The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations

1. 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

2. 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.

3. 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).

4. Context (3)

5. Introduction • Non-Pharmacological interventionsinclude: 1.Reality Orientation 2.Reminiscence Therapy 3.Aromatherapy 4. Music Therapy (Mitchell and O’Donnell, 2013)

6. Introduction (2) • ‘Doll therapy’ is one such non-pharmacological intervention utilized for some people with dementia.

7. The Origins of ‘Doll Therapy’

8. 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)

9. 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”.

10. 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).

11. 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.

12. 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)

13. Type of Doll

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

15. Kitwood’s Malignant Social Psychology (1997) Kitwood’s Positive Person Work (PPW) (1997) • Treachery • Disempowerment • Infantilisation • Imposition • Mockery • Validation • Relaxation • Play • Facilitation • Creation The therapeutic use of dolls in people with dementia can be seen through multiple lenses.

16. Ethical Considerations (3) • Autonomy • Beneficence • Non-Maleficence • Consent • Dignity

17. 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.

18. 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. 

19. 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.