Therapeutic use of dolls for people living with dementia: A critical review of the literature

Rationale for review

As illustrated, therapeutic engagement with dolls has the potential to be beneficial to the well-being of people living with dementia. This is coupled with the fact that the therapy is also cost-effective. Despite these perceived micro and macro benefits there has been a paucity of empirical investigation on the therapeutic use of dolls for people living with dementia. There are also a number of theories, ranging from child psychologies to person-centred psychologies, which have been used interchangeably to describe the reasons for its effectiveness. The paucity of clinical guidelines and associated ethical tensions provide a strong rationale for carrying out this review.

On review of the existing evidence base, it would also appear that no reviews of the literature have been carried out on doll therapy for people living with dementia. This review will serve to support healthcare professionals to understand the potential benefits and disadvantages of doll therapy identified from empirical evidence. In addition to this, the review will also demonstrate how doll therapy has been utilised in different clinical settings to date.

Search strategy

A comprehensive search of the literature was carried out in April 2014 using the following terms: dementia, Alzheimer’s Disease, people with dementia, doll therapy, doll, soft toy, baby doll, play therapy and residential care institutions. These terms were used in the following databases: CINAHL, PsycINFO, Medline, Embase, Internurse, Cochrane Library, Joanna Briggs Institute, PubMed and NHS Evidence.

Inclusion criteria and exclusion criteria

There is a paucity of empirical evidence on the phenomenon of doll therapy for people living with dementia. As a result there were minimal exclusions applied to this review, except those studies that were not written in English language, those studies that were not carried out with people who are living with dementia and those which were not empirical. During the searching stage of this review, it was found that Fernandez, Arthur, and Fleming (2013) have published a systematic review protocol on the effect of doll therapy in managing behaviours that challenge in people living with dementia. This review has not yet been completed and appears to have a primary emphasis on measuring behaviour change, like ‘agitation, verbal aggression and physical aggression’, through validated scales. The purpose of this review differs as it seeks to not only explore the benefits and challenges of doll therapy for people living with dementia within a practice context, which consequently will take into account factors associated with well-being and ill-being and in turn may include what Fernandez et al. (2013) term agitation, verbal and physical aggression’, but also explore additional factors related to theoretical underpinnings and bioethics. Figure 1 provides an overview of the results from the search strategy that found 11 studies eligible for inclusion. OPEN IN VIEWER

Study setting

Over half of the included studies were carried out in the UK. Six studies were carried out in England and one in Scotland. In addition to this, two studies were carried out in the USA, while one study was identified in Japan and one in Australia. It is also interesting to note that, five studies (Alander, Prescott, & James, 2015; Ellingford, Mackenzie, & Marsland, 2007; Fraser & James, 2008; James, Mackenzie, & Mukaetova-Ladinska, 2006; Mackenzie, James, Morse, Mukaetova-Ladinska, & Reichelt, 2006) were carried out by personnel from the same centre, the Newcastle Challenging Behaviour Service (UK). This concentration of studies in the United Kingdom may raise some questions over generalisability.

The settings for the included studies, which incorporated people living with dementia, were most often long-term care facilities or nursing homes (Bisiani & Angus, 2013; Cohen-Mansfield, Thein, Dakheel-Ali, Reiger, & Marx, 2010; Ellingford et al., 2007; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013; Tamura, Nakajima, & Nambu, 2001). Only two studies investigated doll therapy within a hospital setting (Green et al., 2011; Minshull, 2009).

Research design

The majority of studies sought to investigate the phenomenon of doll therapy through observational data collection of people engaging with doll therapy (Bisiani & Angus, 2013; Cohen-Mansfield et al., 2010; Green et al., 2011; Stephens et al., 2013; Tamura et al., 2001). Four studies sought to examine healthcare professional perceptions on the use of doll therapy through the administration of questionnaires (James et al., 2006; Mackenzie et al., 2006) and semi-structured or focus-group interviews (Alander et al., 2015; Fraser & James, 2008). The one remaining study conducted a retrospective analysis of case notes pre and post-doll therapy (Ellingford et al., 2007).

