliciting and describing aspects of circus use
by occupational therapists common to all cases.
The findings of this study into occupational therapists’ actual use of circus reveal
that most therapists use circus in individualistic, reductionist and occupation-based ways,
albeit with awareness and motivation for more community and socio-political focused
practice. Through this study, a potential is realised for circus to be used by occupational
therapists for community development and to advocate for occupational justice. This
research contributes a model for advancing the occupational therapy profession in
actualising this potential and moving toward meeting the complex needs of individuals
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and communities in collaboration with other social activists. Recommendations are made
regarding strategies for progressing occupational therapy education, complimentary use
of occupation-based and occupationally-focused approaches and increasing collaboration
opportunities for using circus in community health contexts globally.
Statement of Authorship
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Except where reference is made in the text of the thesis, this thesis contains no
material published elsewhere or extracted in whole or in part from a thesis accepted for
the award of any other degree or diploma. No other person’s work has been used without
due acknowledgement in the main text of the thesis. This thesis has not been submitted
for the award of any degree or diploma in any other tertiary institution.
The research procedures undertaken were all approved by the La Trobe
University Human Research Ethics Committee, in accordance with all policies and
procedures associated.
Jill Maglio
May 20, 2024
Acknowledgements
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Thank you to my supervisors Professor Carol McKinstry and Associate Professor
Tracy Fortune for their unwavering patience and support as I have grown through this
humbling process experiencing the temporariness and value of both success and failure. I
am also grateful to my parents, Lois and Angelo Maglio for their continual support in so
many ways throughout my education journey.
Thank you to all CircusAid participants over the past seven years. Working
together with a diverse group of participants, volunteers, and partner organisations has
taught me so much about resilience and the importance of collaboration which continues
to inspire my work as an occupational therapist.
To the occupational therapists who participated in this study, I am grateful for
their time, energy, reflection on their practice, and willingness to speak with me about it.
The data provided by the case study participants provided the base for the knowledge
presented here.
This research is dedicated to the marginalised, the outsiders, the refugees, the
renegades, the anarchists, the freaks, the square pegs in round holes, the misunderstood,
the great minds who do not have the privilege of higher education, the tolerant, and all
those trying to create a more empathic and humane society.
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CHAPTER 1 INTRODUCTION
Circus as Occupation in Individual, Community, and Socio-Political Contexts
The research undertaken and reported on in this thesis relates to the use of circus
by occupational therapists. In this chapter I outline why this research is important, what is
already known about the intersection of circus and occupational therapy and related
topics. The research questions or gaps the thesis will address to advance knowledge are
also outlined. The research question for this study is focused on how circus is being used
by occupational therapists in the individual, community, and socio-political contexts of
their practice. This focus is important for the occupational therapy profession,
occupational therapy services users and those involved with circus, specifically those
using circus as a therapeutic or community-building method.
The use of circus in occupational therapy is increasing, with more occupational
therapists using circus as part of their practice with individuals, groups and communities
of different ages and backgrounds (Baumgold, 2017; Fernandez et al., 2018; Loiselle et
al., 2019; Maglio & McKinstry, 2008; Thompson & Broome, 2021). In the literature,
there is evidence that different forms of circus have been used to positively impact
community well-being through performances that challenge political structures and
Social Circus programs that promote social and emotional health (Grimes, 2011;
Infantino, 2015; Li, 2010; Maglio & McKinstry, 2008; Spiegel et al., 2015; 2018; 2019).
Circus is an emerging area of practice for occupational therapists that has not been widely
researched. The professions of occupational therapy and circus appear to have common
values related to community and socio-political wellbeing with calls for occupational
therapists to work beyond the individual and consider communities as clients.
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Several occupational therapy practice models propose collaborative action focused on
occupational rights, and circus is posited to be an occupation through which such an
agenda could be advanced.
Community development has been identified as an important domain of practice
for occupational therapists to improve community health inclusive of individual
capacities, community cohesion, and community action to challenge inequalities
(Lauckner et al., 2019). Occupational therapy and circus are somewhat specialised and
under-researched areas of community development practice that are not widely
understood by mainstream society. From the lack of literature available on circus in
health contexts, it can be assumed that collaboration between occupational therapy and
circus for community health represents a niche practice area. This research set out to
understand and illuminate the common values of occupational therapy and circus,
determine what is currently known about the use of circus among health professionals,
including occupational therapists and explore how circus is currently being used by
occupational therapists internationally. The aim of the research was to contribute
possibilities for occupational therapy practice using circus, to address more complex
societal problems not currently being addressed.
As an occupational therapist and circus practitioner, I am aware of shared
goals for both professions and a simultaneous lack of understanding about the
intersection of circus and occupational therapy. Through this study, I sought to answer
the questions of how and why occupational therapists use circus and to explore the
professional reasoning that informs their practice. I aimed to obtain knowledge about the
ways in which circus is being used by occupational therapists and the extent to which
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occupational therapists’ use of circus reflects philosophies that underpin the evolution of
both circus and occupational therapy practice. I attempted to contribute to the small but
growing knowledge base about occupational therapists’ use of circus in individual,
community, and global health.
The first phase in this journey of exploring and understanding the intersection and
potential of circus and occupational therapy involved understanding the historical use of
creative arts as a means to promote engagement in meaningful occupations. The next
phase included exploring the phenomenon of circus, followed by gaining a better
understanding of how both circus and occupational therapy have evolved over time. I
looked at the alignment of circus with occupation-based practice that utilises activities as
the means to promote engagement in occupations. I also aimed to identify if there exists
an under-utilised potential for circus to be considered as an occupationally-focused
practice, where participation in circus activities is a meaningful occupation rather than as
a means to improved function.
Circus can be understood as a creative art form being used in occupational
therapy practice in both occupation-based (the means) and occupationally-focused (the
ends) ways. The occupational therapy profession has a historic association with the use of
creative arts and crafts as an occupation for health benefits (Wilcock, 1993). This history
may provide insight into the professional reasoning surrounding occupational therapists’
use of circus in their practice. Exploring the potential for occupational therapists to re
embrace traditional occupation-based and focused therapy through creative arts, such as
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circus, for health and wellbeing is a key opportunity enabled through the findings of this
research (Perruzza & Kinsella, 2010).
Occupation-Based and Focused Practice
In this research program, I posed arguments, one of which related to whether
occupational therapists were using circus in an occupation-based and/or occupationally
focused way (Wilding & Whiteford, 2007) and how characteristics of their practice
differentiated between or united these two approaches. The subjective experience of
meaningful participation and autonomy of choice can be stated as ‘activity-as
occupation’, differentiated from ‘activity-as-intervention’ in occupational therapy
(Wilding & Whiteford, 2007). An occupation is something of meaningful significance
that a person chooses to do to occupy themselves (Hasselkus, 2002). The difference
between intervention and occupation is also described as occupation-based or
occupationally-focused, respectively, and reflects whether participation in an activity is
merely the means of increasing abilities to promote engagement in meaningful
occupations (occupation-based) or the means and the ends, the meaningful occupation
itself (occupationally-focused); (Wilding & Whiteford, 2007). A therapist using circus
skills with a client to remediate a functional capacity or improve functional performance
is applying ‘activity-as-intervention’ for a specific means. This is occupation-based
therapy. When participation in activities is meaningful, that is, where occupation is both
the means and ends, it is occupationally focused (Wilding & Whiteford, 2007).
At the beginning of the research undertaken within this thesis, I was aware that
some occupational therapists were using circus as a creative arts medium within their
practice. What was not known or fully understood was whether the use of circus was
being used to remediate individual capacities (performance components) to enable
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participation in other meaningful occupations or whether circus was being used as a
meaningful occupation in its own right. Understanding the intentions, similarities and
differences of occupational therapists using circus was considered an important area of
exploration to help inform future practice.
Understanding Historical Practice for Present-Day Relevance
The use of creative arts is significant in the evolution of occupational therapy
practice. Understanding the development of occupational therapy practice over time is
essential to ensure the quality and effectiveness of occupational therapy practice in an
ever-changing world (Richardson et al., 2004). There is no one core definition of creative
art occupations; however, this concept may be better understood as original forms of
meaningful expression that apply to all activities and may generate positive feelings
(Perruzza & Kinsella, 2010; Schmid, 2005). Creative arts used as occupations date back
to the 1940s and 1950s (potentially even earlier), particularly within psychiatric
institutions (Adamson, 2011). During the institutionalisation era of mental illness, people
diagnosed as having mental health issues were separated from their families and
communities. Occupational therapists working within these institutions developed their
practice around group participation in creative art occupations of craft and recreational
activities (Adamson, 2011). Influenced by a response to the alienating effects attributed
to industrialisation, occupational therapists used handcrafts such as weaving, leatherwork,
ceramics and macrame to help their clients simultaneously connect with nature and create
inner peace within themselves (Ikiugu & Ciaravino, 2007). Patients experienced
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individual and community health benefits from participating in creative arts occupations
(Adamson, 2011).
Occupational therapists use various creative arts to increase occupational
participation and performance (Lynch et al., 2018; Rodger & Ziviani, 1999). Play is a
creative occupation that has been used by health professionals including occupational
therapists working with children and adults to develop the skills needed to participate in
daily living activities, leisure, and productive work or school occupations (Mohammadi
et al., 2017; Rodger & Ziviani 1999). Through play people learn practical skills to enable
them to survive, to interact with others, to choose future roles, and to develop according
to their environment and cultural values (Wilcock, 1993). Throughout the 1960s and
1970s, with the emerging popularity of the biomedical model, occupational therapists,
keen to garner respect as a relatively new profession, tried to align themselves with the
medical paradigms of knowledge that resulted in more means-based interventions
(Adamson, 2011; Molineux, 2004; Wilding & Whiteford, 2007).
The injustices that occurred in the past created a departure from the use of
creative and other occupations as means and ends within the 1950s and 1960s (Molineux,
2004). This departure saw the profession steer off course from early philosophical
principles that were more firmly centred on occupation, resulting in a mismatch between
current practice and the profession’s foundational values (Fortune, 2000). The
introduction of practice models from the 1980s, such as the Model of Human Occupation
(MOHO; Taylor, 2017), achieved a contemporary realignment in which occupationally
focused values were reprioritised while still validating occupation-based practice for the
legitimate purpose of addressing the functional performance deficits needed for
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participation in occupations (Molineux, 2004).
Creative arts are relevant to both occupation-based and focused practice. When
utilised as therapy, they enable individuals to improve performance abilities such as self
esteem and confidence (Schmid, 2005). Creative arts also provide opportunities for
