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Aging Matters
Addressing issues related to geropsychiatry and the well-being of older adults
Juh Hyun Shin, PhD, RN
Doll Therapy
An Intervention for Nursing Home Residents With Dementia
ABSTRACT
The use of dolls as a therapeutic intervention for nursing
home residents with dementia is relatively new. The current
article describes a research study implemented with nurs-
ing home residents in Korea to examine the e ects of doll
therapy on their mood, behavior, and social interactions. A
one-group, pretest–posttest design was used to measure
the impact of doll therapy on 51 residents with dementia.
Linear regression demonstrated statistically signi cant dif-
ferences in aggression, obsessive behaviors, wandering,
negative verbalization, negative mood, and negative physi-
cal appearance after introduction of the doll therapy inter-
vention. Interactions with other individuals also increased
over time. Findings support the bene ts of doll therapy for
nursing home residents with dementia; however, further
research is needed to provide more empirical evidence and
explore ethical considerations in the use of doll therapy in
this vulnerable population. [Journal of Psychosocial Nursing
and Mental Health Services, 53(1), 13-18.]
© 2015 Shutterstock.com/Thomas M Perkins, Elena Dijour
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 53, NO. 1, 2015 13
Aging Matters
Nursing home residents with
dementia present a challenge
to caregivers, who struggle to
identify interventions that can help
these individuals whose loss of cogni-
tive function often leads to impair-
ment of self-maintenance, aggressive
behaviors, and poor social connections
(Alzheimer’s Association, 2013; Toye et
al., 2012). The current article describes
the therapeutic use of dolls, an inter-
vention that was implemented among
Korean nursing home residents with
dementia to have an impact on mood
changes and behaviors and enhance
social interactions.
Approximately 40 million
individuals are living with dementia,
making it a critically important global
problem (Alzheimer’s Disease Interna-
tional, 2012). Alzheimer’s disease (AD),
the most common type of dementia, is
an irrevocable progressive brain disor-
der that results in the loss of brain cells
and is identifi ed by a steady, advanced
decrease in cognition, function, and
psychomotor competency (Alzheimer’s
Association, 2013). Dementia is often
accompanied by depression, and to-
gether, the two conditions account for
$30 billion in annual Medicare spend-
ing (French et al., 2014). With the ex-
tensive losses from AD and other types
of dementia, the burden and stress for
family members and caregivers can be
overwhelming.
To move toward a holistic model of
care for individuals with dementia, it is
important to limit the use of psychotro-
pic medications and explore other inter-
ventions to enhance care for these indi-
viduals (Mitchell & O’Donnell, 2013).
As the number of older adults with
dementia is increasing, caregivers
have introduced nonpharmacological
interventions to improve the quality
of life for individuals with dementia
(Mitchell, McCormack, & McCance,
2014). The use of therapeutic dolls for
individuals with dementia is a low-cost,
nonpharmacological intervention that
is receiving increased interest from cli-
nicians (Mitchell & O’Donnell, 2013).
Dolls have been introduced in vari-
ous countries for nursing home resi-
dents with dementia to decrease their
agitation and increase feelings of af-
fection and attachment (Mitchell &
Templeton, 2014). Past experiences
and memories may give meaning to
individuals with dementia (Angus &
Bowen, 2011). Baby dolls may help re-
trieve memories of parenting, promote
feelings of calmness and competence,
enhance stimulation through touch,
and improve communication with
others (Ehrenfeld, 2003; James, Mack-
enzie, & Mukaetova-Ladinska, 2006;
MacKenzie, Wood-Mitchell, & James,
2007). Moreover, self-esteem may be
enhanced with activities of nurturing,
holding, and singing lullabies, helping
bring older adults back to a secure time
in their lives (Ehrenfeld, 2003; James et
al., 2006; MacKenzie et al., 2007).
