Ja, das ist ein Snoezelen-Bank; or, There's One Born Every Minute

Looking for the funnies in the Philadelphia Inquirer (AKA Fluffya Inkwire) this morning, I was surprised to come across an article about a practice I hadn’t met for quite a few years: snoezelen (see http://www.philly.com/philly/health_and_science/20110314_A_Dutch_therapy_that_stimulates_the_senses_seems_to_soothe_dementia_patients.html). Snoezelen (a made-up word) is the term for giving a patient experiences in a room that contains a variety of different scents, sights, sounds, and touch experiences-- a multisensory environment that may involve music, color changes, bubble tubes, and all sorts of real bells and whistles.

I first encountered snoezelen about 10 years ago when I was first inquiring into unconventional psychotherapies of various kinds. At that point, snoezelen rooms seemed to be intended for fun and entertainment-- a sort of elaborate form of disco ball or lava lamp. I don’t recall whether marijuana was suggested as a way to intensify the experience, but that was certainly the sort of thing it made me think about. A plate of hash brownies would seem to fit right in. That such an arrangement could be considered as a serious form of treatment was not mentioned at that time, as far as I know.

Fast-forward 10 years, and we see more than the suggestion that snoezelen is a treatment for dementia, autism, and so on. We also see a number of public-spirited companies that will provide the makings of a snoezelen room for about $15,000. According to the Inquirer article, one of these companies sold such rooms to over a hundred nursing homes and other facilities in the United States last year.

Do you suppose those nursing homes used state or Federal funds to buy their snoezelen equipment? Do you suppose their administrators thought or were told that the use of snoezelen was an evidence-based practice, as is generally required for such funding? If so, we’re looking at a sticky situation (and I don’t mean in a multisensory way). There is presently no evidence basis for the use of this kind of treatment, and it would be difficult (though not impossible) to achieve one.

Stacey Burling, the Inquirer reporter, pointed out that “three major teaching hospitals in Philadelphia were unable to find experts who felt qualified to talk about” snoezelen; in fact,it’s likely that none of those highly-trained people had ever heard of it. She also noted that the Dutch, who were the originators of snoezelen, did not do outcome research on the practice or even regard it as anything but amusement. However, Burling went on to comment on the apparent positive outcomes of some informal local studies, while reminding readers of some real research difficulties.

It would not be impossible to do serious outcome research on snoezelen, but it would be expensive and labor-intensive. One issue would be the need to make the experience exactly the same for each patient so that we would know what factors were the possible cause of a given outcome. This requirement, called intervention fidelity, is important in all studies of psychological treatments because differences in patient experiences are a factor that can seriously confuse our understanding of cause and effect. In the case of snoezelen, the practice of tailoring or fine-tuning treatments for different patients makes it difficult to know whether one or all of the treatments are effective.

For example, one individual interviewed by Burling commented that somewhat fewer doses of medication were used for dementia patients in the course of some weeks of snoezelen treatment than had been used before. The patients also had fewer falls, possibly because of the reduced medication. But these points bring up additional research issues. It would appear that staff were giving medication when they felt that patients’ mood or behavior warranted it. Of course this is perfectly legitimate, but the problem is that the medication decision rests on staff members’ judgments, and those judgments can be influenced by staff awareness of the availability of snoezelen treatment. If it’s about snoezelen time, a staff member may decide against administering medication, whereas the same patient mood or behavior may be seen as needing medication under other circumstances.

Research on treatment outcomes ideally involves blinded designs, in which staff members making evaluations or medication decisions (for instance) would not know which patients were receiving snoezelen treatment and which were not. This kind of design would prevent staff expectations from affecting the way they assess or treat patients--- whether a staff member thinks snoezelen is silly or is effective cannot cause different treatment if the person does not know what therapy a patient is getting. As long as research is unblinded and staff members know which patients receive which therapies, it is difficult to be sure that any patient changes are due to the therapy rather than other factors. This is currently a problem for snoezelen.

It’s very difficult to see how 15 to 20 minutes per week of snoezelen (as noted by Burling) could create a measurable change in the behavior or mood of dementia patients or others. Because there seems to be no obvious way that such a change could occur, it’s especially important that reliable research evidence showing good outcomes should be in hand before public funds are spent on this or similar treatments. Private institutions or families also owe it to their patients and themselves to investigate the effectiveness of all treatments before investing resources that might be much better spent. Let’s all use our ability to think these matters through before giving too much consideration to commercial claims.


.