experiencing meaningful processes and outcomes such as purpose, belonging and
autonomy through freedom of expression and imagination (Perruzza & Kinsella, 2010).
Despite the knowledge and evidence that validates both occupation-based and
occupationally-focused practice, the occupational therapy profession has struggled with
integrating the two (Molineux, 2004). Reductionist approaches to treatment, focused on
fixing broken components, have been compared to punishment (Molineux, 2004). This
approach has been criticised with increasing calls for advocacy for occupationally
focused agendas, even though the concept that occupation is a valuable means for
restoring function has pervaded throughout history (Molineux, 2004).
Contemporary models such as the recently developed Canadian Model of
Occupational Participation (CanMOP; Egan & Restall, 2022) responds to the repeated
calls from leaders within the profession for occupational therapy to return to practice that
is grounded in occupation with a progressive ideology that considers the participation of
communities, occupational justice, and social policy (Hammell & Iwama, 2012; Hyett, et
al., 2016; Lauckner et al., 2019; Restall & Egan, 2022). An objective of this thesis was to
explore the reasoning relating to therapists’ use of circus within practice, including what
theoretical models informed practice. Understanding the influence of models and frames
of reference applied by occupational therapists enables a greater understanding of
whether and how circus is being used as the means to develop capacities needed to
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promote engagement in occupations and/or, as the ends, a meaningful occupation.
Exploring the theoretical underpinnings utilised by occupational therapists within this
study was initiated to shed light on the potential of circus as a meaningful occupation that
transcends individual remediation of performance components and looks to community
centred practice inclusive of social policy.
An assumption I held at the commencement of this research program was that
circus was being used by occupational therapists primarily to address the deficits of those
individuals they worked with to promote individual performance capacities. The reason
for this assumption was attributed to two independent factors. One factor was the limited
focus in the literature on the use of circus in occupational therapy. The second factor was
the popularity of certain occupational therapy practice models that promoted the
remediation of individual functional performance capacities. Despite my assumption, I
also held a belief that circus and occupational therapy could be effective partners in
addressing wellness at a community level and influencing social policy. This belief was
bolstered by my knowledge of the literature advocating for the profession to re-embrace
occupationally-focused, community-centred and social-political consciousness (Fortune,
2000; Hammell & Iwama, 2012; Hyett et al., 2015; Picotin et al., 2021). A focus on
community and social policy by occupational therapy scholars provided the incentive and
justification for me to increase understanding of the awareness therapists using circus had
of the macro-level potential of their work.
Leaders within the occupational therapy profession have called for therapists to
return to their roots, prioritising occupation and meaning-focused practice, inclusive of
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creativity, to transcend micro-level, individual-focused practice (Molineux, 2004). A shift
towards macro-level, society-focused practice that better embraces the rights of
communities to engage in meaningful occupations is also implied. In conceptualising the
potential of circus as a creative art occupation, the question arises as to whether it is
possible for circus to be used as an occupation-based intervention to improve
performance components while simultaneously being a meaningful occupation for
individuals and communities. In consideration of individual, community and socio
political contexts for practice, I attempted to determine the intentions of therapists in
relation to this query. This thesis represents an exploration of the potential for
occupational therapists to embrace tradition while looking to the future to address
contemporary health and wellbeing challenges. Occupational therapists’ practice using
circus is researched to explore the ways in which circus as therapy enables function
and/or participation in occupation at an individual level. The potential for occupational
therapists to exert an influence at a broader level to impact social and community
participation is also researched.
Circus as Creative Arts Occupation
Occupational therapy has a history of being occupation and creativity-focused.
Scholars have argued that creativity is an innate need of the human condition that
positively impacts the physical, mental, and social health of individuals (Hasselkus, 2002;
Molineux, 2004). Circus is a creative art form that has evolved over time and is being
used increasingly by health professionals as a form of play for therapeutic utility (Heller
& Taglialatela, 2018; Seymour & Wise, 2017). Circus activities usually include the
distinct disciplines of aerials (e.g., silks, trapeze), object manipulation (e.g., juggling,
plate spinning, hula hooping), equilibristic activities (balancing activities such as
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tightwire, Rola bola/balance board, and stilt walking), acrobatics (similar to floor skills
seen in gymnastics) and clowning (Coulston et al., 2023). The variety of circus activities
listed include incremental challenges that enable people with different abilities to engage
in similar tasks while progressing at their own pace (Coulston et al., 2023).
The multi-disciplinary nature of circus presents an opportunity to therapeutically
address different individual capacities such as balance, emotional regulation, and hand
eye coordination (Coulston et al., 2023). These capacities may be required for
participation in many self-care, leisure, and productivity occupations. Engagement in
occupations using creative arts is stated to benefit individuals and their relationships with
others, including the wider community (Lo, 2021). Evidence of creative arts as
occupations throughout the evolution of occupational therapy practice can assist
occupational therapists in advocating for the creative arts in health promotion at a policy
level that goes beyond individual and group-based health services (Lo, 2021). Circus, in
its various forms, can be conceptualised as a creative arts occupation with participation
and engagement-focused practices that address community needs as well as inform social
policy.
The Evolution of Circus Mirroring the Evolution of Occupational Therapy
A common theme in circus arts literature, more prevalent in historical, drama
studies and education contexts, relates to how circus continually evolves to reflect current
social trends in a progressive society, thus making it a political influence (Infantino,
2015; Spiegel et al., 2015; Ursić, 2021). The capitalistic structures (Bouissac, 2012;
Davis, 2002; Ursić, 2021), exploitation of human and non-human beings (Bouissac,
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2012; Ursić, 2021), empowerment through occupational choice and autonomy (Arrighi,
2014; Bolton, 2004; Davis, 2002; Infantino, 2015) hegemonic social and family systems
(Bolton, 2004; Ursić, 2021) socially and culturally diverse, while simultaneously
segregated by class, race, occupation and gender (Davis, 2002; Ursić, 2021) are all part of
the complex and multifaceted history of circus that included social transformations,
progressions and injustices (Ursić, 2021). Similar injustices and progressions exist today,
further emphasising the complexities and diversity in circus culture. The New Circus
movement which gained popularity in the 1990s, was respected for increased artistry and
a departure from using non-human animals in their shows (Stephens, 2012). Circus
history literature demonstrates the humane treatment of non-human animals, while New
Circus has been criticised for overworking human performers and exploiting vulnerable
children (Bouissac, 2012). Acknowledging and presenting the dichotomy of social justice
and injustice within circus past and present is essential for a future circus that can do
better. Every industry is susceptible to people with power lacking integrity, morality, or
awareness harming others knowingly or not. Past injustices and those that continue today
are a product of human behaviour rather than being inherent in the circus art form. The
harmful practices that are part of circus history do not diminish the evidence of positive
social values and change that also exists (Biquet, 2014; Infantino, 2015; Oliveira, 2014:
Spiegel et al., 2015) but instead highlight the relevance of circus as more than
entertainment but an expression of the social-political (Ursić, 2021). As social-political
stakeholders, circus and occupational therapy professionals are responsible for
influencing equitable social change.
28
Social justice, community empowerment and activism are values evident from the
earliest documentation of circus as an art form (Infantino, 2015). These values are similar
to those of the occupational therapy profession (Durocher et al., 2014; Hammell, 2017;
Picotin et al., 2021; Wilcock, 2005). Looking at the trajectory of how circus has evolved
over time provides insight into its alignment with well-being and why it may be a
valuable option for health professionals focused on enabling change at an individual,
community, and socio-political level to positively impact health and wellness.
The lead-up to circus beginning as discussed in Roman times appears to be a
multi-cultural, multi-discipline and ambiguous occurrence (Bolton, 2004). Jugglers and
contortionists are depicted in artwork on the walls of the Pyramids dating back to the 4th
century BC, while also by Chinese scholars citing paintings and sculptures of circus arts
in the 10th century and Shamanic researchers telling of magic performed with objects and
animals by tribal witch doctors and clowns (Bolton, 2004). In 1770, Philip Astley created
a collaboration of his equestrian riding school with visual entertainers who were being
ousted because of Shakespearian elitism taking over the theatres of England (Bolton,
2004). The Philip Astley Equestrian Arena provided a refuge for marginalised theatre
performers, creating a spectacle of equestrian acrobats, jugglers, and comedic elements
(Jando, 2024). Modern circus commenced in England in 1970 as a significant event
because of a surge in circus popularity (Jando, 2024). The roots of collaboration and
empowering marginalised people were present at the birth of modern circus in England,
and that value system has pervaded since, making it comparative with the evolution of
occupational therapy, which similarly evolved in the era of the incarcerated insane.
29
Historically, a perspective exists of circus as an artform that valued and celebrated
marginalised people for their uniqueness not their conformity (Bolton, 2004). These
values have social justice and community development undertones (Hocking, 2017;
Infantino, 2015; Trentham et al., 2007). Examples of New Circus, such as Circus Oz,
have been characterised as providing increased choice and autonomy for their performers,
with a humanitarian focus, promoting gender equity and operating as a team under
collective ownership (Bouissac, 2012). New Circus gained momentum in various nations
during the 1970s, evolving with an intention to make audiences think and contemplate
society as a mechanism in which to invoke activism (Infantino, 2015; Maleval & Mullett,
2002; Ursić, 2021). Activism aims to create environments that are reflective of the needs
of the majority including the occupations people pursue. The choice and autonomy
associated with New Circus throughout its evolution could be perceived as being
complementary to occupational justice preceding occupational therapy scholars such as
Hammell and Iwama (2012), Townsend et al. (2009), and Picotin et al. (2021) formally
espousing the notion as a direction for practice.
Traditional Circus, New Circus and Community (or Social) Circus are
different types of circus that have evolved over time with similar skills and techniques
while changing in purpose and values. To justify the claims relating to the inherent
connection between circus, social justice and occupational rights, a brief description of
these three types of circuses will be presented for context. This is followed by a summary
of the shared values with occupational therapy, presented through an occupational lens.
Traditional Circus
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Traditional Circus reflects a somewhat insular community empowerment ethos of
valuing inclusivity and diversity within the rigidity of Traditional Circus family culture.
Traditional Circus is documented as being characterised by a nomadic familial structure,
whereby families travelled to cater for audiences that were migrating west in the United
States of America during the early 19th century (Bolton, 2004; Bouissac, 2012; Davis,
2002). Tradition circus shows had mixed levels of appreciation by mainstream society
associated with both wonder and awe as well as vagrancy and transgression because of
the nomadic lifestyle pushing the boundaries of social and physical norms, raising
questions of what is considered achievable and respectable (Stephens, 2012). Traditional
Circus encompassed a collaboration of diverse skill sets including taming animals, tent
construction, acrobatics, concession sales that involved people with different strengths
and limitations, all working together towards a shared common goal. Although
oppressive social inequalities were present, many circus people who were outsiders of
society felt included, part of a family within these nomadic communities that provided
them better income than available elsewhere (Davis, 2002). A successful show inspired
and entertained the consumers while generating enough funding to sustain the production
and the family.
Reflecting on today’s perspective, using a frame of reference that acknowledges
the rights and inclusivity of people who are considered atypical, the ‘freak-show’
component of Traditional Circus may be confronting. This form of circus provided a
place where people who looked and acted outside mainstream society were included, and
valued, for their uniqueness. Bolton (2004) supports this statement referring to it as “the