Sampling

Across the 11 included studies a total of 448 people living with dementia and 49 healthcare professionals were recruited (n = 497). It should be noted that the study conducted by Cohen-Mansfield, Thein, Dakheel-Ali, Reiger, and Marx (2010) examined the impact of different stimuli (one of which was doll therapy) for people living with dementia. It is the only study that is included in the review that does not explicitly evaluate doll therapy and included 193 people living with dementia which is almost half of the participants of this review. In relation to the number of participants in this review, the mode was 14 participants, the median was 14 participants and the mean number of participants was 45. Seven of the eleven studies included in this review were conducted with 16 participants or less (Alander et al., 2015; Bisiani & Angus, 2013; Fraser & James, 2008; James et al., 2006; Mackenzie et al., 2006; Minshull, 2009; Stephens et al., 2013; Tamura et al., 2001). There were no studies that sought to investigate the phenomenon from the perspective of care partners (relatives or informal carers).

For a comprehensive overview of the included studies see Table 1.

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Table 1.

Summary of included studies.

#	Author, year, country, city Research design	Aim	Method	Sample	Key findings
1	Tamura et al. (2001) Japan Miyazaki Cohort study	To assess if dolls could be therapeutic for people with advanced dementia.	Following presentation of 3 dolls, by an occupational therapist, people living with dementia were observed (by OT). Results were categorized into 4 categories (no reaction, close observation, taking care of the doll or communication with other patients).	13 people living with dementia (3 male and 10 female) living in a long-term care facility. Average age of 90.2 years (range 82–102 years) All had Alzheimer’s disease. Purposive sample (authors selected 13 residents with twilight syndrome from 40).	People living with dementia in this study preferred the more ‘realistic’ baby doll. This was reported as those which were “made of silicon, which mimics the texture of a real baby” (p. 117). Most people living with dementia believed the dolls were real babies. People living with dementia who will engage with a doll will do so within around 90 s. The most common observed behaviours from engagement were: “carrying while supporting the dolls neck, clasping the dolls hand, calling out to dolls” (p. 115). While there were brief accounts of men engaging with dolls, the phenomenon was mainly applicable to women.
2	Mackenzie et al. (2006) England Newcastle Cohort study	Pilot study to examine the impact of the introduction of dolls on people living in a dementia care unit.	Dolls offered to all residents with dementia. If a resident selected a doll, his or her interaction was monitored by staff over a 3–6 week period. 5-item questionnaire for all care staff. In addition, key workers of those who engaged with doll therapy were asked to complete a 14-item questionnaire. This sought to assess impact of doll on person (i.e. level of activity, agitation and interactions with others).	37 people living with dementia offered doll. 14 people living with dementia (12 women and 2 men) used the doll. Non-probability sample (all 37 residents were included in this study). 46 care staff completed 5-item questionnaire (96% response in care home 1 and 79% response in care home 2). 100% response to second questionnaire from 14 key workers. Neither home employed “qualified staff” (p. 441)	14 dolls out of the 20 were used by residents. This represented 38% of the care unit population. 35% of carers reported some problems with the dolls, namely “arguments between residents over ownership, residents trying to feed their dolls and dolls being misled” (p. 442). In relation to initial impressions on doll therapy, 9 staff had either major/minor concerns, 16 were neutral and 21 were minor/majorly positive. In relation to concerns quotes include “thought it was babyish, totally demeaning, patronizing, inappropriate and could confuse residents further” (p. 442). Well-being of the people who used dolls was judged to be either a little better (30%) or much better (70%) by carers. In particular staff perceived the dolls to be calming (p. 443). Well-being increases were associated with the following; “greater levels of interaction with staff, fellow residents, appeared happier, less agitated and more amenable to personal-care activities” (p. 442).