DOLLS AS THERAPY
The therapeutic use of dolls for in-
dividuals with dementia can be under-
stood through the concept of attach-
ment. Although attachment theory was
originally applied to children, Miesen
(1993) refocused this theory to apply to
individuals with dementia (Mitchell &
O’Donnell, 2013; Stephens, Cheston,
& Gleeson, 2013). Theorists have sug-
gested that dolls may serve as a “tran-
sitional object” (Stephens et al., 2013,
p. 701) for individuals with dementia,
acting as an “anchor” (Mitchell &
O’Donnell, 2013, p. 330) in a period of
uncertainty, similar to the blankets or
soft toys that children use when mov-
ing toward adulthood.
Several studies described the ben-
efi ts of using dolls for nursing home
residents with dementia. James et al.
(2006) observed increased bonding
and communication when residents
with dolls were gathered together; they
named dolls after their children, gave
piggyback rides, and changed the dolls’
clothes. Mackenzie, James, Morse,
Mukaetova-Ladinska, and Reichelt
(2006) reported that staff generally
had positive perceptions about provid-
ing dolls for residents with dementia,
and 69% of staff agreed that lives of
residents with dolls improved. Using
a retrospective analysis of case records
of nursing home residents with demen-
tia, Ellingford, James, and Mackenzie
(2007) found that positive behaviors,
such as looking happy and engaging
in activities, increased, and aggressive
behaviors decreased more for residents
with dolls than for residents without
dolls.
In a case study, Bisiani and Angus
(2012) used a life-like baby doll with
a female nursing home resident with
AD to assess physical, emotional, and
psychosocial factors. Doll therapy ap-
peared effective in decreasing anxiety,
agitation, tremors, hyperventilation,
and panic and increasing social com-
munication and affection with pets,
staff, visitors, and other residents.
Heathcote and Clare (2014) reported
12 cases since 2009 that showed ma-
jor benefi ts from using doll therapy; it
decreased agitation, increased interac-
tions, and improved eating. Additional
studies reported that older adults with
dementia developed signifi cant and en-
joyable relationships with dolls, feeling
attachment and pride and engaging in
meaningful activity (Alander, Prescott,
& James, 2013; Fraser & James, 2008;
Lash, 2005; Stephens et al., 2013).
Limited research is available regard-
ing the effect of doll therapy on resi-
dents with dementia. The introduction
of dolls in long-term care settings in
Korea is at the beginning stage; to date,
no published Korean articles exist on
this topic. Moreover, most published
research comprises anecdotal case re-
ports, pilot studies, investigations of
attitudes of health care professionals,
and case studies (Mitchell & Temple-
ton, 2014). It is timely to move toward
a scientifi c research phase to evaluate
the effects of doll therapy on residents
with dementia.
METHOD
The purpose of the current study was
to examine the effects of dolls on the
14 Copyright © SLACK Incorporated
Aging Matters
physical, emotional, and psychosocial
facets of individuals with dementia in a
Korean nursing home. The primary re-
search question was: For nursing home
residents with dementia, what is the
effect of using therapeutic dolls on be-
haviors (i.e., positive/negative verbal-
ization, aggression, obsessive behavior,
and wandering); mood (i.e., positive/
negative mood and positive/negative
physical appearance); and social inter-
actions (i.e., interactions with other in-
dividuals and engagement in activities
provided by the nursing home)?
A one-group, pretest–posttest design
was used. The setting was a 70-bed, for-
profi t nursing home; all residents were
eligible for long-term care insurance for
older adults in Korea. Participants were
nursing home residents with AD or de-
mentia. Inclusion criteria were (a) mild
to severe cognitive impairment and
(b) residence of more than 3 months
in the current nursing home. Cognitive
impairment was defi ned as a score of
<25 points on the Mini-Mental State
Examination (MMSE; Folstein, Fol-
stein, & McHugh, 1975).
Residents who were excluded were
those who (a) were cognitively intact
(i.e., score >25 on the MMSE), (b)
were not diagnosed with dementia or
AD, (c) resided for rehabilitation pur-
poses, (d) resided less than 3 months in
the current nursing home, and (e) were
diagnosed with any type of psychologi-
cal disease.