31
significant moment when an outsider becomes an insider” (p. 10). It was not uncommon
for marginalised individuals to use circus events as opportunities to empower themselves
by “demonising people considered ‘lower’ on the social hierarchy than themselves”
(Davis, 2002, p.32), so it may be overly optimistic to view the Traditional Circus period
as a fully inclusive place for people with disabilities. Nevertheless, Traditional Circus did
provide opportunities and validation to atypical members of society and in this respect,
shares similar values to occupational therapy, particularly those enabling an appreciation
and celebration of diversity.
Traditional Circus prioritised the production, the spectacle that served to provide
an escape or distraction from everyday life. Freedom of choice pertaining to group
affiliation and exploration of self and character was not emphasised in the Traditional
Circus era, as it was later in New Circus. Although Traditional Circus folk were activists
in their own right, where they engaged in an alternative lifestyle outside of mainstream
society, the Traditional Circus era did not have the same agenda of invoking
contemplation of political structures. An expression of social activism was later evident
in what is known as the New Circus era, that invoked freedom of expression and
autonomy.
New Circus as a Socio-Political Occupation
New Circus evolved from Traditional Circus, diminishing the use of animals
while prioritising disruption of social and political structures that demeaned choice and
free will. This change can be summed up by Waite (1985) when recalling a significant
feature of Circus Oz recruitment, when the musical director asks the newcomer, not
“what instrument can you play?” but “what would you like to play?” (Waite, 1985, p. 68
32
as cited in Bolton, 2004). New Circus was developed in response to 1960s counterculture
and the desire to create a visceral, political, and non-hierarchical performance experience
(Ursić, 2021). Circus shares values with occupational therapy, not only relating to
meaningful occupationally-focused participation for individuals but also in attempting to
influence social policy.
New Circus evolved with the intention of making audiences think and
contemplate society as a mechanism for invoking activism. For example, Circus Oz,
driven by an artistic vision, focused on social integration, promoting equity for refugees,
asylum seekers, and marginalised members of the global population (Bouissac, 2012).
Ursić (2021) discusses the intersection of clown and activism with the symbolism of pie
throwing. In this ritual, one clown throws a pie, representing the space of abjection, into
the face of another, representing order, law and power. The intention is to trivialise the
position of the oppressor. Activism is used within circus to create discourse that reflect
human rights including meaningful occupational engagement.
John Hawkes (2004), one of the founding members of Circus Oz argued that a
whole-of-government cultural framework that listens to the social, environmental, and
economic needs of all its people is essential for the well-being of society. New Circus
exists with an important societal role to preserve and express culture that is ignored by
governments. Circus has been described as a dichotomous mirror that resides on society’s
periphery only because of its confronting centrality (Bouissac, 1976). El Circo de Los
Muchachos was a touring circus created as an alternative, autonomous, self-sustaining
community in resistance to fascist Spain (Grimes, 2011). This touring circus was founded
by a priest named Father John Silva and visited Portugal, France, America, Australia,
Canada, Colombia, Germany, Italy, Japan, Switzerland, Russia, Mexico and Venezuela
33
(Lavers, 2016). The human pyramid performed in every show had a small child at the
top, conveying the intended moral message that the stronger supported the weaker
(Lavers, 2016).
El Circo de Los Muchachos influenced New Circus traditions developed in
France, Australia, Canada, South America, and the United States of America, connecting
them with comparable social influences and aesthetics (Infantino, 2015; Lavers, 2016;
Maleval & Mullett, 2002).
There is an aesthetic especially evident in high-risk acrobatics that conveys
a social message of freely pushing boundaries and expresses taking personal
responsibility for yourself with respect to others who share a stage. This communicates a
powerful message in times when members of a society are dissatisfied with the actions of
the powerful and hope to change the status quo. New Circus is relevant in today’s social
and political climate where democracy is fragmented and there exists increasing unrest
and divide within nations.
During the period between the 1970s and 1990s, when occupational therapists
were trying to find their way back to practice grounded in occupation, there was a revival
of circus in the United States, Australia, Canada, Europe, and Argentina characterised by
the social movement of freedom of expression and the uprising of political awareness
(Bolton, 2004). Meaningful occupationally-focused engagement of artistic expression
arose from the politically and socially engaged progressions of the late 1960s (Infantino,
2015).
New Circus artists are portrayed in the literature as nomads without theatres,
34
symbolic of destabilising and revitalising live performance during a time of political
unrest in which they used circus as performance art to criticise and transform the cultural
foundations of society (Maleval & Mullet, 2016). Progressive leaders within the
occupational therapy profession who have advocated for the use of creative arts as
meaningful occupation and community-centred practice are evidence of the strong
parallels of change that existed within the evolution of occupational therapy and circus.
These parallels relate to the societal constructs that influence the choices people have for
how they spend their time, sustain themselves, and their ability to express needed
changes for more equitable societies.
New Circus emerged cross-culturally, democratising public spaces while inviting
more citizens into the conversation with Street Circus. New Circus brought the
conversation of societal issues to the people while critiquing existing theatrical scenes
that were judged as stagnant (Maleval & Mullett, 2016). In Argentina in 2002, new
performance groups emerged combining circus with local traditions presented in the
public spaces. The intention of these performances was to express freedom in opposition
to the previous period of dictatorship (Infantino, 2015). The ability to occupy public
space was a freedom that citizens had previously been deprived of (Infantino, 2015).
Street performance, also called Street Circus (Infantino, 2015), is a branch of New Circus
that changed the connection with the audience because it began to invite dialogue,
creating conditions for real communication with a wider sector of society (Infantino,
2015). Street performance enabled political utopianists and artists to collectively have a
louder voice (Maleval & Mullett, 2002). How Street Circus is conveyed in the literature
resembles what Egan and Restall (2022) and Reisch (2017) refer to as a meaningful
35
occupation that transcends micro-level individual-focused participation towards macro
level community-focused participation. The use of Street Circus as a method to enable
society to contemplate social equity and access is relevant to occupational therapists
using circus as well as occupational scientists who are calling for more community
development practices.
Street Circus demonstrates compatible values with an occupational justice
framework aligning with community-centred, occupationally-focused ideology by
invoking the participation of audiences to play, interact and express opinions and
preferences (Infantino, 2015; Maleval & Mullett, 2016). Audience members are
intentionally invited to share in the success of the show while empathising with the
experience of failure and struggle. The social and emotional assets of solidarity and
empathy are intentionally embedded in the experience (Infantino, 2015; Maleval &
Mullett, 2002). Street circus opposes hegemonic art while promoting transgression and
liberation as artists recreate an environment in which the public have choice and voice in
respect to paying, staying, applauding, and criticising the establishment (Infantino, 2015).
Street Circus also introduced autonomous artistic and work alternatives that challenge the
increasingly unstable areas of employment offered to young people.
The examples of Street Circus, which invited dialogue about social issues by
bringing performance art to public spaces, demonstrate an invitation for community
action to challenge inequalities, revealing a shared social construct value with community
development.
The balance and acquisition of life skills in addition to performance skills
36
becomes a necessity for the longevity of self-governing New Circus collectives. The New
Circus era coincided with the globalisation of cross-cultural participation of independent
circus artists, carving their own future employment path. Other aspects of this freelance
labour opportunity supported by New Circus, included entrepreneurship and the
associated components of financial, mechanical, physical, and emotional management
(Bolton, 2004). New Circus ensembles highlighted the realisation that sustainability is
dependent on more than an alluring act but also an ability to work together, communicate
effectively with consumers and have strategic plans for performance management.
The evolution of circus as an artform can be seen to share a similar values
pathway to occupational therapy. Both movements have progressed values centred on
autonomy, community justice and human rights. New Circus evolved from Traditional
Circus in response to current socio-political contexts while having the similar anti
establishment flavour of the post Roma Gypsy Circus along with modern day progressive
values relating to the rights and treatment of all animals (Bolton, 2004). The New Circus
performers of today have the choice to be autonomous, not being tied to a specific family
or company but can choosing to be self-branded, collaborating with different companies
for shows and projects, based on short-term contracts as opposed to birth rights.
Authors present New Circus as having a unique balance of the autonomous
individualistic nature of modern-day society with progressive attitudes of community
development, political awareness, and activism (Biquet, 2014; Bolton, 2004; Infantino,
2015). New Circus could be an asset for occupational therapists wanting to use circus in
their practice to advance the occupational rights of communities. There is a heightened
37
and unique non-risk-averse intelligence in New Circus that does not gravitate to the same
exclusive hierarchical and rule-based intelligence that was present in Traditional Circus
models and is still prevalent in many mainstream societal structures. New Circus
balances individuality with community, socialism with free-will and intelligence with
inclusivity (Arrighi, 2014; Biquet, 2014; Bolton, 2004; Hawkes, 2004; Infantino, 2015;
Oliveira, 2014) making it a valuable resource for occupational therapists aspiring to
progress justice-informed practice.
Social Circus as both Occupation-Based and Focused
Social or Community Circus refers to process-focused circus arts programs that
aim to create socio-political consciousness and capacity-building opportunities for people
in diverse living conditions. Social and Community Circus are differentiated from New
Circus and Traditional Circus due to the shift in focus from the production (performance)
to the process, where there are no audience members, but everyone is a participant
engaging in circus activities. Performance exemplifies a subtle yet profound difference
between New Circus and Social or Community Circus. In New Circus, commercial
entertainment and performance quality is a necessary component of sustainability
(Arrighi, 2014; Bolton, 2004). Social Circus has been characterised as accessible and
socially transforming through promoting autonomous and creative development of
students’ critical thinking skills, thereby strengthening equal socio-productive
opportunities for vulnerable youth (Infantino, 2016). In Ecuador, Circo Social Ecuador
was launched as part of an initiative to recover indigenous communal values and promote
cultural empowerment and identity (Speigel et al., 2019). The philosophy driving this
action was based on the conviction that collective creativity, trust and positive risk-taking
38
build solidarity and encourage positive social transformation, resulting in increased social
equity (Spiegel & Parent, 2018). In Social (Community) Circus, the shared ethos is that
performance is part of an educational agenda to promote the process-focused objective of
life skill acquisition and social and emotional health, and not a commodity (Biquet, 2014;
Maglio & McKinstry, 2008; Spiegel et al., 2019). Community Circus has been described
as a sub-culture of circus that exists adjacent to the commercial and professional
production focus of performance-focused circus (Arrighi, 2014). However, there are
instances where Social Circus participants want to experience a professional circus role
which creates tensions between engagement as social development and the cultivation of
performance artists (Spiegel et al., 2015).
Social Circus appears to have similar values to occupation-based occupational
therapy, in which engagement in a variety of circus activities is used to increase
psychosocial skills. Social Circus is congruent in many ways with occupationally focused
models of occupational therapy such as the CanMOP (Egan & Restall, 2022). The
CanMOP focuses on equity and providing social services for people who are
marginalised by environmental injustices (Egan & Restall, 2022). Social Circus has
similar goals enacted by providing creative ways for young people to become self
actualised, learning how to advocate for themselves and develop the personal skills
needed to work with others in transforming inequalities that limit life choices and
freedom of expression (Infantino, 2015; Spiegel, et al., 2015).
The relevance of occupational therapy to socio-political constructs can be better
understood by looking at the problems that result from environmental and occupational
injustices. For example, a breakdown in democracy occurs when government
39
organisations fail to create channels for the expression of community values that directly
