Therapy Overload: The Weird World of Snoezelen Therapy
I had no idea what to expect before I walked through the door. I had visions of the suicide chambers from Soylent Green, or the Ludovico technique. A friend suggested that it sounded like something out of Dr. Seuss ("You know," he said, "in books like Green Meds and Ham or Horton Hears a Voice That Tells Him to Do Bad Things").
Though Snoezelen is, in fact, a new method for treating dementia?autism, say, or Alzheimer's?it's a very gentle technique, with no pain and no side effects. Better yet, it's one that seems to be getting good results through a process of sensory overstimulation. By making the senses do some work, the theory goes, Snoezelen helps reconnect dementia patients to the world they left behind.
Dr. Jason Staal, a 35-year-old psychologist working out of a small office in a quiet wing of Beth Israel, is currently the only American researcher probing the whys and hows of Snoezelen. According to Dr. Staal, while Alzheimer's patients may lose basic communication skills and forget how to dress or cook for themselves, the Snoezelen method can help them reduce antisocial behavior, improve memory, mood, verbal skills and concentration?even help them relax. And it can do all those things, strange as it may seem, by simply providing these patients with an experience they enjoy.
Snoezelen (the name's a contraction of two Dutch words meaning, roughly, "activation and relaxation") grew out of two primary sources. Research into sensory deprivation in the 60s showed that an understimulated brain will start hallucinating in order to make up for the lost sensory input. Then, in the early 70s, behavioral studies were done on institutionalized geriatric patients?studies that concentrated for the first time on the institutional environment.
"Lo and behold," Staal says, "when you enrich the environment, people tend to be less anxious, less depressed. And in general, the quality of life improves."
Shortly after these initial studies were done, unfortunately, the research?for some reason?stopped. At least in America.
"It's unfortunate," Staal says, "because the consequence is that people went about their business as usual in long-term care facilities and hospitals, not really paying the environment any mind." That is, hospitals remained sterile prisons where patients tended to get worse, not better.
The Dutch, however, picked up the research, and turned sensory deprivation upside down. Instead of depriving the senses, the idea was to stimulate them with smells and colored lights and music in a very controlled setting.
Snoezelen was first used as a treatment for autistic children. "People who have these problematic behaviors often do things for sensory reasons," Staal explains. "For example, if you see someone with autism taking their thumb and jamming it into their eye, you think, 'Wow, what's rewarding about that?' But the idea is, if you tap the eyelid with the eye closed, you would see a little burst of light...and suddenly that becomes very rewarding. So they attempt to repeat that behavior." Snoezelen could provide the same stimulation, but without the threat of injury.
After the method showed positive results on autistic cases, it was a fairly easy step to transfer it to patients with Alzheimer's.
Researchers "were conceptualizing Alzheimer's patients as people who were withdrawn?like people with autism?into their own world. They started to focus on the use of the senses to awaken and engage them." The big difference with Alzheimer's patients was that, unlike most autistics, they had led full lives before the disease struck. They had jobs and spouses and children and a lifetime of experiences behind them. With luck, Snoezelen would allow these patients to tap into those things again.
After even more success with the elderly, Snoezelen's popularity exploded across Northern Europe in the late 80s and 90s. At present, there are approximately 70 Snoezelen rooms set up across the Netherlands.
"It's taken on quite a role over there in the care of the elderly. What I'm trying to do is make it happen here," Dr. Staal tells me. It's become such an industry, in fact, that a British company has trademarked the name and is now the world's sole producer of official Snoezelen equipment?like the bubble tubes and the optic fiber mirrors.
Though it's one of the major criticisms aimed at Snoezelen by the medical community, Stall defends the commercialization. "This approach relies upon equipment. You can certainly do it on the cheap, and that's okay?but if you really want to create a system of service delivery, that means you need equipment that's going to do what you need it to do when you want it to. You can't be dependent on makeshift kinds of things."
?
Fact is, "Snoezelen rooms" are sprouting not only in American hospitals and institutions, but in schools, offices?even private homes. The difference between all those people and Staal is that they're practitioners, whereas he's the only one doing actual research into why it has the effects it does.
Dr. Staal's research into Snoezelen is a fairly recent development, following a long series of trials and frustrations. After a stint as the clinical director at a school for autistic children, he took a similar job at a nursing home, where he was asked to set up programs to help the Alzheimer's cases.
"I was horrified," he says about the conditions he found. "It was unbelievable. You can't treat psychiatric patients, or schoolkids, or your dog or cat this way. I saw stuff that was like the old snake pit days?10, 11 people in the dayroom, screaming, carrying on, no one interacting with them. Certified nursing assistants watching Wheel of Fortune."
State-of-the-art treatment, he says, involved little more than changing diapers and keeping people doped up. "Basically, there's a fine line between the efficacy of the medication and its use as just a chemical restraint... The quality of life was really bleak."
So he began searching for programs that could actually help these patients. And while he found a lot of good programs in other facilities, they were all lacking in some way. Some would try to make part of the facility look like someone's home. Others installed fake gardens. Still others brought in pets and children to liven things up.
"The biggest nemesis there," he says with some bitterness, "is television. You have all these people and you don't know what to do with them, so you put the telly on, as if that's going to do anything for them. But it gives people the sense of, 'Well, they're watching television.'"
After exhausting the available stateside programs and not finding anything he liked, Staal set his sights on Europe. He needed something that was positive, nonthreatening, non-pharmaceutical and reproducible, and that didn't involve anything that the patients had to learn.
"That's what I discovered when I started looking into Snoezelen," he relates. "I knew I needed to do what I needed to do to make this happen."
