November 2014 - Prof. Dr. Krista Mertens em.  

Snoezelen today in education in therapy
1. Foundation and aims of "International Snoezelen Association" (ISNA)
In the mid-eighties I had heard about Snoezelen from a head of a special needs school in Paderborn-Schloss Neuhaus and wanted to see for myself what the incredible description of shiny rooms for people with disabilities was all about. It didn't take long for me to realise its amazing potential and that we had to keep an eye on it. In 1981 I travelled to the Netherlands to visit the de Hardenberg centre in Ede and met Ad Verheul. I visited the Snoezelen rooms where I also met Jan Hulsegge who worked with Ad Verheul. Over the next few years there was a regular exchange - mainly trips with my students - and the idea was born to scientifically research and underpin the effects of Snoezelen.
In 2002 the first International Snoezelen Symposium  "Many countries - many concepts" took place at the Humboldt University in Berlin from the 10th to the 12th of October. 120 participants from Japan, Canada, Israel, Russia, England, Sweden, Switzerland, Poland and Germany took part. That is when the "International Snoezelen Association" was founded. (During the congress the students searched the internet to ensure that the abbreviation "ISNA" was still available.)
The idea of Snoezelen was completely new to people working with disabled people, especially for the severely disabled. Earliest private and at the time mainly church led facilities were set up at the beginning of the 19th century.
'Activating care'  and the developing promotion for people with special needs in the 50ies in the Scandinavian countries and the Netherland served as a model for special needs teachers in Germany. So it is not surprising that the foundation for Snoezelen in the Netherlands in De Hartenberg was already laid in 1950. It would take another 30 years until the motto "nothing has to be done, everything is allowed" (cf. Hulsegge, J.; Verheul, A. 19976) would reach Germany. But from my understanding of special needs education the motto had to be adapted slightly to "some has to be done and not everything is allowed", especially if Snoezelen was to be effectively applied in promotion and therapy.
Over the last 10 years Snoezelen has spread worldwide. Following the initial experiences in the Netherlands the rooms - aimed at facilitating rest, recuperation, relaxation etc.- have gained widespread acceptance. But unfortunately they are not always equipped to be target group specific. The term "sensory cafeteria" as used by Cleland and Clark in the first known publications in the "American Journal of mental deficiency" (1966/67) is still justified to this day when we are looking at inconsiderately equipped rooms in which the clients are exposed to sensory overload.
By now ISNA has members from 31 nations (with the largest percentage coming from Germany) who are all interested in the further development of Snoezelen and use their expert knowledge  to propagate the concept of Snoezelen and provide advice on target group specific installations of Snoezelen rooms. We pursue correct information and qualified training courses. During training events the basic principles of Snoezelen, target group specific contents and promotion and therapy concepts as well as diagnostic procedures that have been developed and tested over the years are being introduced and modified for different clienteles. Furthermore we have established an international network between Snoezelen facilities worldwide. Experts who have obtained ISNA's internationally recognised Snoezelen qualification are based in various institutions. They exchange experiences, observe each other, learn from one another and adapt their training concepts based on their research results.

2. What is Snoezelen
Snoezelen (pronounced snoo ze len) is a fictional term derived from the two English expressions “to snooze” and “to doze. Behind Snoezelen is a multifunctional concept: In a purposely designed room (mostly a white room) the use of light and sound elements, scents and music initiate sensual sensations. These have both relaxing and activating effects on the different perception areas. The specific design directs and arranges the stimuli; it creates interest, brings back memories and guides relationships. Snoezelen induces wellbeing, in a calm atmosphere fear will be taken away, people feel secure. (Mertens in Brockhaus Encyclopaedia Vol. 25, 2006,429).
The Snoezelen room can be filled with gorgeous scents which trigger pleasant memories and animate clients to dream. Visual effects are created by various light sources and projectors, colour wheels, revolving mirror balls and cosy lounging and seating areas. Snoezelen is therapy and support measure suitable for all age ranges (from toddlers to elderly people).