impact society’s function (Hawkes, 2004). Community values include access to resources
(environmental justice) and the ability to pursue occupations that people do to give their
lives meaning (occupational justice). New and Social Circuses address cultural values
and injustices in society (Infantino, 2015; Oliveira, 2014; Spiegel et al., 2015; 2018;
2019). For example, Ferreira’s Zip Zap Circus School was established to invoke the past
to understand the present; it celebrated idealism as well as suggesting disenchantment and
mourning; it constituted a place of hope and loss, reflecting upon the nomadic and
transitory essence of circus as well as the social, political, and economic flux of Cape
Town (Oliveira, 2014). Cirque du Monde, the Social Circus branch of Cirque du Soliel
began in 1995 operating in partnership with community health-focused organisations.
Cirque du Monde’s programs are global, operating under the same ethos of providing
access to activities for young people who are perceived as vulnerable and marginalised as
a result of complex social factors that have put them at risk of suffering from low
academic achievement, not contributing to society as adults, or as a result of health
challenges (Arrighi, 2014). Thompson and Broome (2021), in their study on Social
Circus for people with disabilities, reported that the social inclusion experienced due to
participation in Social Circus extended beyond the circus activities and transferred into
other areas, such as participants’ friendships and educational experiences. Social Circus
addresses social justice through engagement in circus as an occupation.
The Participatory Occupational Justice Framework (POJF) is underpinned by
epistemological foundation focus areas of human rights, equalised power relations, social
inclusion, social and cultural relevance, equitable opportunities and resources, and
40
agency within adverse environments (Whiteford et al., 2018). Social inclusion and social
and cultural relevance are present within the Social Circus examples of Arrighi (2014),
Oliveira, 2014), and Thompson and Broome (2021) presented above. The POJF tries to
ensure that users of the framework “are cognisant of the power relations ever present in
the complex, multi-layered environments in which actions to tackle occupational
injustices occur” (Whiteford et al., 2018, p. 497). The POJF may further facilitate social
inclusion by raising awareness within the Social Circus industry of occupational
injustices and how to address them, increasing understanding of the power dynamics
present and how to mitigate them.
Social Circuses have emerged throughout the world with commonalities of re
imagining and re-purposing circus arts within a social situation (Oliveira, 2014; Arrighi,
2014; Bolton, 2004). In Latin America, specifically Brazil and Argentina, Social Circus
began as a strategy to invoke change in the individual and society. The concept of change
posits another similarity to the occupational therapy profession, with therapists
considered change agents, adapting environments and working with people to build
individual capacities to enable occupational participation (Picotin et al., 2021). At an
individual level, the change from participation in circus is perceived to result in increased
autonomy, critical thinking skills and creativity, while on the societal level, increased
opportunities for access to future productive roles as adults were perceived (Infantino,
2015). Occupational therapists aspire to be effective in ensuring occupational justice for
marginalised populations (Picotin et al., 2021). As a result of neoliberalism that punished
the most neglected members of society including the younger generations, the 1990s
were a popular time for Social Circus to continue a tradition of evolution in response to
socio-political and environmental injustices in Latin America (Infantino, 2015). The
41
increased popularity of Social and Community Circus in the 1990s and early 2000s
demonstrates the common threads of collaboration and response to social inequality, that
are evident in the evolution of both circus and occupational therapy.
Circus and its diversity of activities and roles, provides new opportunities to
pursue creative art occupations while simultaneously promoting the development of life
skills that positively contribute to whatever role a participant chooses to pursue in
adulthood (Maglio & McKinstry, 2008). In Social Circus programs, activities are
delivered with an emphasis on creating change in specific capacities and patterns of
behaviour that can be transferred into other contexts. The results may not necessarily
include participants taking on a particular role, for example, an acrobat; however, they
may embody the characteristics of trust, positive risk taking, empathy, problem solving,
and teamwork, from experiences of having to rely on and support each other’s safety and
performance capacities in acrobatic activities that occur as part of the circus curriculum
(Maglio & McKinstry, 2008). In this way circus has an occupation-based legitimacy for
the occupational therapy profession. Although some participants may be interested and
motivated to pursue a role as a circus performer, for most facilitators of Community and
Social Circus programs, circus is used as a method for increasing social and emotional
health. This form of circus provides opportunities for participants to engage in activities
that require a variety of life skills.
The motivation to participate in Social or Community Circus programs is intrinsic
and not based on external rewards (Arrighi, 2014; Fernandez et al., 2018; Loiselle et al.,
2019; Maglio & McKinstry, 2008). Program continuation and funding are not contingent
on measurements of performance capacity. Many participants of group-based Social
42
Circus programs have experienced environmental injustice and/or occupational
deprivation that has limited their perceived life choices (Infantino, 2015; Spiegel et al.,
2015; 2018; 2019). Opportunities for future employment in circus arts are available;
however, this may not be the objective. The process-focused nature of Social and
Community Circus is comparable to what occupational therapists describe as meaningful
occupationally-focused participation.
Social Circus Intersection with Health Professions and Occupational Therapy
Circus is inherently diverse, having many forms and subsections with different
values worthy of analysis and academic study. The scope of this research includes an
abridged evolution of circus, rather than a comprehensive account of recent contemporary
advancements made in the last decade, some of which include circus as an increasingly
mainstream occupation reflecting capitalistic society values. A small part of the evolution
of circus involves its use in health and wellbeing, making it of significant importance to
occupational therapy and other health professions. Fernandez et al. (2018) explored the
experiences of children with disabilities participating in a 10-week community-based
circus project in which their parents’ perspectives on changes they perceived in their
children were also reported. Experienced circus trainers facilitated this circus program,
with an occupational therapy student supporting the younger group sessions (Fernandez
et al., 2018). Thompson and Broome (2021) assessed the link between occupational
therapy practice and Social Circus for people with disabilities by observing YouTube
videos through an occupational therapy-informed lens, MOHO. Loiselle (2019) explored
the impact of Social Circus on young adults living with physical disabilities from their
43
and their parents’ perspectives.
These studies all demonstrated similar benefits of improved social,
emotional, physical, and cognitive well-being of individuals from participation in Social
Circus activities that were assessed by occupational therapists (Fernandez et al., 2018;
Loiselle et al., 2019; Thompson & Broome, 2021). However, none of these studies
discussed how occupational therapists were using circus within their practices, nor did
they discuss greater community impacts. The health professions of social work and
occupational therapy are particularly aligned with circus in that they both focus on
community health and human flourishing through diversity (Loiselle et al., 2019; Spiegel
et al., 2015). The use of circus by occupational therapists is an evolution in individual and
community health for both circus and occupational therapy disciplines and is the focus of
this thesis.
Similar to innovative occupational therapy practice models, circus responds to the
changing circumstances of the socio political and economic environment. With the
increase of corporate, investor and grant funding, Social and Community Circus
organisational structures have created a bridge to communicate with policy makers
through research that discusses socioeconomic tensions. Speigel et al. (2019) analysed
Ecuador’s Social Circus program to increase understanding of “the relationships amongst
politics, social policy and the ways in which community arts programmes impact
collective health” (p. 901) Speigel et al. (2018) explored how Social Circus is leveraged
as community development where there is friction between the corporate and capitalistic
models that fund many Social Circus programs aimed at improving individuals’ ability to
44
function in existing inequitable socioeconomic systems, and the transformation of these
systems themselves.
Creating alliances with governmental bodies has the potential to fulfil the need of
cultural generation by redesigning operating structures to express the meaning, identity,
and purpose of society members (Hawkes, 2004). The increase of non-government and
non-profit organisational entities under which many Social and Community Circuses
identify portrays circus as a phenomenon attempting to meet not only people where they
are but greater societal needs as well. Although there are benefits to the
institutionalisation of Social Circus, there is also fear of homogenisation.
Stein and Faigin (2015), warn about detrimental outcomes of the arts becoming an
instrument for perpetuating oppression and the status quo when they are framed in terms
of their capacity to remediate or fix an individual or community. This statement shares
similar concerns with occupational therapists warning of the detrimental effects of
occupation-based practice being more focused on the remediation of skills than
participation (Lynch et al., 2018; Molineux, 2004). There are commonalities between
occupational therapy informed circus and Social Circus as well as differences that will be
further explored in the next chapter. Some Social Circus experts have reported capacity
building benefits of circus that are embedded in the activities delivered through a Social
Circus lens without needing health professional input (Agans et al., 2019; McCaffery,
2014; Seymour & Wise, 2017). The question arises as to whether it is possible for the
benefits of circus to exist independent of collaboration with a health professional. For
example, Stevens et al., (2019) looked at recreational leisure-based circus activities for
mainstream youth populations that did not specify special needs or marginalisation. They
concluded that circus supports youth development in terms of psychological needs,
45
resilience, and intrinsic motivation.
McCaffery (2014) and Seymour and Wise (2017) reported that Social Circus
improved the life skills of children on the Autism Spectrum. Similar to Stevens et al.
(2019), these improvements were not noted as being related to a specific healthcare
provider’s input. Asking the question of whether Social Circus can be beneficial from an
occupational therapy perspective, insight and collaboration and vice versa is warranted
and worthy of consideration. Social Circus organisations are increasingly working with
health professionals such as occupational therapists that promote capacity changes in
social, emotional, physical, and cognitive abilities (Fernandez et al., 2018; Neave et al.,
2020; Maglio & McKinstry, 2008; Thompson & Broome, 2021). Seymour and Wise
(2017) offer the concept of a circus culture for children with Autism shaped by circus
trainers, participants, and their families. Their concept claims that Social Circus develops
the same motor skills and muscle memory outcomes targeted in occupational therapy and
physical therapy while promoting play and creativity, enabling children to enjoy the
therapeutic process. A greater understanding of how occupational therapists are using
circus in their practice may contribute valuable knowledge about whether Social Circus
can be ethically and comprehensively included as part of occupational therapy and by
other health professionals.
Social Circus practitioners may be using the same circus activities as occupational
therapists to address similar performance component deficits. The absence of
occupational therapist input however may result in falling short on important aspects to
promote meaningful participation such as, task analysis, client-centred care, grading of
tasks, motor and neurological components, along with occupational therapy education,
46
assessment and evaluation experience. The overarching research question guiding the
empirical phase of this study, intended to explore occupational therapists’ use of circus.
As part of this exploration, the extent to which collaboration is possible and optimal
between occupational therapists and non-health-orientated circus practitioners could be
revealed. A greater understanding of the professional reasoning of occupational therapists
that have used circus is needed, including the extent to which theories and models of
practice have guided their circus practice. The findings of this thesis are intended to
inform recommendations for how, as health professionals, occupational therapists can
work congruently with contemporary approaches to occupational therapy practice and in
collaboration with other disciplines, to progress circus in ways that are responsive to the
changing needs of society.
My personal experience as a student researcher, circus practitioner, and
occupational therapist has informed my belief that potential exists for the Social Circus
movement and the occupational therapy profession to effectively address societal needs.
My long-held assumptions are that collaboration to create and sustain circus-based
community development opportunities can address occupational justice and human rights
issues. Agentic leadership, where occupational therapy graduates can promote change