3	James et al. (2006) England Newcastle Cohort study	Following on from Mackenzie et al. (2006) pilot study, the authors sought to examine how: (1) Doll therapy affected people living with dementia. (2) If residents had preference of either doll or teddy bear. (3) If care staff could predict which residents would opt to engage with dolls.	15 dolls and 15 teddy bears were offered to people living with dementia in one care facility. 2 members of staff selected by home manager to monitor residents prior to therapy. (1) They would complete a prediction sheet (i.e. to predict which residents who engage with the therapy) (2) They would complete an impact questionnaire (Likert scale) to access therapy. This impact questionnaire was the 5-point questionnaire used in the Mackenzie et al. (2006) pilot. These impact sheets were completed at weeks 1, 2, 4, 8 and 12 post-introduction of toys.	34 people living with dementia offered doll or teddy bear. 14 people living with dementia engaged with dolls (12 women and 2 men). Non-probability sample (all 33 residents were eligible). 2 members of staff were selected by care home manager.	Care staff only predicted with 56% accuracy, which residents would use the doll. The 2 care staff members however were more accurate in relation to residents they felt would not use the doll (82% accuracy). 14 residents out of 34 residents (41%) engaged with doll therapy. 13 out of 14 residents (93%) opted for a doll as opposed to a teddy bear when offered the choice. General well-being increase was noted for those using dolls in the form of “activity, interaction, happiness” (p. 1095). One resident referred to her doll by a name, one (a former GP) regularly examined the body of the doll. A group of women sat together with their dolls and interacted with one another “staff labelled these as the mothers group” (p. 1095). Some residents were noted to have obtained “little, if any beneficial effects from doll usage” (p. 1095). However, the authors go on to comment that doll therapy did not worsen the well-being of anyone with dementia during their study. One resident became possessive of her doll and would take other people’s dolls which caused some distress. Other examples of ownership problems were noted, despite all residents having their own personal dolls. Another challenge pertained to staff and relative opinions on dolls. One relative removed the doll from his mother, while some staff felt the therapy was demeaning.
4	Ellingford et al. (2007) England Newcastle Retrospective audit	To examine the impact of doll therapy by retrospective analysis of case notes of residents before and after the introduction of dolls.	Retrospective audit of resident’s case notes, examining data over a 6-month period (3 months pre-doll therapy and 3 months post-doll therapy).	66 people living with dementia from 4 care homes already using doll therapy. (34 residents used doll therapy and 32 did not).	92% of doll users were female. All those who used a doll showed “significant improvement in all of the behavioural measures” (p. 37).
5	Fraser & James (2008) England Newcastle Grounded theory qualitative analyses	To develop an understanding of why doll therapy improves the well-being of some people living with dementia.	Grounded theory interviews with 8 health professionals on 2 occasions. First interview was exploratory while the second was designed to receive feedback on a model the authors constructed based on the first round of interviews.	8 health professionals (included: 2 psychologists, 2 nurses, 2 care assistants, 1 psychiatrist and 1 occupational therapist).	Participants perceived that doll therapy could meet a number of individual needs for people living with dementia which included “attachment, comfort, inclusion, activity, communication, interaction, identity and fantasy” (p. 56). In relation to attachment, “when residents move into a care home, they often lose figures and/or objects of meaningful attachment, such as family members [dolls could offer support this emerging need]” (p. 56). In relation to communication, healthcare professionals suggested that common conversation could be shared between health professional and person with dementia.
6	Minshull (2009) Scotland Edinburgh Cohort study	To identify whether doll therapy improved well-being for people living with dementia.	Unstructured doll therapy sessions carried out on a hospital ward by an occupational therapist once a week for 1 month. The Bradford Dementia Group Well-being Profiling Tool (2002) was used to assess reactions of people pre-/post-doll therapy. Well-being profiling was carried out by the author and verified by a student OT.	9 people living with dementia engaged with dolls along with an unspecified number of nursing professionals.	For the 9 people engaging in doll therapy, there was a notable increase in the well-being of 7. The authors observed that healthcare staff appeared to naturally play with the doll, “bouncing it on my knee while reminiscing with a patient” (p. 37). Healthcare staff commented that prior education on doll therapy was extremely limited and additional reading material, provided by the authors prior to the study, was very beneficial. Post-study, the author states that the doll therapy sessions have continued and that the department has purchased a pram in order to further doll activities.
