Motivation in Ethnography and Previous Research

This project is grounded in preventive cardiology and ethnographic research on interpersonal conflict. Cardiovascular health is increasingly understood as the accumulation of behaviors, perceptions, and emotional reactions throughout life. This lifestyle view is reflected in etiological metaphors for cardiovascular disease; even the explanation of heart failure is shifting from the dichotomous model of a "broken pump" to the process of "progressive remodeling." Cardiovascular disease progression is influenced by an array of stressors, including hostility or proneness to interpersonal conflict (reviewed in [11]). The cumulative stress of repeated interpersonal conflicts, like the damage incurred by insufficient sleep, poor nutrition, and inactivity, leads to a prolonged deregulation of the autonomic nervous system and what is termed "allostatic load" [12].

Psychological interventions can help people modulate interpersonal stress and its consequences. Cognitive behavioral therapy can have dramatic effects by training people in "emotional regulation" or what mindfulness practitioners call "catching the flicker before the flame." Patients learn to critically evaluate the automatic thoughts and maladaptive interpretations that generate negative emotions and reactions. To address a highly conflictual style, this therapy emphasizes the tendency to perceive irritating situations as intolerable and unjust. Through self-awareness, patients learn to modulate their emotional and physical reactions to stress. The therapy also emphasizes alignment of behaviors with goals, assertive problem solving, and relaxation exercises [13].

The biggest limitations in behavioral medicine and psychotherapy are scalability: few people have access to good mental health care. The continued stigma associated with psychotherapy adds another barrier to those who could benefit. Furthermore, interventions are generally not available in the moments of greatest need. Therapy appointments are scheduled, stressful interactions are not.

Ethnographic interviews illuminated contexts for interpersonal stress, physical symptoms associated with conflict, and personally tailored coping strategies. Below are several examples that inspired concept development.

• Irritated by loud fellow travelers on the subway, a woman sheltered herself with mobile tools "I shifted my iPod* to something more soothing, opened my book and locked myself in a little cocoon."
• "Sometimes I'll lock myself in the bathroom (just to take a breath)... my kids are pounding on the door." This self-described "married single mom" sets her phone display to read "calm now." (Figure 5).
• A man invents reasons to leave irritating work meetings, "I'll say I have to go get something at my desk... just to get out of a meeting for a bit... sometimes I half convince myself that this is true... it's a really internalized strategy I've developed to step away."

Figure 5: A woman reprograms her mobile phone display "I look at it, I breathe and I get calm."
 

As an ethnographer and a clinician, I was impressed by the immediate effectiveness of these strategies. In contrast to common therapeutic techniques, they are highly contextualized, personalized, and almost instantaneous. They point to exciting opportunities for mobile therapies to enhance and expedite clinical medicine.

The Research Prototype

Continuous monitoring of stress is coupled with timely mobile feedback (see Figure 6). Mobile interventions are prompted by cardiovascular, contextual, and subjective stress indicators. The interventions are inspired by cognitive behavioral therapy and mindfulness practices and they are translated to mobile interfaces. The intent is to provide support, when and where it is most needed, to help alleviate emotional distress and limit cumulative risk of cardiovascular disease.

Figure 6: Mobile heart health. Mobile therapy is triggered by physiological, contextual and self-reported stress indicators. This woman's phone provides an "exit strategy"–a call away from a conflict–after detection of cardiovascular stress. The goal is to improve emotional regulation and reduce the risk of cardiovascular disease.

 

Components of Embedded Assessment

Monitoring. Wireless monitoring of physiological, contextual, and self-reported stress occurs via worn and environmental sensors and phone applications. Physiological sensing occurs via a chest-worn sensor that tracks heart rate characteristics, temperature, and movement. Contextual indicators are measured with location beacons and a calendar system. Self monitoring occurs via a touch-screen translation of a mood questionnaire [14], and a "panic button."

Below Figures: In addition to physiological sensors, location beacons, "mood mapping," and a "panic button" also monitor stress indicators.

Figure 7a: Bluetooth* and iMote* detect stressful transitions between home and work, and prompt contextually appropriate therapies
 

Figure 7b: Mood Mapping allows touch-screen indication of emotional valence and intensity
 

Figure 7c: Pressing the "panic button" expresses fiery rage and initiates the "exit strategy" intervention
 

Compensation. Feedback based on cognitive therapy protocols [13] to encourage reinterpretation of negative thoughts, physiological relaxation and behavioral change is triggered by the stress indicators above. The feedback is adapted to the mobile form factor and personalized. Examples include animated breathing exercises, provocative questions, music and imagery.

Below Figures: References to cognitive therapy [13].

Figure 8a: Breathing exercises offer guided relaxation
 

Figure 8b: Positive images are beamed before stressful encounters to inoculate against conflict
 

Figure 8c: Invitation to reappraise automatic thoughts
 

Prevention. This system is intended to reduce the risk of cardiovascular disease by improving emotional regulation and limiting the cumulative toll of interpersonal stress.

The mobile heart health system illustrates some of the value propositions and capabilities of embedded assessment that could inform future products. In upcoming field studies, we will examine how people relate to this feedback system over time, how they integrate it with their other healing and communication practices, and most importantly, how it affects their emotional and physical health.