through their political acumen, independence, and leadership skills (Fortune et al., 2013)
in bold and new areas of practice, has been suggested to address emerging societal issues
in which marginalised populations continue to develop. This research was undertaken to
challenge my assumptions and investigate whether circus and occupational therapy may
be an emerging practice area where marginalised populations are supported in self
actualisation and the development of a wide range of performance capacities. In
47
exploring circus, the question arose as to whether occupational therapists can make useful
contributions by adopting policy-driven and organisational roles involving circus for
community health.
Community or Social Circus programs that were previously dependent on
collaboration with external funding sources, such as grants, to maintain their operations
and infrastructure costs have an opportunity to embrace new sustainable models of
organisational autonomy through social enterprise. There is a need to understand what
potential exists for occupational therapists to support this transition with skill sets primed
for political acumen and community development. Social enterprise enables organisations
to achieve their social mission while making a profit, enabling them to decrease their
dependence on donors’ generosity in ways that may limit their social impact
(Muziramakenga et al., 2016). Social enterprise business models may be an asset for
Community or Social Circus programs and for occupational therapists working in
community development. Social enterprise is worthy of consideration to compensate for
government arts and health funding that do not provide autonomous and sustainable
solutions.
There has been a continual call to action from leaders of the occupational therapy
profession to become more socio-politically aware and active (Hammell, 2017;
Townsend et al., 2009; Wilcock, 2005; Yerxa, 1998). This research program was
intended to explore how occupational therapists are using the creative art of circus and
aimed to increase understanding of where the profession is situated with regards to the
use of circus in occupation-based and occupationally-focused ways to contribute to
48
individual, community, and socio-political health.
Social Circus Through an Occupational Therapy Lens
This research program explores the potential of Social Circus to provide
occupationally-focused opportunities for therapists to impact community and global
health through social change. Theoretical and philosophical principles informing
professional occupational therapy models such as the CanMop (Egan & Restall, 2022),
the Kawa Model (Iwama et al., 2009) and the MOHO (Taylor, 2017) are useful in
guiding therapists in their consideration of how to advance, achieve, and enable health
equity, cultural relevance, the acquisition of life skills and participation capacity through
programs informed by Social Circus philosophy. The CanMOP and Kawa Model
embrace a focus on promoting cultural relevance and community development in
occupational therapy practice, making them both useful to explore in tandem with circus.
Occupational therapy practice for diverse populations may also build on previous
academic literature relating to Social Circus outlined by Biquet (2014), Niederstadt
(2009), and Spiegel et al. (2015; 2018; 2019). Research into Social Circus claims to
address change in individuals’ capacity to participate, yet there is a lack of rigorous
evaluation by external sources (Biquet, 2014; Niederstadt, 2009; Spiegel et al., 2015).
Although it is stated that Social Circus programs promote participation through
influencing the social and emotional life skills of participants, it is not clear how
participation in broader occupational or life roles is impacted and how that is measured
(Biquet, 2014; Spiegel et al., 2015).
Many Social Circus programs around the world, and particularly across the
49
Americas have “social justice” and/or “health equity” as explicit objectives even though
impacts of such successes and of Social Circus programs are unclear (Spiegel et al.,
2015). Spiegel et al. (2015) stated that the people involved in Social Circus groups
already believe that it is effective but lack the understanding of why it works. Many
Social Circus programs are internally evaluated with a pre-existing belief about the social
and emotional effectiveness of those programs. Occupational therapy models such as the
CanMOP and Kawa Model emphasise cultural and social determinants of health in ways
that intend to guide occupational therapists to positively influence health equity at a
community level. The CanMOP and Kawa Model may enable an enhanced understanding
of the unique offerings of circus themed community-centred occupational therapy that is
unified through a common goal of increasing health equity and/or influencing social and
occupational justice through artistic expression.
Social Circus and Occupational Therapy for Individual and Community Wellness
The theoretical and practice models used by occupational therapists that are
considered within this study may assist in increasing understanding of the potential for
both Social Circus and occupational therapy to work together for individual, community,
and social political health. The widely used and mostly Western developed occupational
therapy theoretical models that focus on individuals, include the Person-Environment
Occupation Model (PEO) (Law et al., 1996), the MOHO (Taylor, 2017), and the
Occupational Performance Model (OPM; Chapparo, 2016). The CanMOP (Egan &
Restall, 2022) and Kawa Model (Iwama et al., 2009) are particularly relevant when
looking at community-centred practice and therefore were selected for further exploration
in this study. Understanding the influence of these models and how they are enacted in
50
actual practice may lead to more comprehensive and effective circus participation
experiences. An increase in understanding is sought to support futuristic practice and be
accessible for Social Circus facilitators and occupational therapists who use circus to
improve individual and community health.
Occupational therapy, as a profession, continues to be strongly focused on
working with individuals, and accordingly, many occupational therapists are likely to be
guided by individual-centred intervention approaches. The MOHO is an individually
focused model, which explains how occupation is motivated (volition), patterned
(habituation), and performed (performance) (Taylor, 2017). Volition pertains to why
individuals are motivated to do what they do, consisting of personal causation, values,
and interests (Taylor, 2017). Habituation refers to how occupational behaviour is
organised and structured, the habits and routines that emerge as repeated behaviour
becomes patterned (Taylor, 2017). Performance encompasses how well a person can do
the things they are motivated to do based on their skills or capacities. Volition,
habituation, and performance are in constant interaction with each other and change with
the intake, process, and output information of humans. When this system is unhealthy,
occupational dysfunction occurs. When this system is working, improved or optimal
performance occurs for the individual further reinforcing occupational engagement.
Participation and engagement in the circus experience are considered by Social
Circus practitioners to be determinants of health (Spiegel et al., 2015). The health
promoting potential of social circus has been attributed to the underlying social and
emotional development that is inherent to the process and believed to promote the uptake
51
of specific roles within the wider community (Barndt, 2011; Biquet, 2014; Spiegel et al.,
2015). Exploring therapists’ perceptions of the individual experience of their clients
through the lens of the MOHO may provide insights into why and how participants
(either as individuals or as members of community groups) engage in circus-themed
occupational therapy.
The Kawa Model was developed by Michael Iwama, a Japanese occupational
therapist, who came to the realisation that contemporary theories about human occupation
and occupational participation needed to strongly reflect the moral values, beliefs, and
social norms of the social contexts they emerged from (Paxson et al., 2012). The
underlying theories of the Kawa Model complement the values of Social Circus in that it
was developed as a response to challenges in having culturally safe and relevant models
of practice that resonated with the day-to-day realities of the people they serve. The
Kawa Model, in Figure 1, aims to explain universally the complexities of subjective
human experience (Iwama, 2011). The narrative of occupation in the Kawa Model
proposed that the individual is inseparable from the environment (Paxson et al., 2012).
What happens within the environment is reflected in a person’s role in society and their
occupational participation choices.
Figure 1
52
The Kawa Model
Note: Adapted from Iwama et al., 2009
The components of the Kawa Model (Iwama et al., 2009) include the river flow,
riverbanks, rocks, driftwood, and spaces all with their own symbolism that can be applied
to either an individual’s or community’s environment and function. In terms of applying
the Kawa Model to communities, the river flow represents the past, present and future of
a community. The riverbanks represent the physical, social, and political environment:
Living conditions, community support, health care, access to resources, access to
meaningful occupations of choice, and culture. The rocks represent the problems a
community may face, for example, occupational deprivation, marginalisation, lack of
equity relating to access to resources and opportunities, and oppression. Driftwood
represents assets such as, skills, abilities, beliefs, social connectedness, and infrastructure.
Occupations are the spaces between objects that can improve the river flow. Change takes
place when the rocks are broken or moved by the flow of the river, hit by driftwood, or
moved by the opening of spaces between the objects or riverbanks. Exploring the Kawa
Model and how it intersects with Social Circus can assist in answering research questions
pertaining to how participation in circus activities can potentially transform inequitable
53
social policies.
The CanMOP (Egan & Restall, 2022) incorporates a detailed community
development perspective, and can guide occupational therapists to adopt a community
development approach to support individuals and collectives towards collaboratively
creating opportunities for participation in occupations (Rudman et al., 2022). The
CanMOP (Egan & Restall, 2022) is incorporated into this research to assist the
compatibility, viability, and applicability in supporting occupational therapists’ work
with circus. This research program explored how models such as the CanMOP (Egan &
Restall, 2022) might support communities to engage in Social Circus and to communicate
their needs to policymakers.
Circus and the Macro Context of Occupational Rights
This thesis explores how circus is being contemplated and used by occupational
therapists to increase individual capacities, promote community health equity, and
influence social and occupational justice through artistic expression. The practice of
circus themed occupational therapy requires initial exploration and description of the
activities and professional reasoning that underpins what occupational therapists are
currently doing. Greater understanding of what occupational therapists are doing and why
is essential to inform research on how circus and occupational therapy can contribute to
evaluations that are external, rigorous, and aim to demonstrate effectiveness.
Occupational therapy and circus, and in particular, New Circus, Community or
Social Circus, have complementary purposes of empowering people with adaptable life
skills in ways that may also support health equity and an increase in life choices.
Although they exist separately, occupational therapy (Fortune et al., 2013; Hocking,
54
2000; Iwama, 2011; Paxson et al., 2012; Wilcock, 1993; Yerxa, 1998) and New Circus
(Arrighi, 2014; Biquet, 2014; Bolton, 2004; Grimes, 2011; Hawkes, 2004; Infantino,
2015; Maleval & Mullett, 2002; Spiegel et al., 2015) advocate for the cultural and human
rights of marginalised individuals and communities.
Social or Community Circus has gained increasing recognition within the
occupational therapy profession as a potential therapeutic medium (Baumgold, 2017;
Fernandez et al., 2018; Loiselle et al., 2019; Maglio & McKinstry, 2008; Thompson &
Broome, 2021). Community or Social Circus has a seventy-year history of documented
social and educational capacity building programs however there is little published
evidence of effectiveness. Although there are occupational therapists using circus in a
variety of countries, for a variety of reasons, there is a lack of knowledge relating to the
collaboration of occupational therapy and circus as an emerging practice area. The aim of
this research was to increase understanding of how circus is being used by occupational
therapists in individual, community-centred, and socio-political contexts of practice.
Literature relating to circus and occupation presents circus as a strategy for
activism (Biquet, 2014; Bolton, 2004; Infantino, 2015), as a therapeutic or educational
tool (Biquet, 2014; Li, 2010; Maglio & McKinstry, 2008; Oliveira, 2014) and an activity
that advocates for equity (Spiegel et al., 2015). Social Circus encompasses process-driven
activities that can address globally relevant social issues such as life skills acquisition,
trauma, and community well-being (Biquet, 2014; Infantino, 2015; Spiegel et al., 2015)
consistent with occupational therapy practice that prioritises community development.
Literature relating to circus and health professionals can assist to inform the practice of
occupational therapists who are striving to understand the nature and meaning of circus
55
as an occupation and how it may impact emotional and social skills along with
occupational participation.
Summary and Overview of Next Chapters
In this Chapter I have presented occupational therapy as a profession moving
towards a greater understanding of and focus on community health. This shift in focus
requires consideration of more complementary theoretical models and strategies than
those that have guided the individual performance component and group occupation
based intervention focus that has largely defined the profession. This introduction chapter
also provided a background to circus and its evolution, relevant to the occupational