7	Cohen-Mansfield et al. (2010) USA Maryland Cohort study	To examine the impact of different stimuli on people living with dementia. While not explicitly based on doll therapy, this study did post findings on the phenomenon.	Each person was presented with 23 predetermined different engagement stimuli (e.g. life-like baby doll, a robotic animal, a real baby, a real dog, a magazine, a ball, etc.)	193 people living with dementia residing in 7 nursing homes. Average age of 86 years old (151 female, 42 male).	With specific attention to the phenomenon of doll therapy, residents who chose to engage with dolls were considerably more likely spend longer with life-like dolls. The authors also found that residents preferred dolls as opposed to animal shaped toys.
8	Green et al. (2011) USA Chicago Cohort study	To determine the effects of doll therapy on geriatric patients related to PRN prescriptions of haloperidol.	Staff observations were recorded in a log book.	All patients admitted to the 21 bed gero-psychiatric unit over a period of 3 months (115 patients, 72 women, 43 men). Mean age of 69 years. 39% of these participants had a clinical diagnosis of dementia.	The authors found that people engaging in doll therapy were more likely to receive less PRN haloperidol prescriptions as opposed to those who did not.
9	Stephens et al. (2013) England Bristol Focused ethnography	To explore the relationship people living with dementia have with physical objects using focused ethnography.	21 residents and the staff of a care home were observed over a 2-month period. 30 h of observation were completed over a 2-month period.	21 people living with dementia and 27 staff members.	Person with dementia was observed to carry a plastic doll in the style of a young baby, “she would not let go of it, and would become distressed if she thought it was being taken” (p. 701). Attachment was considered as a need that could be met through dolls. In another observation, one resident would not relinquish her doll even when it needed washed. Even when family brought a second doll, the resident would not engage in the same way with the substitute. The authors found that dolls should seem real, or have warmth, texture, or have some quality that shows them to have reality. This realism would promote a more authentic.experience (i.e. because the doll was thought to be a baby).
10	Bisiani and Angus (2013) Australia Melbourne Mixed methods single case-study	To examine the therapeutic effect of a life-like baby doll on a person living with dementia.	Observation alongside Aged Care Funding Instrument (ACFI) to evaluate well-being.	Case-study of 1 female participant with moderately advanced Alzheimer’s disease.	Prior to doll therapy Mary was socially withdrawn and did not communicate with many people, she wandered and became easily distressed. Following introduction of a doll, these behaviours were noted to have decreased. “Reduction in appearance of anxiety, panic, tremors, hyperventilation and searching” (p. 456). “Improvement in dining experience, social interaction with staff and other residents, improved self-esteem as Mary was so proud to be the ‘one’ with the doll” (p. 457).
11	Alander et al. (2015) England Newcastle Grounded theory qualitative analyses	To understand how people in care, doll-users and non-doll users make sense of a doll in their setting.	Grounded theory focus-group interview with 5 participants and grounded theory interviews with 11 people.	16 participants (11 of which had dementia, 4 were actively using dolls). 2 doll users were male and 2 were female.	Both doll users and non-doll users believed that a doll represented a sense of ownership, which promoted a sense of control. It also filled people with a sense of pride. One doll user remarked, “I’m bringing them up marvellous you see” (p. 5). Almost all participants believed engagement with doll give a sense of purpose and provided an activity to keep the person occupied. Some participants perceived that this would protect doll users from becoming lonely, bored or isolated. Dolls could promote a sense of attachment or bonding as evidenced by “carrying, feeding, bathing, dressing” (p. 6).

