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Doll therapy is a psychosocial intervention that aims to meet psychological needs of persons living with dementia.
What is Doll Therapy?
Doll therapy is a non-pharmacological intervention that aims to reduce the behavioral and psychological symptoms of dementia (BPSD) that a person may experience.
It involves presenting the person living with dementia with a baby-like doll which has human-like features such as facial expressions, sound, and texture during therapy.1
Doll therapy is more than merely offering a doll to a person living with dementia. It requires:
- Validating the feelings of the person living with dementia.2
- Engaging with the doll by carrying, communicating and caring for it.
Benefits of Doll Therapy
Doll therapy has shown to increase the well-being of the person living with dementia by calming them, reducing their feelings of loneliness, and giving them a sense of purpose.3
Doll therapy can be implemented with the aim of meeting the psychological needs of persons living with dementia, which include attachment, comfort, occupation, identity, and inclusion.
The use of doll therapy as a non-pharmacological intervention has become increasingly popular. Psychosocial interventions, which are non-pharmacological interventions, may sometimes be used first before or in conjunction with pharmacological interventions, as medications can generate side effects such as increased drowsiness and increased fall risk.4
Whom is Doll Therapy for?
Doll therapy is most likely to benefit:
- Both men and women.
- People living with moderate to severe stages of dementia who would perceive the doll as a baby.5
- People who are experiencing an early stage of dementia who may enjoy holding or dressing the doll.
- People living with dementia who have strong memories of parenthood, who may be having delusions or hallucinations about their children crying, or who might frequently be looking for their infant children.
- People living with dementia who have formerly enjoyed being around children or babies.
Past Studies on Doll Therapy
Study 1
A small study by Alander, Prescott and James (2015)6 supports the claim that doll therapy reduces behavioural challenges in people with living dementia. All 16 study participants (persons living with dementia) from 3 residential homes appeared calmer than before the doll therapy sessions. It was found that the dolls provided meaningful engagement as the study participants were kept occupied purposefully. The dolls also offered companionship, which resulted in the participants feeling more connected, more included, and less lonely. Caring for the dolls was also found to uphold their self-identities of their roles as parents.
Study 2
A “Baby Doll Therapy” project by Braden and Gaspar (2015)7 in which doll therapy guidelines were used with doll therapy sessions showed positive behavioural improvements as 27% of the people living with dementia in the dementia care centre where the study was conducted were happier, less anxious, more energetic and easier to work with because they found meaning in the therapy.
Study 3
Another small study done by Pezzati, et.al (2014)2 involved 10 persons living with dementia who were residents at a nursing home. The study found that through the process of caring for these dolls, the participants’ well-being improved as their attachment needs were met through the relational bond developed between participant and doll.
Concerns About Doll Therapy
Concerns About Deception
A level of deception may be involved when dolls are used, as persons living with dementia often believe that the dolls used are real infants. Caregivers and care professionals may need to play along with this belief to facilitate the interaction between the person and the doll.
On one hand, it has been argued that acting as if the doll is a real human infant is an example of malignant social psychology, which takes away personhood from the person living with dementia.8 This is because the acting, which can qualify as deception, violates a person’s right to autonomy, and by extension, their right to dignity and respect.
A point of view that addresses the previous point’s concern is that the deception used in doll therapy is ethical as it is used with the intention to better the wellbeing of persons living with dementia on two counts. Firstly, it reduces the negative behavioural and psychological symptoms of dementia that they experience, such as agitation or a depressive mood. Secondly, it can meet psychological needs such as attachment and occupation, while raising the mood and engagement of the person.
Another way of understanding the situation is to know that the person living with dementia is by themselves coming to a belief that the doll is a human being. Trying to convince them that their belief is false may actually be counterproductive, as it may not be possible to orient them to reality that the doll is not a human infant, and may instead confuse and agitate them.4 The only other viable way forward would be to play along with the person’s belief while encouraging their therapeutic outcomes to be met.