therapy profession in its efforts to shift focus toward community development.
The potential compatibility between circus and the practice of health
professionals, specifically occupational therapists has been presented. Chapter 2 extends
this brief overview, by presenting a scoping review of literature that pertains to circus use
by health professionals and what is currently known in the literature about the
relationship between circus and occupational therapy. In chapter 3, the overarching
research paradigm guiding the research is outlined, as is the collective case study design
used to answer questions about ‘what’, ‘how’ and ‘why’ circus is being used by
occupational therapists. In Chapter 4, the case study research findings are presented,
which then informs Chapter 5, a discussion that draws connections between how
occupational therapists use circus and occupational therapy practice models. Connections
drawn between the findings, occupational therapy models, and the literature relating to
occupational therapy, community development and Social Circus provide the basis for a
56
new Collaborative Occupational Therapy and Circus Model, developed to support more
progressive and relevant uses of circus by occupational therapists to contribute to
community health and occupational rights on a global level.
CHAPTER 2 SCOPING REVIEW
57
The previous chapter highlighted the potential for circus and more specifically,
Social Circus to be used in practice by occupational therapists and other health
professionals. Health professionals are defined as people who study, diagnose, treat, and
prevent human illness through the procedures of evidence-based practice (World Health
Organisation, 2023). Circus is an emerging health intervention that over the past few
decades has increasingly been used by various populations to improve health and well
being (Fournier et al., 2014). Circus activities may present a versatile and inspiring health
intervention opportunity that requires a comprehensive review of current circus
interventions and their potential benefits (Coulston et al., 2023). There is limited
available knowledge about if and how health professionals are using circus and Social
Circus within their practice. Exploring how health professionals may use circus within
their practice would increase understanding about the potential for its use within health
fields.
In this chapter, the review of the literature related to physiotherapists,
occupational therapists, social workers, medical doctors, physiologists, psychologists, art
therapists and psychiatrists as the possible health professionals using circus. In the
previous chapter, Social Circus was specifically identified as being congruent with the
work of occupational therapists aiming to create opportunities for occupational
participation that promotes social and emotional well-being. As discussed in the
introduction chapter, there are commonalities between Social Circus and occupational
therapy, with Social Circus including process focused circus arts programs that aim to
58
increase community participation and the acquisition of life skills (Maglio & McKinstry,
2008; Speigel et al., 2015).
‘Change’ in Social and Therapeutic Circus
The term ‘process-focused’ is similar to what occupational therapists consider as
participation-focused. Social Circus refers to participation-focused circus arts programs
that aim to create socio-politically conscious and social and emotional capacity-building
opportunities for people in diverse living conditions (Arrighi, 2014; Bolton, 2004; Maglio
& McKinstry, 2008). Social Circus programs are sometimes inclusive of health
professionals and sometimes not. Understanding how health professionals, including
occupational therapists, are using circus such as Social Circus, is essential for
understanding how their practice impacts the health of individuals and communities.
This scoping review aimed to identify, summarise and present the available
literature and research findings on the use of circus within a therapeutic context. A
therapeutic context is one in which circus is used explicitly to create change within
individuals. A Social Circus context does not necessarily aim to create change within
individuals but may serve to change how society perceives the individuals who
participate in Social Circus.
The intention of change can delineate therapeutic circus from Social Circus and
from non-individual, non-therapeutic (or social) uses of Social Circus. Individual change
is a required component of therapeutic interventions that intend to rehabilitate or improve
some or multiple aspects of a being (Wilding & Whiteford, 2007). Some Social Circus
programs exist without a therapeutic intention (Agans et al., 2019; Speigel et al., 2015)
while some specifically promote change and improvement in the social and emotional
capacities of the participants. For example, Thompson and Broome (2021) described
59
Social Circus as having therapeutic aims such as building confidence or developing life
skills. In contrast, Michel LaFortune, the former Cirque du Monde Social Circus director,
stated that “The objective is not rehabilitation…All we ask of society is to come and
listen and look at these young people in a different light” (Cirque du Soleil, 2011).
The study by Neave et al. (2020) demonstrated that both therapeutic and non
therapeutic intentions can coexist with positive impacts on personal development, social
inclusion, and self-expression. A personal development focus used within Social Circus
may relate to promoting change in an individual’s capacities. Such change may have a
therapeutic intention and outcome, or the change may be an expected result of naturally
occurring personal development supported by a health-promoting environment. Although
the presence of individual change may differ within Social Circus programs, the aspects
remaining consistent include the use of social and participation-focused activities, rather
than production or entertainment-focused activities. Social Circus is a common thread
that is present in most circus contexts used by different health professions. There is an
imperative need to define the use of circus in the various contexts of education, health,
and service (Coulston et al., 2023). This review focused specifically on the use of circus
within a health context. While Social Circus practitioners teach, engage in research and
advocate for Social Circus programs to promote health, this scoping review focuses only
on health professionals using circus, especially Social Circus.
The use of circus as a therapeutic medium is gaining increasing interest and
attention by health professionals in their practice with individuals and communities.
Occupational therapy involving circus is an emerging area of practice. There is a growing
60
awareness of how circus can be used to promote occupational participation in a range of
life pursuits or be an occupation in and of itself (Fernandez et al., 2018; Loiselle et al.,
2019; Maglio & McKinstry, 2008; Thompson & Broome, 2021). In the following
sections, the background, rationale, methods, and findings of this scoping review are
outlined and then followed by a discussion of the review findings and implications.
Background
Given the likelihood of limited research and literature focused on circus as a
therapeutic medium and its use in occupational therapy and other related health
professionals, a scoping review design was selected. Using a scoping review method
allows mapping of the range, extent, and nature of research as well as the identification of
research gaps that can be used to inform future research, practice, and participation into
this topic (McKinstry et al., 2014). A broad research question was intentionally chosen to
gather as much information as possible without posing limitations such as age,
population, and effectiveness which may have restricted the studies located. It is
proposed that increasing understanding and insight regarding the use of circus by health
professionals will benefit occupational therapists who use or are considering using circus
in their practice. Circus use by health advocates can respond to changing individual,
community, and political trends in society (Bolton, 2004; Grimes, 2011; Infantino, 2015;
Maleval & Mullett, 2002).
Aim
The aim of this review was to scope what is currently known about the use of
circus by health professionals, including occupational therapists.
Methods
61
The methods used for this scoping review followed Arksey and O’Malley’s
(2005) framework which involves five specific stages. These stages included identifying
the research question, identifying the relevant studies, selecting studies, charting the data
and collating, summarising and reporting the results. Scoping reviews utilise a
methodological framework that is precise and clear so that results can be reported with
enough detail to enable those who read the scoping review to critique its rigor and
relevance (McKinstry et al., 2014). The steps undertaken here describe what was found
and report on the relevant literature relating to circus use by health professionals.
Identifying the Research Question
In 2020, an initial extensive literature search was conducted with a specific focus
on occupational therapy informed circus. The search terms ‘occupational therapy and
circus’, originally yielded 120 peer-reviewed articles though a large majority of these
articles were not relevant because they only referenced another article that included
occupational therapy and circus. Only eight articles were identified that specifically
related to occupational therapy. A broader view of the literature is sometimes needed to
make an important contribution to a future systematic review (McKinstry et al., 2014),
therefore a more recent literature search conducted in 2023 adopted a broader research
question that included not only occupational therapists but health professionals, while
literature where circus was used as educational strategy was not included. The majority of
the articles found in the original search were omitted because they related to education
and Social Circus without any reference to a health professional. The original research
question was modified to include all health professionals and not just occupational
62
therapists. The search terms were expanded to include “Circus and Health”, “Circus and
Occupational Therapy or Circus and Occupational Science”, “Circus and Social Circus”,
“Circus and Disability” or “Circus and Special Needs”, ‘Circus and ‘Community Health
Promotion’. The databases searched included Proquest (Central, ERIC and Social
Science), CINHAL, Medline, OVID (PsychInfo), Cochrane Library, and INFORMIT
Humanities Database.
Research Question
1. What is known about the use of circus by health professionals?
Identifying the Relevant Studies
A broad search of the terms ‘circus’ and ‘health’ yielded many uses of the word
‘circus’ that did not relate to this study. In health-related literature the term ‘circus’ was
most commonly used as an adjective to allude to a type of chaos within an institution or
in reference to CIRCUS assessment battery or tachycardia. Other articles using the term
‘circus’ related to injuries circus artists experience, or the historical circus ideology and
the treatment of animals. There were some research studies that reported on the impact of
juggling on parts of the brain responsible for controlling movement and coordination
(Gerber et al., 2014). There was limited literature regarding Social Circus and/or
Community Circus and health. Analysis of the retrieved articles revealed a lack of
comprehensive information about the impact of Social Circus programs across various
populations and minimal literature on the use of circus by occupational therapists or other
health professionals. To determine the relevance to the research question, the following
inclusion and exclusion criteria were created (see Table 1).
63
Table 1
Inclusion and Exclusion Criteria
Inclusion
Exclusion
Full- text journal articles in English
Circus used by health professionals
Peer reviewed
M Masters or Doctorate Theses
Abstract only, including conference
abstracts
Use of circus by non-health professionals
Circus used in context of theatre,
performance, education, or injury focus
Grey literature
Circus used peripherally, not as the
intended intervention
Non-peer reviewed literature
‘Circus’ in reference to tachycardia
‘Circus’ in reference to describing a
chaotic circumstance
CIRCUS assessment battery
Literature was excluded if the focus was on circus performance, injury, circus as a
biomedical term, and circus being used as an adjective to describe a chaotic set of
circumstances. Literature on circus in the context of education was omitted if there was
not a health professional component included. Although there is a correlation between
education and health, the two contexts are separate, with education being about learning
and health being about well-being (Eide & Showalter, 2011). This review was focused
primarily on the therapeutic, rehabilitative, health promotion and illness prevention
approaches involving circus used with a health context perspective. Social Circus is a
unique phenomenon that relates to both health promotion and education professions
64
making Social Circus relevant to this thesis if inclusive of health professionals.
A PRISMA-ScR flow diagram (Figure 2) outlines the results of the search and
screening process, including reasons for the exclusion of full-text papers. The most recent
search conducted in September 2023 resulted in a total of 546 records. Of these 546
records, 15 were duplicates while another 504 were omitted because they did not meet
the inclusion criteria, including circus use as an alternative meaning (chaos, Circus
Assessment Battery), were non-human focused, or professional athlete/performer
focused. Twenty-seven full-text articles were considered relevant to the research question
and sought for retrieval after title and abstract screening. The selected articles included
content relating to circus used as health interventions, assessment criteria, novel
approaches used during research, social and emotional skill development, or in relation to
Social Circus. An additional six articles were included after the reference lists of the 27
included articles were reviewed. Out of the 33 full-text articles retrieved, 16 were
excluded because of one or more of the following reasons: a health professional was not
included; circus was used in educational or entertainment settings; or circus was used
thematically but not as the intervention. Seventeen articles meet the inclusion criteria for
this review.