Study appraisal

All studies included in this review were appraised using the Critical Appraisal Skills Programme Checklist (CASP), which was developed in the United Kingdom. Based on the checklist questions, each study was given a score and placed into the category of low, medium or high quality. With regards to this review, seven studies were deemed to be high quality (Alander et al., 2015; Bisiani & Angus, 2013; Cohen-Mansfield et al., 2010; Fraser & James, 2008; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013), one study was medium quality (Tamura et al., 2001) and three were low quality (Ellingford et al., 2007; Green et al, 2011; Minshull, 2009). With regards to the lower quality studies, the rationale for this scoring was mostly due to limited details about methodological approach. It is worth acknowledging that the three lower quality studies included 190 participants of the 497 participants included in the review, which is almost 40%. It is also worth highlighting again that, while Cohen-Mansfield et al. (2010) were judged to have a high quality study based on the CASP, their study used a variety of stimuli interventions, which included dolls, and this accounted for almost 40% (193 participants). In total then, there were 101 participants (20%) included in this review, which were deemed to be high quality and concentrated solely on the use of doll therapy.

Benefits of doll therapy

All studies included in this review clearly articulated a number of benefits that were associated with doll therapy. The most commonly reported benefit was improvement in communication between the person living with dementia and other residents or care staff (Alander et al., 2015; Bisiani & Angus, 2013; Ellingford et al., 2007; Fraser & James, 2008; James et al., 2006; Mackenzie et al., 2006; Minshull, 2009; Stephens et al., 2013; Tamura et al., 2001). The use of dolls gave people living with dementia a means to engage with care staff or residents. In the study by James, Mackenzie, and Mukaetova-Ladinska (2006), it was reported that a group of women who engaged with their dolls began to sit together and connect as a group. James et al. (2006) reported that this group began what was affectionately known as the ‘mother’s group’ (p. 1095). In addition to this, Minshull (2009) reported that some of her participants actually began to better articulate their language and as a result express themselves more clearly to others. In one example, Minshull (2009) recalls how one particular person living with dementia was ‘normally incoherent in speech’ (p. 37) pre-doll therapy. Post-doll therapy Minshull (2009) reported that this same person was able to better articulate their language through the doll by communicating phrases like “baby…tickle her toes…oh pretty colours [regarding doll’s pink cardigan]” (p. 37). The re-establishment of these communication channels is arguably essential when considering the therapeutic relationship between the person living with dementia and healthcare professionals. This notion was supported in the findings of Fraser and James (2008) who conducted semi-structured interviews with healthcare professionals, which included representation from nursing, psychology, occupational therapy and psychiatry. Fraser and James (2008) identified communication as an important theme as healthcare professionals were able to establish new communication channels with people in their care. Fraser and James (2008) proposed that healthcare professionals could frequently use the doll as a starting point for communication and even talk to the doll and the person living with dementia as means of further developing the therapeutic relationship.

While improvements in communication were important, other activities of daily living were shown to be enhanced through engagement with dolls (Roper, Logan, & Tierney, 2000). Considering maintenance of a safe environment, many studies reported reductions in distressing behaviour experienced by people living with dementia (Bisiani & Angus, 2013; Fraser & James, 2008; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013). This distressing behaviour has been mainly described in the literature as: agitation, wandering, anxiety, despondency and disengagement from others. During a single case-study on the phenomenon, Bisiani and Angus illustrated how one resident’s (Mary) previous daily experiences of “trying to leave the facility and asking for attachment/child were all together eradicated” by doll therapy (p. 456). This was supported by the work of Green et al. (2011), who noted that prescription of certain anti-psychotic medications was reduced in populations who engaged with dolls.

An improvement in dietary intake, or the activity of eating and drinking, was also identified as a potential benefit of doll therapy (Bisiani & Angus, 2013; Mackenzie et al., 2006; Stephens et al., 2013). This increased dietary intake was as a result of a better dining experience (as the doll provided immediate company) and increased awareness about food (as the person would sometimes give their own doll food). The studies in this review also found that residents who were previously reluctant to be assisted with elimination and washing/dressing needs, were more approachable when engaging with a doll (Bisiani & Angus, 2013; Fraser & James, 2008; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013). The rationale behind this was related to the calming affect that the doll appeared to have on users. Indeed, through analysis of questionnaires administered to healthcare professionals, Mackenzie, James, Morse, Mukaetova-Ladinska, and Reichelt (2006) found that the most common change in ‘emotional status’ observed in people engaging with doll therapy was that of being ‘calmer’ (p. 443).