Concerns About Infantalisation
Some have suggested that under doll therapy, persons living with dementia are treated like children6, contributing to their perception that doll therapy is demeaning, patronising and infantilising.4
Playing with dolls is often associated with children’s activities and behaviour, as some children may believe that the dolls they are playing with are real infants, while others may play with dolls as part of a role-playing/make-believe activity. This association with childlikeness may make doll therapy be seen as something inappropriate for adults. Some may feel that if adults who have dementia did not have their condition, they themselves might not choose to interact with dolls.
This is a dilemma that some family members may face when thinking about their loved ones participating in doll therapy.9
A way of addressing this concern about doll therapy is to consider that the person living with dementia does have dementia, and is different from how they were before dementia, even though they are adults.
The section above addressing the concern about deception also applies here: doll therapy reduces the negative symptoms of dementia that may be experienced, and can also meet psychological needs such as attachment and occupation, while raising the mood and engagement of the person.
Concerns About Attachment
There are concerns that persons living with dementia may encounter distress if they fear losing a doll they have interacted with, or if the dolls are taken away from them after the therapy session.
In addition, family members may express concern that doll therapy is used as a substitute for human company during resource constraints.6
One way to think about this dilemma is that even under resource constraints, persons living with dementia can still have their wellbeing improved by doll therapy.
Guidelines for Effective Doll Therapy
Staff are encouraged to be educated on the therapeutic objective and protocol of doll therapy to avoid undermining dignity of the people living with dementia.6,9
These are some proposed guidelines for effective doll therapy, adapted from Alzheimer’s Australia:9
Prior to Using the Doll
- Consider the resident’s background and history. This includes traumatic events experienced such as miscarriage or abuse which may prevent acceptance of doll therapy.
- Doll therapy should be offered as a choice instead of a stand-alone strategy because it may be unsuitable for some.2,6
- The type of dolls used should suit the personality and culture of the person living with dementia. For example, avoid using dolls which can cry as they can cause distress, and avoid those with permanently closed eyes as they may be mistaken as being dead.
- Differentiate the dolls with different clothes to avoid confusion over ownership matters.
- Explain to family the therapeutic goals and process as well as obtain family members’ approval to address infantilization concerns.4
- For hygiene purposes, wash hands before and after handling the doll to avoid getting the doll dirty and to reduce infection risk.
Introducing the Doll
- Greet the person living with dementia while cradling the doll and then sit down next to them.
- Do not force the person living with dementia to hold the doll, but wait for them to acknowledge its existence. Invite the person to hold the doll if they show interest.5
- Observe their response to the doll, such as a smile or loving tone to the doll, to assess if they will enjoy interacting with the doll.
- Bring the doll to the person’s attention if they do not seem to notice the doll, and invite their feedback. If the person appears interested and engaged, ask if they would like to hold it. However, if the person is still disinterested, consider reintroducing the therapy on another occasion.
- Put the dolls in prominent and accessible places for the person to exercise their choice when they show interest. Do not assume that the person living with dementia knows whether the doll is real but wait for signs they show.
- Observe whether the person living with dementia appears to be viewing the doll as a real baby. Engage the person by making general comments about the doll, commenting on its eyes/hair/clothes while taking care not to identify it as either a doll or baby at this stage.
- If the person recognizes the doll as a doll, do not deny it but instead, use it as an alternative form of reminiscence and proceed to explore how lifelike the doll is.
Therapy Session
- During the session, the person living with dementia may name the doll. This should be recorded in the resident’s care plan. Address each respective doll by the same name because of its relational value to the person living with dementia.
- Follow his stream of thoughts as the conversation prompts during the session and try to put some structure to the conversation such as talking about their own children when they were babies.
- Respect his perception of the doll. If he is responding positively and perceiving it as a real baby, avoid referring to it as a doll and ensure it is handled like a real child such as avoiding picking it up by the leg or head.