3. Snoezelen rooms for different needs
The Snoezelen room with its seating and lounging areas invites visitors to linger. They will look at the bubble columns and colourful flowing images, listen to beautiful melodies and sometimes they are surrounded by gorgeous scents. The atmosphere is therapeutic and helps particularly disabled people and elderly people to leave their worries behind, to reorientate and to feel comfortable in the pleasant atmosphere. In the Snoezelen room it is easier to talk about problems and worries whilst trained staff can offer their support. The diverse optic, acoustic and tactile stimuli, as well as scents and carefully chosen sounds have healing properties: Children - including those who are hyperactive - as well as adults will learn to improve concentration and memory. Certain melodies and particularly scents can trigger memories and challenge people to talk about it. These life stories enrich everyday life and allow the carer to better understand the client. All age groups, from children to elderly people, generally confirm the experience value of Snoezelen. The Snoezelen room creates an atmosphere for this purpose and is meant to be used that way.
We can use an existing room for different purposes and modify accordingly: Sometimes the room is used for relaxing and possibly for reflection and at other times it can be a learning or development zone.
The main aim is "wellbeing". When designing a room the intention at the outset is for clients to relax, to calm down and wanting to stay a little longer. Seating and lounging areas are adjusted to the needs of the user. With time the colour design and adapting the equipment with the help of small additional tools to achieve the desired effect becomes easier. Various optical, acoustic and tactile stimuli - applied target group specific - have a guiding, regulating and healing function. Certain sounds (i.e. created by instruments such as kantele, rainmaker or gong) and scents trigger memories and challenge reactions. Regardless whether clients are "just" relaxing in the room or using the room to think about life or whether the Snoezelen room is used for support, it is necessary to consider  before each session how to prepare the room for each client (for which special questionnaires have been developed by us). It is the duty of the accompanying person (therapist, pedagogue, carer, relative etc.) to structure the room in such a way that the user feels comfortable. In order to do so the Snoezelen specialist should consider the following aspects:
Is the temperature in the room right? Is the room well ventilated?
Is the equipment tailored to the client's needs?
Is the number of stimuli adequate?
Are the preferences of the user known?
Does the selected music have the desired effect?
Is there enough time to rest, to process the stimuli, to relax?
Does the client have the chance to let the accompanying person know how she/he feels - can the smallest reactions be read?
Did the accompanying person consider how to establish contact and including physical contact?
Is the accompanying person well informed about any strain the client might be under and/or any illness?
There is an aura in the Snoezelen that emanates tranquillity, a sense of safety and security. In the room a person becomes aware of his or her own feelings and moods which the accompanying person can pick up on and respond to. The accompanying person needs to emanate calm and be open to what the client 'communicates'. The special atmosphere of the room does not just support the process of personal reflection but, as it also serves as an environment to enhance learning and development, it demands the exchange between the client/patient and Snoezelen expert/relative. It is disappointing to observe that even nowadays these preliminary considerations essential for the work in the Snoezelen room are often ignored. Snoezelen rooms are often overloaded with electronic devices and it seems that all equipment needs to be used at once. Another problem we face in Germany is that Snoezelen is linked to MSE (Multi-Sensory-Environment). However, the environment - the Snoezelen room- cannot be 'multisensory' but needs to be a controlled environment. It is more of a CSE (Controlled-Sensory-Environment). The Snoezelen expert (accompanying person) needs to adjust the light effects, sounds and music, the scents and the positioning of the client in advance. This is particularly important for clients whose actions are restricted, for example for clients with brain damage or brain injuries. All three factors: Information about the client and his/her current state, the didactic-methodical considerations of the Snoezelen expert and the preparation of the room form a unit in the so-called "Didactic triangle" and relate to each other. Adjusting the room to the state and the needs of the client and the qualification of the accompanying person (i.e. empathy, compassion and specialised knowledge) impact on the success of the intervention, they are interdependent. Because of the different user groups the accompanying persons / Snoezelen experts generally come from various professional fields - particularly from ergo- and physiotherapy, care sector, music therapy, psychology, medicine and similar fields. Often relatives and friends of a patient might train to become a Snoezelen attendant.
4. Snoezelen in support and therapy
As already mentioned, it is not enough and it is irresponsible to perform a Snoezelen session without any preliminary planning as can often be observed, particularly during so-called "free Snoezelen" sessions. The generous application of Snoezelen has its limits particularly when  working with children who display socially conspicuous behaviour or who are very anxious and generally when working with people who display mental, emotional and physical dependencies and are relying on help.
Snoezelen therapy can be enjoyed by all age groups. We have to constantly rethink the rooms as well as the support frameworks and therapy concepts to ensure they are target group specific. The empathetic care of the client is guaranteed, the accompanying person will go all the way with the client, he/she supports the client and helps if and when needed, he/she observes and lets the client take a different path to lead him/her back to the right path. The pedagogical skills are particularly useful when working with people with disabilities.
"Support encompasses all measures influencing a person such as upbringing, treatment, therapy, training and education and in a broader sense training, care, guidance and care" (Stadler, H. 1998, 24). 
A prerequisite is the recording of the initial state of the person which will enable the carer to draw up a support plan. The program should last for at least 10 Snoezelen session with each lasting 45-60 minutes. Usually the sessions take place once a week but could be increased to twice weekly if required. 
Snoezelen as therapy session should only be conducted by professionals who have acquired the "Additional Qualification Snoezelen" and who are working or have been trained in the fields of medicine, therapy or special educational needs. Therapy encompasses "all measures taken to treat an illness with the aim of  restoring health, relieving symptoms or preventing relapses" (Brockhaus Encyclopaedia, 19 A.,BD.22,87). The basis of Snoezelen training is the acquisition of  knowledge about applications of specific diagnostic procedures to record the current state of the client. That includes establishing a biography which incorporates a thorough assessment of the client's surroundings.  For Snoezelen we have developed a number of observation forms and biometric measuring procedures are being used. A therapy plan needs to be established and colleagues who are also treating or caring for the client need to be consulted. A therapeutic measure will usually take a number of months or even years and has to be reviewed regularly. A review might lead to the conclusion that a different measure instead of Snoezelen might be more effective long-term.
In practice for support and therapy "guided Snoezelen" is mainly used. The use of light and sound effects and scents needs to be carefully considered. When it comes to positioning the client, his/her impairments need to be considered and positioning aids used if necessary. The accompanying person / carer / therapist needs to consider the following questions:

