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 ...
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
The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations - Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG ...
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
The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations - Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG ...
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
The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations - Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG ...
Context (3)

  Biomedical   Holistic
     Care       Care

                          4
The Therapeutic Use of Doll Therapy for People with Dementia: Ethical Considerations - Gary Mitchell BA, BSc, MSc, RN. Michelle Templeton BSc, PG ...
Introduction
   Non-Pharmacological interventions include:

         1.Reality Orientation
         2.Reminiscence Therapy
         3.Aromatherapy
         4. Music Therapy

                          (Mitchell and O’Donnell, 2013)

                                                           5
Introduction (2)
   ‘Doll therapy’ is one such
    non-pharmacological
    intervention utilized for some
    people with dementia.

                                     6
The 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

                                                                    7
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)

                                                                          8
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”.

                                                                         9
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).

                                                                       10
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.

                                                                           11
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)

                                                                         12
Type 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’.
                                                                                                  13
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)

                                                                          14
Kitwood’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.
                                                                               15
Ethical Considerations (3)
   Autonomy

   Beneficence

   Non-Maleficence

   Consent

   Dignity

                             16
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.

                                                                     17
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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