- Monitor the person’s response and engagement throughout the session to assess if doll therapy is appropriate.
Record these responses in the care plan. - Thank the person living with dementia for their time and care upon completion of the session. Inform the person that the doll will be taken back to its crib or home to ensure its safety.
- Update the care plan with information such as therapy session goal, time and duration, responses of the people living with dementia when introducing, playing with and withdrawing the doll as well as their behaviour and mood after the session can help monitor any fatigue from the doll therapy and better facilitate handover of caregivers in different shifts.9
Conclusion
Doll therapy can help to manage behavioural and psychological symptoms of dementia (BPSD) if implemented well. It meets some psychological needs of people living with dementia, which include attachment, comfort, occupation, identity, and inclusion.
At the same time, the practice of doll therapy may pose ethical questions that caregivers and care professionals may want to be aware of and think through. Concerns including infantilisation may make doll therapy an intervention which caregivers and care professionals are hesitant to use.
To address these valid concerns, guidelines in doll therapy are needed. These guidelines offer guidance on doll types, how the dolls should be handled, addressed, and kept. They also offer guidance on larger, more systemic factors such as staff education, obtaining consent of family members and the use of a detailed care plan.
Read on to find out about other ways the wellbeing of persons living with dementia can be improved.
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About the Author
Quee Kee
Pursuing her Master of Dementia in the University of Tasmania, Quee Kee focuses on research in non-pharmacological interventions in dementia, specifically on reminiscence, art, music, animal-assisted and doll therapy. As a caregiver for her mother for 13 years, Quee Kee is also passionate in research relating to palliative care approach in dementia, including its ethical considerations and supporting policy such as advance care planning. An advocate for dementia friendly communities in promoting social inclusion and enabling people living with dementia and their caregivers, Quee Kee has been instrumental in initiating her church’s dementia-friendly church project.
- Cantarella, A., Borella, E., Faggian, S., Navuzzi, A., & De Beni, R. (2018). Using dolls for therapeutic purposes: A study on nursing home residents with severe dementia. International journal of geriatric psychiatry, 33(7), 915-925. DOI: http://10.1002/gps.4872
- Pezzati, R., Molteni, V., Bani, M., Settanta, C., Di Maggio, M. G., Villa, I., Poletti, B., & Ardito, R. B. (2014). Can Doll therapy preserve or promote attachment in people with cognitive, behavioral, and emotional problems? A pilot study in institutionalized patients with dementia. Frontiers in psychology, 5, 342. DOI: http://10.3389/fpsyg.2014.00342
- Mitchell, G. (2014). Use of doll therapy for people with dementia: an overview. Nursing older people, 26(4).
- Mitchell, G., & Templeton, M. (2014). Ethical considerations of doll therapy for people with dementia. Nursing ethics, 21(6), 720-730. DOI: http://10.1177/0969733013518447
- Bisiani, L., & Angus, J. (2013). 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 (London, England), 12(4), 447–462. https://doi.org/10.1177/1471301211431362
- Alander, H., Prescott, T., & James, I. A. (2015). Older adults’ views and experiences of doll therapy in residential care homes. Dementia, 14(5), 574-588. DOI: http://10.1177/1471301213503643
- Braden, B. A., & Gaspar, P. M. (2015). Implementation of a baby doll therapy protocol for people with dementia: Innovative practice. Dementia, 14(5), 696-706. DOI: http://10.1177/1471301214561532
- Kitwood, T. M. (1997). Dementia reconsidered: The person comes first (Vol. 20, pp. 7-8). Buckingham: Open University Press.
- Alzheimer’s Australia WA (2018). Guidelines for Use of Dolls and Mechanized Pets as a Therapeutic Tool. Retrieved from https://www.dementia.org.au/files/WA/documents/2.00%20Guidlines%20for%20Use%20of%20Dolls%20and%20Mechanized%20Pets%20as%20a%20Therapeutic%20Tool.pdf