• Who are the rooms for, who is the target group?
• How many people should be in the room at one time?
• What are the main medical conditions of the clients?
• What are the aims, what is the purpose? Do we apply so-called "free Snoezelen" or "guided Snoezelen"?
• Is "guided Snoezelen" a "support measure" or "therapy"?

5. Snoezelen as a learning method
To date the Humboldt University is the only university researching the effects of Snoezelen since 1990. Since people in a Snoezelen room were very interested and focused, the idea came up, to teach lesson contents not just in the class room but extend teaching to the motivating setting of the Snoezelen room. The students investigated the curriculum of children in nurseries and preschools as well as primary and secondary schools and special educational needs schools. With the students' subjects of study in mind topics were selected which fitted with their subjects. That gave them the opportunity to gain their first practical experiences under supervision.
The Snoezelen room provides the ambience that offers the quietness and time needed to attend to children/pupils. The unique atmosphere created by the equipment and lounging areas leads to an changed attitude towards learning. It becomes easier for pupils to establish contact to each other and to the teacher. The use of carefully regulated visual and acoustic stimuli adds another positive stimulant and therefore provides structure and guidance. That enables the teacher to concentrate increasingly on teaching.
One of the basic aims is the "conscious perception of one's own body". Children (but also adults), who feel detached from their body, are unable to control it and finding it difficult to sequence events, will experience further problems with themselves and in the group, i.e. they might struggle to listen to a neighbour, to recognise needs, to be considerate and to wait their turn.  During the initial sessions in the Snoezelen room participants should learn to consciously perceive and control their body parts. They will also learn to see them in isolation and to name them. Activities aimed at exploring material properties and pressure are used for tactile and kinaesthetic experiences. Once participants have explored the seating and lounging areas and have discovered what feels pleasant or unpleasant, they will be able to relax for increasingly longer periods of time.
Sessions like these form the basis and can take three to ten sessions depending on development stages or ages. Only then should specific subject areas from the curriculum be introduced. When we dealt with a  difficult group of students aged 13 to 16 from socially deprived areas we were able to cover the following subject areas:

• Healthy eating
• On a voyage of discovery with Christopher Columbus
• Discovering - perceiving - experiencing rooms
• The room sounds
• A birds flight across the desert
• Animals surviving the desert
• Flight of the storks
• Owls
• Formation of night and day
• Journey through the human body
• Making up and telling stories: "A day by the sea"
• Am I strong or weak?

Other subjects, more aimed at adults particularly at the elderly, focus on:

• Having peace and time
• Gaining trust
• Having contact
• Encouraging communication
• To look out for others and be considerate
• Finding oneself
• Stimulating perception
• Remembering
• Developing learning structures
• Preserving memory and retention
• Using imagination and creativity

One unit in the Snoezelen room of 10 - 15 sessions (over a period of 3 or 6 month) lasts usually 45-60 minutes. Consistency is key, which means constantly changing structures have to be avoided, clear timing instructions and a limited choice of optical equipment are important. The introduction phase should last about 5 minutes to give the group time to settle and to introduce the subject. During the main part the chosen subject is taught (cf. Mertens, K. 2004, 2007; 2008). The concluding relaxation phase should last at least 10 minutes, to allow participants to reflect on the content of the session and to process what they have learned. To conclude the session the group will talk about their experience and the leader will give an indication of the next session.
After completion of the three-month intervention - one session a week - a report is written about each child. The analysis of the report can generally be seen as efficiency control and as a result subsequent sessions will be improved and target the needs of each individual child. This way contents selected for each session are being evaluated in terms of their aim and integrated in the overall concept. Initial and final evaluations will confirm that Snoezelen is the right form of intervention for the client or that perhaps a different intervention needs to be found.
For efficiency measurements to "improve learning in the Snoezelen room" we have used and still use to this day "questionnaires about wellbeing" as well as standardised procedures to measure memory and retention which have been developed at the Humboldt University in Berlin and tested in 2004 in cooperation with experts from Sweden, Finland and Canada.
We were able to confirm that the experiences and knowledge obtained in the Snoezelen room were retained for longer and could be retrieved quicker (controls were carried out after 12 months). Teachers confirmed an improved social behaviour in the group and a more pleasant learning atmosphere in the class.
6. Research at the Humboldt University Berlin
During research projects, carried out in our Snoezelen room at the Institute for Rehabilitation Science, questionnaires and observation forms were completed and efficiency measurements (in cooperation with the chair of signal processing and pattern recognition, Prof. Dr. -Ing. Beate Meffert and her students) carried out (cf. Meffert, B. 2005; Mertens, K., Meffert, B.; Schneider, G., 2005).
For children with conspicuous behaviour (partly with hyperactivity) the following procedures to record concentration and attention were implemented:

• ADHD parent and teacher questionnaire
• Concentration test (DL-KG by Kleber/Kleber/Hans)
• Repeating numbers (subtest from Kaufmann ABC)
• "Tiger Hannibal" (Screening motor skills test to record hyperactivity)
• Fine motor skills test - tracing lines (Schilling, 1992)
• Draw-a-person-test (Ziler)
• Video recordings of mimic and gestures during the same rest exercises at the end of the session