65

Figure 2
Scoping Review Prisma Flow Diagram
Scoping Review Findings
66
In Table 2 below, a summary of the 17 selected studies is charted, outlining the
characteristics of the study, the aims of the research (if applicable), how circus was used,
and the findings or impact of using circus by health professionals. Of these 17 articles
that included circus use by a health professional, six specifically included the
combination of occupational therapy and circus. Eight utilised a psychological health
perspective (psychiatry, social work and art therapy included as subsets of this category),
one included physiology, and two included a combination of health perspectives.
67

Table 2
Summary of Studies Selected
No
.
First
Author/
Year
Country Study
Participants
Health
Profession
Research Design
and Data
Collection
Method
Study Aim:
Individual or
Community Focused
Results or Findings
1. Agans,
(2019)
USA 111 Youth
aged 10- 21
Psychology Quantitative.
Surveys
administered at
conference and
through online
database
To examine the
relationship between
circus and psychological
health. Group based,
individually focused.
Informed by Social
Circus.

‘Relatedness’ strongest
predictor of positive youth
outcomes within the youth
circus context.

2. Bonk,
(2019)
USA 1 Youth
aged 10
Art Therapy Master Thesis
Case study.
Body map
artwork and
participant
interview.

To assess the outcomes
of circus added to an art
therapy program on
body awareness,
emotional regulation and
self-perception.
Increased mood, body
awareness, emotional
regulation and
communication.
3. Baumgold
(2017)
USA 4 Adults
aged 21+
Occupational
Therapy
Qualitative.
Participant
observation
followed by
semi-structured
interviews.
To explore why adults
choose to participate in
community circus and
what they gained from
the experience.
Group based,
individually focused.
Informed by Social
Main themes – participants
experienced:
• Fun
• Social connections
• Improved mood
• Challenges

68
Circus.

4. Coulston,
(2023)
Australia Young
people up to
24 years of
age.
Psychiatry,
psychology,
occupational
therapy,
general
practitioner,
physiotherap
y
Scoping review. To map and synthesise
current evidence on
circus use in health for
participants under 25
years of age regardless
of quality of research.
Positive results in all
populations studied may
indicate generalisability.
Long term follow up is
recommended for future
studies. More clarity and
more comprehensive
description of circus
intervention elements of
also recommended.
5. Csuros,
(2015)
Hungary 10-15
children
aged 4-18
hospitalised
in
psychiatric
care.
Psychiatry. Study design not
described. Data
was collected
through
observation.
To look at Social
Circus’s place within the
psychiatric and
psychological
professions methods and
therapies.