Sample size was determined at an
effect size of 0.5, based on 1 month of
changes in behavior, mood, interaction
with others, and engagement in activi-
ties provided by the facility; at least 31
surveys were required to be completed
(Rosner, 2010). Considering dropout
rates, 62 participants were initially
queried. Ultimately, 51 surveys were in-
cluded for data analysis. Of the sample,
11 residents were not included in the
fi nal analysis due to refusal to partici-
pate (n = 6), relocation to a hospital
(n = 4), and death (n = 1).
As previous studies often used obser-
vation or interviews without engaging
a robust instrument, it was diffi cult to
fi nd an appropriate instrument. In the
current study, to measure changes in
behavior, mood, and interactions with
others, subcategories of the Quality of
Life in Late-Stage Dementia (QUAID)
scale developed by Weiner et al. (2000)
were used. In addition, a single ques-
tion was added to ask the frequency
of engagement in activities provided
by the facility. The QUAID scale can
assess the states and behaviors of indi-
viduals with dementia based on obser-
vations by close caregivers (Weiner et
al., 2000). Additional questions were
developed based on questionnaires
used in previous research investigat-
ing doll therapy for nursing home resi-
dents. Based on feedback from three
nurses who work in the nursing home
and three nursing faculty members who
majored in gerontological nursing in
Korea, questions were slightly revised
to help care workers complete ques-
tionnaires more easily.
Guidelines for using dolls by
MacKenzie et al. (2007) were used to
select dolls. Baby-like dolls were pur-
chased; they weighed approximately 3
pounds, were approximately 17 inches
long, had a soft texture similar to hu-
man skin, and had black realistic hair.
Dolls were made with smiles to convey
calmness and peacefulness, and they
did not cry or laugh. The dolls had eyes
that opened and closed; some residents
may think the dolls are dead if they do
not open their eyes. Because nursing
home residents in the study were all
Korean older adults, Asian baby dolls
were selected. However, different types
of Asian baby dolls were purchased to
avoid disagreements with other resi-
dents over ownership of dolls.
Dolls were placed in the activ-
ity room, and residents chose a doll
to take. Residents were asked to try to
hold the dolls if they wanted to keep
them. If residents refused or were un-
comfortable taking dolls, dolls were not
provided to them.
Data Collection and Analysis
Approval to conduct the study was
obtained from the institutional review
board of a university in Korea. Before
data collection, written approval was
obtained on consent forms from prox-
ies of participants. Data were collected
from June to November 2013. The
purpose of the study, questionnaire
items, and confi dentiality of data were
explained to staff. Guidelines for using
dolls were provided, emphasizing that
staff should (a) ensure that having dolls
was a voluntary decision by each resi-
dent; (b) not specify to residents that
it was a doll or baby; (c) call the dolls
Residents were observed laying dolls on beds in
appropriate positions, checking them constantly,
rocking them back and forth, and talking to
themselves more than usual.
© 2015 Shin
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 53, NO. 1, 2015 15
Aging Matters
“dolls” if residents believed them to be
dolls, or “babies” if residents believed
they were babies; (d) remove dolls
from residents if they were tired from
nurturing the dolls or had poor posture
because of holding the dolls, returning
the dolls after the residents felt better;
(e) allow residents to have dolls as long
as they wanted to have them; (f) not
use dolls as punishment in any way; and
(g) not depend solely on dolls and omit
other activities. Family members were
trained in a similar manner.
Questionnaires were used to mea-
sure baseline data on residents, and post
measurements were taken at 1 week,
1 month, and 3 months after distribut-
ing the dolls. Before data collection,
the project investigator (J.H.S.) visited
the setting and held three workshops
with staff (approximately 1-hour long,
each with a question-and-answer ses-
sion) to describe the research. The
project investigator conducted the
primary measurement of baseline data
and trained qualifi ed care workers in
collection of post measurements. Only
staff who cared for residents more than
4 days per week and had worked more
than 6 months at the institution were
trained in data collection. A total of 10
care workers completed the question-
naires for 62 residents, which means a
care worker was assigned to complete
the questionnaires for approximately
six residents. To ensure interrater reli-
ability, two care workers observed the
same resident.
RESULTS
The average age of residents
was 82.54 (range = 66 to 100 years,
SD = 7.45 years); most participants
were women (86.3%), and 74.5% were
widowed. The average score on the
MMSE was 10.72 (SD = 7.64).