Finally, benefits associated with working and playing, sleeping and mobilisation were also described in the literature. According to the findings of this review, therapeutic engagement with dolls has given rise to a number of behaviours including touch, cradling, cuddling, kissing, carrying, talking and singing (Alander et al., 2015; Bisiani & Angus, 2013; Cohen-Mansfield et al., 2010; Ellingford et al., 2007; Fraser & James 2008; James et al., 2006; Mackenzie et al., 2006; Minshull, 2009; Stephens et al., 2013; Tamura et al., 2001). These behaviours are most perceived as therapeutic and fulfilment of behaviour associated with play. However, as illuminated by Bisiani and Angus (2013), some people who engage with doll therapy are also meeting working needs. For example, Mary was observed to be asking healthcare professionals to ‘babysit’ when she had other tasks that needed to be carried out (p. 456). Improvement in the quality of sleep was another benefit identified by two studies in the literature (Bisiani & Angus, 2013; Stephens et al., 2013). Presumably, a person with dementia (with increased general well-being as a result of doll therapy), is more likely to settle into a better quality of sleep; however this was poorly explored in the evidence. Interestingly one study (Bisiani & Angus, 2013) even identified better mobilisation of a resident (Mary, the resident living with a dementia observed in their single case-study). This was attributed to reduction in episodes of anxiety that manifested as hyper-ventilation and tremors (which had previously been so severe that they had caused falls). Figure 2 provides an overview of the reported benefits of doll therapy. OPEN IN VIEWER

Potential challenges of doll therapy

While there were a number of benefits that were associated with doll therapy, a number of challenges were also identified. According to this review, the therapeutic use of dolls for people living with dementia was approached in two main ways, either as an intervention or a therapy. In the case of an intervention, which corresponds to dolls being offered to people for a set period of time, this was less common (Cohen-Mansfield et al., 2010; Minshull, 2009; Tamura et al., 2001). Naturally, these studies could not assess the long-term impact of dolls in the way that the other studies could. The therapeutic engagement of dolls was deemed as a ‘therapy’ when it was provided to people living with dementia over a longer period of time (i.e. months-permanent). As a long-term ‘therapy’, healthcare professionals were not required to engage directly with the doll therapy (i.e. people living with dementia used the dolls without direction) (Alander et al., 2015; Bisiani & Angus, 2013; Ellingford et al., 2007; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013). This was in contrast to the interventional studies, where healthcare professionals guided or led people living with dementia, on how to use the dolls. These differing approaches raise questions about how best to operationalise doll therapy in practice.

Considering the person living with dementia, there were a number of studies identified in this review that reported limitations with regards to doll therapy. While it has already been reported that doll therapy has clear benefits associated with its use, some studies have noted its effect is not always long-term. Indeed the findings suggest that some of the people who engaged with dolls appeared to lose interest in the activity over a sustained period of time (Stephens et al., 2013; Tamura et al., 2001). Ironically, while one of the key attributes of doll therapy was reduction in distressing behaviour, there were some instances where doll use caused distress for people living with dementia (Alander et al., 2015; Bisiani & Angus, 2013; James et al., 2006; Mackenzie et al., 2006; Stephens et al., 2013). In particular, people who engaged with dolls could become possessive of their doll and refuse to be parted from it (James et al., 2006; Stephens et al., 2013). This possessive behaviour can manifest as either desirable, because the person living with dementia has forged a therapeutic attachment with their doll, or undesirable, because the person can become distressed if they are separated from their doll.