Increased self-efficacy,
perseverance, motivation,
emotional regulation, and
cooperation with peers.

6. Fernandez,
(2018)
Australia 20 School
aged
children and
their
parents.

Occupational
Therapy.

Qualitative.
Semi-structured
interviews.
Explore the experiences
and perspectives of
children with
developmental
difficulties regarding
participation in
community leisure
programs.
Group based,
individually focused.
Informed by Social
Circus.

Positive experiences of
participants:
1.Enjoyment and having
fun
2.Uniqueness and variety
3. Sense of
competence/just right
challenge
4. Social
connectivity/Inclusivity
5. Physical activity.

69
7. Fournier,
(2014)
Canada 15 patients
9 non
patients
11 clinicians
Psychiatry. Mix Methods.
Literature
review,
observation and
interviews
conducted.
To explore and promote
Cirque du Monde, a
private Social Circus
entity as a primary
health care tool for
family physicians.
Patients reported no
significant differences in
social skills relationships
or self-esteem.
Clinicians reported
substantial decreases in
patients’ dependency,
inactivity, social
isolation, and psychiatric
symptoms.

8. Heller,
(2018)
USA Participant
parents of
15 children
aged 4-12.
Psychology.

Quantitative
design using an
online survey
with Likert
Scales. Data
collected at the
first and last
session of an 8
week program.

To introduce a play
therapy program using
circus and evaluate
physical and emotional
benefits.
Group based,
individually focused.
Informed by Social
Circus.
Significant improvements
in skills relating to
physicality, teamwork,
and following directions.
Improvements in
sociability and emotional
control were not
statistically significant.
9. Loiselle,
(2019)
Canada 9 young
adults living
with
physical
disabilities
and their
parents
recruited
from local
rehabilitatio
n centres
and schools.

Occupational
Therapy.
Exploratory
phenomenologica
l qualitative
design.
Pre and post
semi-structured
interviews.

To explore impact of
social circus on young
adults living with
physical disabilities
from their and their
parents’ perspectives.
Group based, individual
and community focused.
Informed by Social
Circus.

Both participants
and parents reported
increases in
communication, mobility,
relationships, community
life and responsibilities.
The strengthening of self
perception and self
efficacy enhanced
participation.
10. Maglio,
(2008)
Australia Social
Circus
Occupational
Therapy.
Qualitative
Evaluation/Focus
Conduct a process
evaluation and create an
Increases in social and
emotional health and life

70
facilitators
and School
aged
children/you
th (number
not
provided).
Groups with
Social Circus
facilitators

evaluation tool that
assesses outcomes of
future circus programs
against Victorian
Essential Learning
Standards criteria.
Group based, individual,
community and social
politically focused to
address government
policy.

skills acquisition among
participants. Created a
bridge between Social
Circus and occupational
therapy.
11. Miller,
(2016)
Australia 44 children
aged 5 – 16
years and
their
caregivers.
Physical
Therapy and
Occupational
Therapy.
Exploratory
study within
larger
Randomised
Control Trial.
Questionnaires:
Dimensions of
Mastery and
Paediatric
Volitional
Questionnaire.

To assess the
predictability of mastery
motivation for
engagement in upper
limb (UL) interventions
for children with
unilateral cerebral palsy
Children in circus group
demonstrated higher
positive risk taking,
problem solving and
overall engagement than
the control group.
12. Momeso,
(2015)
Brazil 60
overweight
children
aged 9-11
years.
Physiology
and
Biophysics
Experimental
Study (not
further
described)
Measurement
tools included
tetrapolar
bioimpedance
and Lymphocyte
isolation of blood
samples.

To compare lymphocyte
activation mechanisms
between overweight
children practicing
regular circus physical
exercises with non
exercised children.
Improved immune
systems and reduction in
lymphocyte proliferation
of the circus group
participants.

71
13. Neave,
(2020)
United
Kingdom
89 children
(27 control
group 67
intervention
group) and
their
teachers
(number not
specified)
from 3
schools in
the
north-east
England.

Psychology.

Quantitative: Self
report for
children and their
teacher ratings.
Repeated
measures design.
Baseline, post
and follow-up
questionnaire 6
months later.

To assess psychological
and behavioural
differences between the
control group and
intervention group
Group-based, individual
focused.
Significant reduction in
teacher ratings of
emotional problems for
intervention group. No
significant differences
between control group and
intervention group of self
reports.

14. Ratcliff,
(2002)
Australia 2 women
with a
history of
Childhood
Sexual
Abuse
(CSA)
Occupational
Therapy.

Qualitative. In
depth interviews.
Storytelling as
inquiry

Explore the subjective
experience of engaging
in physical occupation
for women survivors of
Childhood Sexual Abuse
(CSA).
Participants identified
engagement in physical
occupation supporting re
connect with their body
and integration of the
dissociated abuse
experience. Both women
highlighted the importance
of an environment where
they felt safe and valued.

15. Seay,
(2004)
USA 157 middle
school
participants
(6th – 8th
grade)
93 parents
12 teachers.
Psychology. Before and after
design with
measurement
tools:
Rosenberg Self
Esteem Scale,
The Revised
Body-Esteem
Scale, the
Nowicki-
To evaluate the impact
of circus on self-esteem,
body image, physical
activity motivation,
levels of participation,
and locus of control for
participants, observers,
and a control group of
no exposure.

Self-report measures of
participants of the three
groups did not differ
significantly on measures
of psychosocial
functioning.
Parent reports indicated
increases of social activity
and participation
compared to control

72
Strickland
Internal-External
Locus of Control
Scale, the
Physical Activity
Motivation Scale,
Teacher and
parent
questionnaires.

group.

16. Spiegel,
(2015)
Ecuador 248 Social
workers
volunteer
social circus
program
instructors
and
monitors.
Social Work Qualitative.
Focus Groups.

Explore the nationwide
Social Circus program
in Ecuador.
Group based, individual,
community and social
politically focused on
addressing a government
policy.

Circus enabled relatedness
between social workers
and the participants.
Social workers were able
to identify psycho-social
issues of participants for
follow up in home visits.
17. Thompson,
(2021)
Australia Children,
young
people, and
adults with
disabilities.
Occupational
Therapy

Qualitative
Two-part
thematic analysis
of YouTube
videos
transcripts.

Examine examples of
Social Circus for people
with disability (via
YouTube videos) using
the Model of Human
Occupation (MOHO)
lens to consider the link
between Social Circus
and contemporary
occupational therapy
practice. Group-based,
individual focused.
Motivation was attributed
to the expressed sense of
joy. Flexible participation
enabled autonomy.
Repetition of practice
resulted in improvement
of skills. Capacities
addressed included
balancing, grasping,
reaching, strength, and
posture. Motor, process,
communication, and
interaction skills
improved.
73
Populations
The included studies had various research populations. These included neuro
typically developing children (Agans et al., 2019; 2018; Maglio & McKinstry, 2008;
Neave et al., 2020) and children with disabilities (Miller et al., 2016; Fernandez et al.,
2018; Heller & Taglialatela, 2018; Thompson & Broome, 2021) including those with
social and environmental hardships (Spiegel et al., 2015). Other studies targeted young
adults, including neuro-typical adults (Baumgold, 2017), adults with developmental
needs (Loiselle et al., 2019), those from marginalised communities (Spiegel et al., 2015),
and female survivors of sexual assault (Ratcliff et al., 2002).
Social Circus Use Within Health Professions
The studies included in this review focused on occupational therapists and other
health professionals using circus and Social Circus. Health professionals such as social
workers, occupational therapists, psychologists, art therapists, psychiatrists,
physiologists, and physiotherapists discussed the potential benefits of circus intersecting
with the already established evidence-based practices and viewpoints of their health
professions. Of the 17 studies, ten drew explicitly on philosophies, ideologies, and
practices from Social Circus (Agans et al., 2019; Baumgold, 2017; Csuros, 2015;
Fernandez et al., 2018; Heller & Taglialatela, 2018; Loiselle et al., 2019; Maglio &
McKinstry, 2008; Neave et al., 2020; Seay, 2004; Spiegel et al., 2015). Two studies
involving occupational therapists did not specifically refer to Social Circus (Miller et al.,
2016; Ratcliff et al., 2002). One study described similar practice features to Social
Circus, focusing on emotional and social well-being of participants where circus was
used therapeutically for individual trauma healing (Ratcliff et al., 2002). The other study
involved children with cerebral palsy participating in circus, among other activities, in
74
evaluating the effectiveness of Constraint Induced Movement Therapy versus Bimanual
Training (Miller et al., 2016). Although there were no intentional social and emotional
benefits, it did resemble other group-based Social Circus programs by being process
focused and having a variety of activities for participants with the leadership and support
of Social Circus facilitators.
An analysis of the intention and participant experience within the included studies
was conducted to determine if the circus programs were therapeutic or consistent with
Social Circus features or both. Most studies focusing on social and emotional health with
a process-focused nature appeared to be influenced by Social Circus even if not
specifically named. These practices included circus being used in a group context and
participation intentionally orientated to promote social and emotional well-being (Agans
et al., 2019; Baumgold, 2017; Csuros, 2015; Fernandez et al., 2018; Heller &
Taglialatela, 2018; Loiselle et al., 2019; Maglio & McKinstry, 2008; Neave et al., 2020;
Seay, 2004; Spiegel et al., 2015). The case study by Bonk, (2019) reported on circus
skills eliciting the same positive social and emotional impacts as Social Circus
interventions but was used with an individual instead of a group.
Social Circus was specifically named in 11 studies: Agans et al. (2019);
Baumgold (2017); Colston et al. (2023), Csuros et al. (2015), Fernandez et al. (2018);
Fournier et al., (2014) Heller and Taglialatela (2018); Loiselle et al. (2019); Maglio and
McKinstry (2008); Neave et al. (2020) and Spiegel et al. (2015). The wide use of Social
Circus in many of the studies appear to indicate that Social Circus is the