Linear regression was used to mea-
sure the effects of using therapeutic
dolls on behaviors, mood, and social
interactions (Table). At a statistically
signifi cant level, older adults used
fewer swear words or shouted less, were
less aggressive, exhibited fewer obses-
sive behaviors, and wandered less (all
p < 0.01). However, no statistically
signifi cant effects of positive verbaliza-
tion, such as expressing appreciation,
were identifi ed (p = 0.56).
Statistically signifi cant differences
emerged in positive mood (i.e., calm-
ing) and positive physical appear-
ance (i.e., looking comfortable) (all
p < 0.01). In addition, statistically
signifi cant decreases in depression and
looking uncomfortable (all p < 0.01)
emerged. Interactions with other indi-
viduals increased over time (p < 0.01),
but no statistically signifi cant differ-
ence emerged in engagement in activi-
ties (p = 0.41). Findings from the cur-
rent study support the benefi ts of doll
therapy in promoting positive mood,
behaviors, and social interactions for
residents with dementia.
Statistically signifi cant long-term
effects emerged in different points of
measurements during the study period.
Statistically signifi cant improvement
occurred in verbalization, aggression,
obsessive behavior, wandering, look-
ing comfortable/uncomfortable, and
depression at 1 and 3 months. Resi-
dents felt calmer immediately after
applying therapeutic dolls at 1 week
and 3 months.
DISCUSSION
Findings from the current study
support those of previous studies (An-
gus & Bowen, 2011; Bisiani & Angus,
2012; Ehrenfeld, 2003; Ellingford et
al., 2007; Heathcote & Clare, 2014;
James et al., 2006; MacKenzie et al.,
2007; Wiley, 2003) in that doll ther-
apy can be a valuable tool to promote
positive mood, behaviors, and social
interactions in individuals with de-
TABLE
RESULTS OF DOLL THERAPY INTERVENTION IN KOREAN NURSING
HOME RESIDENTS WITH DEMENTIA
Variable tp Value
Behavior
Positive
Verbalization (expressing appreciation) 0.59 0.56
Calming –9.34 <0.01
Negative
Verbalization (saying swear words or shouting) –13.05 <0.01
Aggression –16.31 <0.01
Obsessive behavior –6.15 <0.01
Wandering –17.76 <0.01
Mood
Positive
Looking comfortable –4.28 <0.01
Negative
Looking uncomfortable –18.05 <0.01
Depression –18.22 <0.01
Social Interaction
Interaction with sta , other residents, family
members
–8.41 <0.01
Engagement in activities –0.82 0.41
16 Copyright © SLACK Incorporated
Aging Matters
mentia. Although this was quantita-
tive research, researchers also observed
residents with dolls and interviewed
staff. Most residents appeared to love
the dolls. When residents “met” their
respective doll for the fi rst time, they
had bright faces, saying, “Whose baby
is this?” and laughing, saying, “I would
give a hug if it cries, but it doesn’t even
ask for milk.” Residents were observed
laying dolls on beds in appropriate
positions, checking them constantly,
rocking them back and forth, and
talking to themselves more than usual.
When leaving their bedrooms for meal
time, they looked at the dolls and the
blankets as if to ensure it was safe.
Residents talked to the dolls as if they
were real babies and spent time with
them. Some residents talked about the
time when they cared for their own
children and grandchildren.
Close care workers observed resi-
dents, and 24 (47.1%) of 51 residents
perceived the dolls as babies, whereas
15 (29.4%) residents recognized the
dolls as dolls. The remaining 12 resi-
dents were not interested in the dolls.
Some residents’ perceptions of the dolls
as real babies or merely dolls seemed to
vary day to day. However, whether resi-
dents appeared to think of the dolls as
real babies or not, loving and hugging
the dolls seemed to bring emotional
calmness.