That's how, shortly thereafter, he ended up in that quiet wing of Beth Israel, where he works alone, seeing only three or four patients, spending much of his time putting together grant proposals to further his work.
"It's been a real quest for me. Finally I have what I think is one of the first research centers."
?
Central to his research are the improvements he's made on the original Dutch program. The first involved adding a behavioral concept known as "sensory reinforcement"?providing the patients with input they enjoy. The other was to begin amplifying the clinician's voice over the other sounds in the room, helping the patient to focus and concentrate better.
"If you engage in the process of Snoezelen you can actually have fun, because it's individualized?it's based on what you like to experience. People want to go back and experience it again. That's very rare."
The reason Snoezelen concentrates on the basic senses is that Alzheimer's patients, while losing so many other faculties, usually retain things like color and music preferences.
"I think the best reality orientation for a demented person is when they say, 'Wow, that's the color green.' That's much more important than what day of the week it is, or knowing if they're in a hospital." This is why he determines the patient's musical and other tastes before bringing them into the room for the first time.
I ask Dr. Staal if he's ever encountered a patient who was terrified at first being introduced into this admittedly peculiar environment.
"No," he replies. "That's why we do the assessment first. The same thing could be said if you went on vacation and you didn't do your research, and thought that going to Alaska was the same as going to Puerto Rico. You'd be sadly mistaken?and woefully underdressed."
The key, he says, is matching the patients' preferences with what they find in the Snoezelen room. The better the match, the better the brain functions and the more effective the treatment becomes. The amount of time spent in the room varies from patient to patient. Some stay 15 minutes, some an hour. Some come twice a week, others every day.
"Most of the time, people don't want to leave," Staal says. "After they leave, the rest of the environment looks terribly impoverished."
And that's a problem. The effects, he admits, are not permanent. They can last anywhere from one to six hours, depending on the kind of environment the patients return to. If they're going back to a gray, featureless institution?or one that's loud and confusing?the effects will diminish much more quickly.
I ask Dr. Staal what sort of effects?apart from just making the patient happy for a little while?he's talking about.
"Well," he replies, "if you can make a dementia patient 'happy,' that's really good, because there are very few things that can."
Beyond that, however, he says he's seen cases where people will begin talking more. "One of the best illustrations of that was a patient who'd be so happy to see me he'd say, 'It's you, it's you, it's you.' He'd even raise his hands. He wouldn't do that for anybody else... The interpersonal relationship increases. Verbal behavior increases. For some people, reminiscences can actually occur. Let's say you provide them with the scent of strawberries and ask, 'How would you use strawberries? Was it something you used to eat?' And suddenly the person will say, 'Oh! I remember eating strawberries with cream...' Suddenly they're in touch with something they had not been before."
One of the most remarkable examples he cited was the patient who, upon hearing the Glenn Miller Orchestra, forgot all about his cane, stood up and danced. "He and his wife saw Glenn Miller right before he left for the war," Staal explained. "That was a defining point in their lives... Again, musical therapy will speak to these kinds of behaviors."
Another benefit he mentions is the fact that Snoezelen is something families can do together?and going into a room filled with music and odors and lights gives them a hell of a lot more to talk about than a visit to a ward.
"People who have loved ones in the program are so supportive," Staal says, "because...it makes sense, and it's been a long time coming. Because they know that people languish in dayrooms, and live according to someone else's schedule. And the only thing they get is medication. There's got to be something we can do for these people. Hopefully this is it."
?
It was time to get my own taste of Snoezelen, the way any other patient would. After choosing the Ramones from Dr. Staal's CD collection, he walked me down the hall, stopping to point out the gray, flat walls.
"If you look at that," he said, pointing to the wall, "it'll play tricks on your eyes pretty quickly. This is what patients get most of the time. And this is the 'house of wellness.'"
He unlocked the door and brought me into the room. After I took a seat on the couch (the hospital paper, he explained, was there in case of accidents), he activated each piece of equipment one by one. He dimmed the overheads to increase the effect of the other light fixtures, then put on the Ramones, who tore into a cover of Tom Waits' "I Don't Wanna Grow Up."
He placed tennis balls and Koosh balls in my hands. Let me play with little musical instruments, offered to play catch (I declined) and introduced various other odors?tangerine, black currant?into the room.
In some cases, he explained, they had to cover the mirrors, so they wouldn't confuse people.
He asked me what I thought of various lights and patterns, and let me change the color of the bubbles in the bubble tube.
"Curiosity," he said, "awe, wonder?all kinds of emotions are produced at the very onset of all this."
We sat back and listened to the Ramones for a while. Then he said, "I'm going to illustrate something." He took the Ramones off, and replaced them with the lightest of new-age jazz. He asked what I thought of the difference.
"Well, you know," I said, "I don't smoke pot. But somehow, when the Ramones were on, I wanted to. And with this on, I feel like I have." I felt like I was 16.
In the future, Staal hopes to expand the use of Snoezelen?not just for dementia cases, but also for cardiac patients, and as a means of reducing job stress.
Forty-five minutes later, he gradually turned the lights up again and let me turn off all the equipment with a remote control.
"The best benefit I've seen from all of this," he said, "is that people organize positively around it. The reinforcement and the experience of reinforcement help them to have some positive meaning in their lives. So suddenly, when they can't explain why things happen, they can talk freely about the music and the lights, during and after the session. It's like taking a young kid to Disneyland."
And sure enough?for reasons I couldn't quite explain?I left the hospital that afternoon feeling much better about things.