Chiara Kreutzjana has developed a support program of 14 sessions for children with ADS which she explained in her scientific paper "Snoezelen, a method to promote attention in children" (which could have been rated as dissertation). 6 children in a support class off 11 children from a special educational needs centre were selected. The average relaxation period of the children almost tripled over a period of seven weeks. The children "....have learned to use the relaxation phase at the end of a session as counterpart to the first part of the session that demanded a lot of attention. The children had the opportunity, to relieve the tension and to gather new strength...." (Kreutzjans, C.  ,).
Dr. Martin Buntrock also applied the measurements in his dissertation "The effects of special relaxation music in the Snoezelen room" (Buntrock, M. 2010). The music - specifically composed for the intervention Snoezelen - supports the relaxation process on a physical and a psychological level. Particularly in the care of people with mental illnesses, craniocerebral injuries, dementia and oncological patients the suitable design of the room and the correct choice of music are part of the care and therapy and have a verifiable positive effect on the patients' ability to rest, recuperate and relax.
In the first few years Snoezelen focussed on people with (severe) mental disabilities. Over the last 15 years the application fields have been extended and Snoezelen is now also being implemented in nurseries and preschools, schools, leisure facilities, nursery homes, clinics and hospices. Occasionally Snoezelen rooms can even be found in management sectors or spas. So-called "free Snoezelen" is still the basis - however it is not entirely "free" and should be described as guided as the certain aspects such as device settings and choice of music require preplanning. To be a recognised intervention in the fields of education and therapy it is not enough to offer Snoezelen on the principle of "nothing has to be done, everything is allowed". There is an urgent need to develop concepts and methods and to obtain teaching qualifications to get the support of the ministry for social affairs, ministry of health, ministry of education and which will then lead to worldwide recognition of the intervention Snoezelen as a support and therapy measure.

Reference
Buntrock, M. (2010): Wirkung von spezieller Entspannungsmusik im Snoezelenraum.
Cleland, Ch. C.; Clark, Ch. M. (1966/67):  Sensory deprivation and aberrant behavior among idiots. In: American Journal of mental deficiency. 2, 213-225
Hulsegge, J.; Verheul, A.(19976): Snoezelen – Eine andere Welt

Kreutzjans, C. (2004): Snoezelen, eine Methode zur Förderung der Aufmerksamkeit bei Kindern. Wiss. Hausarbeit. Humboldt-Universität zu Berlin

Stadler, H. (1998): Rehabilitation bei Körperbehinderung. Eine Einführung in schul-, berufs- und sozialpädagogische Aufgaben. Kohlhammer-V., Stuttgart u. a., 24

Meffert, B (2005): Snoezelen und seine Wirkung auf Biosignale. In: Mertens, K.; Verheul, A.: Snoezelen – Anwendungsfelder in der Praxis. Bericht von dem 2. Internationalen Symposium der ISNA, 89-98

Mertens, K. (20032): Snoezelen – Eine Einführung in die Praxis
Mertens, K. (2005): Snoezelen – Anwendungsfelder in der Praxis

Mertens, K. (2006): Definition Snoezelen. In: Brockhaus Enzyklopädie. Bd. 25, 429

Mertens, K.; Meffert, B.; Schneider, G. (2005): Forschendes Lernen. Begleitung diagnostischer und therapeutischer Verfahren in der Rehabilitationspädagogik. Ein interdisziplinäres studentisches Projekt. In: humboldt-spektrum (3), 54-58

Mertens, K.; Tag F.; Buntrock, M. (2008): Snoezelen – Eintauchen in eine andere Welt.

Prof. Dr. Krista Mertens (em.)
Humboldt-Universität zu Berlin
Institut für Rehabilitationswissenschaften
ISNA-Snoezelen professional e.V.
Rüdesheimer Str. 4
14197 Berlin