Residents showed different types
of attachment to the dolls. Some resi-
dents complained because the dolls did
not cry or blink, suggesting they may
benefi t from being able to choose a doll
that blinks or responds to attempts to
stop it from crying. Five residents ap-
peared to lack enthusiasm for the dolls,
only holding them peacefully without
changing their position. Some residents
did not pick dolls up when they were
dropped or seemed to periodically lose
interest and not look for them. A few
residents appeared to dislike the dolls
themselves, even when others were
playing with them. In addition, some
showed strong rejection of the dolls
when they were fi rst exposed, but when
seeing others take care of a doll, they
showed slight interest, saying, “What a
pretty baby.”
Concerns emerged from previous
research (James et al., 2006) that some
residents were aggressive about wanting
to own more than one doll. Although
the majority (86.3%) of residents with
dolls in the current study did not try to
take other residents’ dolls, fi ve residents
tried once during the study period, and
two residents tried more than three
times per week to take other residents’
dolls.
Evaluation of the use of dolls as an in-
tervention for individuals with demen-
tia remains controversial. Although
support is increasing for benefi ts gained
through doll therapy, concerns have
been raised by some researchers that
doll therapy may be unethical because
the use of the toy can be seen to vio-
late principles related to dignity, truth
telling, and deception (Andrew, 2006;
Cayton, 2001; Mitchell & Templeton,
2014). Family members’ viewpoints
should be explored, as without realizing
the potential benefi ts of doll therapy,
they may see the intervention as de-
meaning to their loved ones (Andrew,
2006). The United Nations Conven-
tion on the Rights of Persons with
Disabilities provides a legal framework
that places the individual with demen-
tia at the center of any ethical dilemma
(Smith & Sullivan, 2012). Viewing
these vulnerable individuals as “rights
holders” may help health professionals
resolve any ethical tensions by focusing
on what is right for a specifi c person
in a specifi c situation and facilitate his
or her personal choices when possible
(Mitchell & Templeton, 2014).
Some research teams are developing
ethical guidelines to apply therapeutic
doll therapy. The Newcastle Behavior
Service at Newcastle General Hospi-
tal proposed guidelines that emphasize
that a doll should be applied strategi-
cally so that any older adult with de-
mentia can decide to have one if desired
(Andrew, 2006; Killick & Allan, 2001;
MacKenzie et al., 2007). Moreover,
guidelines developed by MacKenzie
et al. (2007) for using dolls described
strategies to decrease problems, includ-
ing ownership and disrespecting atti-
tudes toward dolls.
LIMITATIONS
The current study had several limi-
tations. Only one nursing home with a
small sample was used, which limits the
generalization of fi ndings. Although
the same care worker was asked to
observe and complete the question-
naires for specifi c participants, other
extraneous factors sometimes made
this impractical. For example, possible
factors included physical or emotional
burden of the care worker, the status
of aggressiveness of each resident, or
the presence of family members, which
could not be controlled in the current
study. Finally, outcomes were based on
the observations of care workers, which
may have introduced bias through care
workers’ personal opinions about the
use of doll therapy and dialogue among
care workers or other staff.
CONCLUSION
The current study supports the
benefi ts of doll therapy for nursing
home residents with dementia. Future
research should explore strategies to
improve physical, psychosocial, and
cognitive competencies of nursing
home residents in various contexts.
Culturally sensitive application guide-
lines for the use of therapeutic dolls
are necessary. Further research should
(a) be conducted with a larger sample
and different populations worldwide
and (b) explore ethical perspectives
related to the use of this therapeutic
intervention.
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Dr. Shin is Assistant Professor, Department
of Nursing, College of Health Sciences, Ewha
Womans University, Seoul, Korea.
The author has disclosed no potential con icts
of interest, nancial or otherwise. This research
was supported by a grant from Ewha Womans
University Research Grant of 2013 and by the Basic
Science Research Program through the National
Research Foundation of Korea funded by the
Ministry of Science, ICT & Future Planning (2-2014-
1221-001-01).
Address correspondence to Juh Hyun Shin,
PhD, RN, Assistant Professor, Department of
Nursing, College of Health Sciences, Ewha Womans
University, Helen Hall 205, Daehyundong,
Seodaemoongu, Seoul, Korea; e-mail: juhshin@
ewha.ac.kr.
Posted: January 14, 2015
doi:10.3928/02793695-20141218-03
18 Copyright © SLACK Incorporated