Healthcare professional attitudes were found to be a potential barrier to engagement with doll therapy (James et al., 2006; Mackenzie et al., 2006; Minshull, 2009). In the study carried out by Mackenzie et al. (2006), the authors found, through use of questionnaires, that some people thought the use of dolls was “babyish…demeaning…patronising…inappropriate” (p. 442). These attitudes were observed in practice through the work of Minshull who noted that during her doll therapy intervention, “nursing assistants were sniggering” (p. 37). Interestingly, the authors who identified staff scepticism as a potential issue appeared to correct this through education (Mackenzie et al., 2006; Minshull, 2009). Administration of literature, information sessions and on-the job experience were shown to increase healthcare professional awareness and practice with doll therapy.

Emerging theoretical underpinnings

As alluded to, there have been some scant theoretical underpinnings as to how doll therapy can enhance the well-being of people living with dementia based on the theories of attachment and person-centred care. Two studies identified in this review have produced comprehensive explanatory models based on grounded theory methods that are significant in relation to emerging theory on doll therapy (Alander et al., 2015; Fraser & James, 2008). Fraser and James (2008) developed a model, based on empirical investigation, to assist practitioners in understanding the rationale for improvement in well-being for people living with a dementia who engage with dolls. Fraser and James (2008) acknowledged the importance of attachment in their model, but importantly recognised there were a number of other equally pivotal factors which included; inclusion, comfort and identity. Importantly these factors directly correspond with what Kitwood determined were the fundamental needs of the person with dementia (Kitwood, 1997).

In addition to these factors, which correspond directly to previous theory on doll therapy, Fraser and James (2008) reported emerging factors which relate to activity, innate drivers and memories. Doll therapy could offer an opportunity for people living with a dementia to engage in meaningful activity and as a result provide people living with a dementia with a sense of purpose, examples of this may include nursing, feeding, dressing or singing to the doll). On innate drivers, Fraser and James (2008) found that participants believed that people engaging with dolls were responding to instinct-like behaviours, for example, the innate wish to engage in social contact. Through grounded theory analyses it was also suggested that doll therapy could evoke pleasurable memories for the person living with dementia.

Alander, Prescott, and James (2013) used grounded theory to explore older adults’ views and experiences of doll therapy. This ultimately supplements Fraser and James’ (2008) work, which drew on a healthcare professional group. Alander et al. (2015) found that there were a number of intrapersonal features which directly influenced the well-being of people living with dementia and these included; ownership of a doll, purpose, role and attachment. In addition to these intrapersonal features, Alander et al. (2015) found that there were also a number of external interpersonal factors that could promote a person’s well-being and these included; companionship, communication with others and greater inclusion. Interestingly Alander et al. (2015) note that the majority of older adults involved in this study considered that intra/interpersonal factors were more likely to outweigh any practical or ethical concerns.

In addition to the two studies that sought to generate theory (Alander et al., 2015; Fraser & James, 2008), only two other studies identified in this review made explicit reference about their theoretical underpinnings (Bisiani & Angus, 2013; Stephens et al., 2013). These two studies drew on Bowlby’s attachment theory (1969) and the theory of personhood by Kitwood (1997). Stephens, Cheston, and Gleeson (2013) also utilised Winnicott’s transitional object theory (1953). Interestingly the studies identified in this review that do underpin their research with theory are the more recent, which perhaps illuminates the emerging development of research into doll therapy. Undoubtedly an explicit theoretical foundation is important with regards to doll therapy because, as found in this review, healthcare professionals may be resistive to using the therapy and therefore making the case from a sound theoretical basis is important.

Summary

The findings of these empirical studies have illuminated a number of potential benefits in the use of doll therapy for people living with dementia. In particular, the studies have associated therapeutic engagement with dolls as a means to promote the well-being of people living with dementia, particularly through improvements in activities of living. The empirical studies included in this review provide some insight to potential challenges associated with doll therapy but in less depth when compared to the benefits of the practice. Limited professional awareness about appropriate utilisation of the therapy, problems pertaining to doll ownership and negative pre-existing ideologies about the therapy appear to be the main challenges of the therapy according to the review.