The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations - Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG ...
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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.
2
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).
3
Context (3)
Biomedical Holistic
Care Care
4
Introduction
Non-Pharmacological interventions include:
1.Reality Orientation
2.Reminiscence Therapy
3.Aromatherapy
4. Music Therapy
(Mitchell and O’Donnell, 2013)
5Introduction (2)
‘Doll therapy’ is one such
non-pharmacological
intervention utilized for some
people with dementia.
6The Origins of ‘Doll Therapy’
Bére Miesen
(Attachment Theory
applied to people
with dementia)
(1993)
John Bowlby Donald Winnicott
(Attachment Theory) (Transitional Object)
(1969) (1953)
Empathetic
Doll
Therapy
7Empirical 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)
8Empirical 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”.
9Empirical 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).
10Empirical 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.
11Empirical 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)
12Type of Doll
Description of dolls used in practice
‘Three animal shaped toys…a gorilla, a tiger and a dog’.
Nakajima et al (2001)
‘Baby is a cute battery operated doll purchased in the toy
Gibson (2005)
department of a local store’.
‘Teddy bear’.
Lash (2005)
‘Dolls…were all plastic…had eyes that opened and closed…had
Ellingford et al (2007)
different faces and clothes…no auditory functions such as crying’.
‘Empathy dolls’.
Mackenzie et al (2007)
‘The doll we chose is from an American company…it is weighed
Minshull (2009)
to feel like a baby’.
Scott (2011) notes that the ‘babyloid’ is being developed in Japan
at present but there have been favourable results in patients with
Scott (2011) 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’.
‘Henry was regularly seen with a Popeye doll…Ruby…carried a
Stephens et al (2012)
knitted doll’.
‘The face was anatomically correct, female and the expression was
Bisiani and Angus (2012)
one of peace and tranquillity’.
13Ethical 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)
14Kitwood’s Malignant Social Psychology Kitwood’s Positive Person Work (PPW)
(1997) (1997)
Treachery Validation
Disempowerment Relaxation
Infantilisation Play
Imposition Facilitation
Mockery Creation
The therapeutic use of dolls in people with
dementia can be seen through multiple lenses.
15Ethical Considerations (3)
Autonomy
Beneficence
Non-Maleficence
Consent
Dignity
16Discussion
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.
17References
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.
18References (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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