The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG Dip, MPhil. For correspondence please contact: gmitchell08@qub.ac.uk

Context Current estimates suggest that around 40 million people

worldwide live with some form of dementia.

This number is expected to grow to around 66 million people by 2030 and possibly reach 115 million by 2050.

In 2010, Alzheimer’s Disease International estimated the global cost of dementia as $604 billion (1% of global GDP).

According to the World Health Organisation this equates to potentially one new case of dementia every four seconds.

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Context (2) Distress is a common feature witnessed in people with dementia.

It is estimated that 60%-90% of people with dementia will exhibit

some form of distress (James et al, 2008)

Healthcare approaches to distress remain sporadic and problematic.

Non-pharmacological interventions may offer an easily accessible

and cost effective means of relieving mild to moderate distress (Mitchell, 2013).

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Context (3)

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Holistic Care

Biomedical Care

Introduction Non-Pharmacological interventions include:

1.Reality Orientation 2.Reminiscence Therapy 3.Aromatherapy 4. Music Therapy (Mitchell and O’Donnell, 2013)

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Introduction (2) ‘Doll therapy’ is one such

non-pharmacological intervention utilized for some people with dementia.

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The Origins of ‘Doll Therapy’

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Empathetic Doll

Therapy

John Bowlby (Attachment Theory)

(1969)

Bére Miesen (Attachment Theory applied to people with dementia)

(1993)

Donald Winnicott (Transitional Object)

(1953)

Empirical Evidence Plethora of anecdotal evidence

“Reduction in agitation, aggression and wandering” (Verity, 2006) Reduction in “challenging behaviour” (Lash, 2005) “Like a gold medal” (Moore, 2001)

Newcastle Challenging Behaviour Service, collectively complied first sources of empirical evidence pertaining to the phenomenon of using

dolls for people with dementia. (James, et al. 2006; Mackenzie et al, 2006; Ellingford et al 2007)

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Empirical Evidence (2) James et al (2006):

Provided 30 soft toys (15 teddy bears, 15 dolls) to residents in

one care home in Newcastle (UK).

93% of people with dementia preferred doll.

Majority of residents observed (n=14) were “more content…less anxious”.

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Empirical Evidence (3) Ellingford et al (2007):

Examined case notes of 66 residents with dementia in 4 care

homes over a 6 month period. 3 months pre-doll therapy intervention and 3 months post doll-

therapy intervention.

The doll intervention group (n=34) exhibited an increase in their wellbeing when compared to the group without dolls (n=32).

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Empirical Evidence (4) Mackenzie et al (2006):

Provided 14 dolls to 37 residents in 2 care homes over a 3 week

period.

32/46 (70%) of care home staff noted that the resident’s wellbeing appeared ‘much better’ after engaging in doll therapy.

13% of staff thought doll therapy was “demeaning, patronising...babyish”.

35% of carers reported problems concerning ownership of the dolls.

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Empirical Evidence (5) ‘Doll therapy’ is not exclusive to the UK, research has also been

carried out in Australia and Japan. (Mitchell and O’Donnell, 2013)

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Type of Doll Description of dolls used in practice

Nakajima et al (2001)

‘Three animal shaped toys…a gorilla, a tiger and a dog’.

Gibson (2005)

‘Baby is a cute battery operated doll purchased in the toy department of a local store’.

Lash (2005)

‘Teddy bear’.

Ellingford et al (2007) ‘Dolls…were all plastic…had eyes that opened and closed…had different faces and clothes…no auditory functions such as crying’.

Mackenzie et al (2007)

‘Empathy dolls’.

Minshull (2009) ‘The doll we chose is from an American company…it is weighed to feel like a baby’.

Scott (2011)

Scott (2011) notes that the ‘babyloid’ is being developed in Japan at present but there have been favourable results in patients with dementia. The babyloid ‘looks a bit like a baby seal…it has the ability to make certain human emotions via a moving mouth…eyelids…can emote happiness and sadness...even crying’.

Stephens et al (2012) ‘Henry was regularly seen with a Popeye doll…Ruby…carried a knitted doll’.

Bisiani and Angus (2012) ‘The face was anatomically correct, female and the expression was one of peace and tranquillity’.

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Ethical Considerations Kitwood (1997), ‘Malignant Social Psychology’.

A social environment in which interactions and communications

occur which diminish the ‘personhood’ of those people experiencing that environment.

‘Malignant’ interactions are not necessarily perpetrated from an intent of malice but rather through lack of insight or knowledge of the negative effects created and their impact on others.

The occurrence of malice may be linked to the environment and/or culture, and is particularly notable in the field of dementia care.

(Mitchell, et al., 2012)

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The therapeutic use of dolls in people with dementia can be seen through multiple lenses.

Kitwood’s Malignant Social Psychology (1997)

Kitwood’s Positive Person Work (PPW) (1997)

Treachery

Disempowerment

Infantilisation

Imposition

Mockery

Validation

Relaxation

Play

Facilitation

Creation

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Ethical Considerations (3)

Autonomy

Beneficence

Non-Maleficence

Consent Dignity

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Discussion The therapeutic use of dolls for people with dementia can be a

contentious issue for numerous reasons: ◦ Paucity of empirical evidence.

◦ Attitudes and misconceptions about doll therapy as a demeaning

practice particularly among healthcare professional.

◦ The absence of clinical guidelines.

Despite limited knowledge and numerous contentions, ‘doll therapy’ could be a beneficial intervention to reduce

distress for some people with dementia.

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References Alzheimer’s Disease International. World Alzheimer Report 2012:

Overcoming the stigma of dementia. Alzheimer’s Disease International: London, 2012.

Bisiani, L and Angus, J. (2012) ‘Doll therapy: A therapeutic means to meet past attachment needs and diminish behaviours of concern in a person living with dementia – a case study approach’, Dementia, 15 February 2012.

Bowlby, J. (1969) Attachment and loss: Volume 1. Attachment. London: Hogarth Press

Ellingford, J., Mackenzie, L. and Marsland, L. (2007) ‘Using dolls to alter behaviour in patients with dementia’, Nursing Times, 103, (5), pp. 36-37.

Gibson, S. (2005) ‘A personal experience of successful doll therapy’, Journal of Dementia Care, 13 (3), pp. 22-23.

James, I., Mackenzie, L. and Mukaetova-Ladinska, E. (2006) ‘Doll use in care homes for people with dementia’, International Journal of Geriatric Psychiatry, (21) pp. 1093-1098.

Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Open University Press: Buckingham.

Lash, M. (2005) ‘My darling bear’, Journal of Gerontological Nursing, 31 (8), pp. 54-56.

Mackenzie, L., James, I., Morse, R., Mukaetova-Ladinska, E. and Reichelt, K. (2006a) ‘A pilot study on the use of dolls for people with dementia’, Age and Aging, pp. 441-443.

Mitchell, G., McCollum, P. and Monaghan, C. (2012) ‘The person with dementia: the personal impact of diagnosis disclosure’, 22nd Annual Alzheimer Europe Conference. Vienna: Austria.

Mitchell, G. and O'Donnell, H. (2013) 'The therapeutic use of doll therapy in dementia', British Journal of Nursing, 22, (6), pp. 329-334.

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References (2) Mitchell, G. (2013) 'Applying pharmacology to practice: The case of dementia', Nurse Prescribing, 11, (4), pp. 185-190

Miesen, B. (1993) ‘Alzheimer’s disease, the phenomenon of parent fixation and Bowlby’s attachment theory’, International Journal of Geriatric Psychiatry, 8, pp. 147-153. Minshull, K. (2009) ‘The impact of doll therapy on well-being of people with dementia’, Journal of Dementia Care, 17 (2) pp. 35-38.

Moore, D. (2001) ‘It’s like a gold medal and it’s mine – dolls in dementia care’, Journal of Dementia Care, 9 (6), pp. 20-23.

Nakajima, K., Nakamura, J., Yonemitsu, S., Oikawa, D., Ito, A., Higashi, Y., Fujimoto, T., Nambu, M. and Tamura, T. (2001) ‘Animal-shaped toys as therapeutic tools for patients with severe dementia’, Proceedings of the 23rd Annual EMBS International Conference; 2001 Oct 25-8; Istanbul, Turkey: 2001.

Scott, A. (2011) ‘Therapeutic use of dolls in dementia care’, paper presented at Living well with dementia: Activity for meaningful lives conference. Trinity Capital Hotel: Dublin.

Stephens, A., Cheston, R. and Gleeson, K. (2012) ‘An exploration into the relationships people with dementia have with physical objects: An ethnographic study’, Dementia, 22 March.

Verity, J. (2006) ‘Dolls in dementia care: bridging the divide’, Journal of Dementia Care, 14 (1), pp. 25-27.

Winnicott, W. (1953) ‘Traditional objects and transitional phenomena: A study of the first not-me possession’, The International Journal of Psychoanalysis, (34), 89-97.

World Health Organization. Dementia: A public health priority. Geneva: World Health Organization, 2012.

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